CORNELL UNIVERSITY. THE l^ostoen p. Isomer Itibirairg THE GIFT OF ROSWELL P. FLOWER FOR THE USE OF THE N. Y. STATE VETERINARY COLLEQE. 1897 Cornell University Library RC 71.D11 1895 Medical diagnosis, witli special referenc 3 1924 000 220 305 The original of tiiis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000220305 1 " • MEDICAL DIAGNOSIS WITH SPECIAL REFERENCE TO PRACTICAL MEDICINE.. LIBRARY. GUIDE TO THE KNOWLEDGE AND DISCRlM^^vtV TION OF DISEASES. BY J. M. DA COSTA, M.D., LL.D., PRESIDENT OF THE COLLEGE OF PHYSICtANS OF PHILADELPHIA ; EMERITUS PROFESSOR OF PRACTICE OF MEDICINE ANIt OF CLINICAL MEDICINE AT THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA: PHYSICIAN TO THE PENNSYLVANIA HOSPITAL, ETC. lUustratefi toitfi 3Engrat>ings on EIGHTH EDITION, REVISED. PHILADELPHIA:' J. B. LIPPINCOTT COMPANY. LONDON; 10 HENRIETTA STREET, COVENT GARDEN. 1895. Entered, according tolCct of Congress, m the year 1890, by J. M. DA COSTA, M.D., In the Office of the Librarian of Congress at "Washington. Copyright, 1895, by J. M. Da Costa, M.D. 7 ( ■ :dvI . Electrotyped and Printed by J. B. Lippincott Company, Philadelphia, U.S.A. EXTRACT FROM PREFACE TO THE FIRST EDITION. My chief aim in writing this work has been to furnish ad- vanced students and young graduates of medicine with a guide that might be of service to them in their endeavors to discrimi- nate disease. I have sought to offer to those members of the profession who are about to enter on its practical duties a book on Diagnosis of an essentially practical character, — one neither so meagre in detail as to be next to useless when they encounter the manifold and varying features of disease, nor so overladen with unnecessary detail as to be unwieldy and lacking in precise and readily-applicable knowledge. In executing my undertaking, two plans oifered themselves : either to describe morbid states in compliance with the usual pathological classification followed in treatises on the Practice of Medicine; or to group theni according to their marked symptoms. The former plan would have been far the easier, but the latter seemed to me the more suitable for a volume of this kind ; and, although it has involved much labor, and has rendered the task much more difficult of accomplishment, its advantages appeared to me so great that I have adopted it throughout. That this attempt at a purely clinical classification is not perfect, I am fully aware. But, with all its shortcomings, I venture to hope that it will not be devoid of value. Some of the statements made may appear too absolute, and as not taking sufficient notice of the many exceptions which may arise. But it was impossible to avoid this without very lengthy discussion : and even in the lengthiest discussion all exceptions and all possible points of fallacy would not have been mentioned ; for Nature does not limit herself in her irregularities any more than in her rules. The text must, therefore, be looked upon as treating only of general laws and of their niost notable infrac- tions ; in fact, but as a series of etchings, with here and there a prominent figure shaded, but not as an attempt to reproduce the 3 4 PEEFACE TO THE EIGHTH EDITION. coloi's of au original whose varied hues could not be closely copied, even by the hand of a master. The main object of this work is, what its title implies, the consideration of Medical Diagnosis. In connection with this, 1 have endeavored to take cognizance of the prognosis of indi- vidual aifections, and occasionally the record of cases has been introduced by way of elucidation. To have done this to a much greater extent, though in some respects desirable, would have swelled the work to an inordinate size. The wood-cuts employed as illustrations are all original. Many are from sketches, or at least are based on sketches, taken directly from cases of interest. Philadelphia, April, 1864. PREFACE TO THE EIGHTH EDITION. Another edition having been demanded, I have revised the work and altered some of its chapters. New matter has been inserted, old matter in parts condensed. I have endeavored to incorporate whatever of bacteriological interest appeared to be established as valuable for diagnostic purposes. The introduction of a number of additional wood-cuts and of temperature charts taken from cases actually observed will, I trust, conduce to greater clearness and accuracy. I gladly acknowledge the efficient aid of Dr. Eshner, Dr. Woodbury, and Dr. Leffmann in preparing this edition for the press. Since the work was last published, my attention has been called to a further Italian translation. 1700 Walnut Street, August, 1895. CONTENTS. INTRODUCTION. PAGE General Considerations 17 CHAPTER I. EXAMINATION OP PATIENTS, AND SOME SYMPTOMS OP GENERAL IMPOET. General Considerations 27 Position of the Body 30 General Aspect — Expression of Countenance 32 Skin 84 Pulse 35 Temperature of the Body 43 Tongue 52 Sensations of Patients 55 CHAPTER II. DISEASES OP THE BEAIN AND SPINAL CORD, AND OP THEIR NERVES. General Considerations . • 57 Cerebral Localization 57 Sensory Centres, and Conducting Paths 63 Spinal Localization 65 Deranged Intellection 67 Delirium 67 Stupor 70 Coma 70 Insomnia 72 Deranged Sensation 72 Hyperaesthesia 72 Anaesthesia 74 Headache 81 Vertigo 83 Derangement of Special Senses 87 Vision 87 Hearing 98 Deranged Eeflexes 99 6 6 CONTENTS. PAGE Deranged Motion 103 Paralysis 103 Hemiplegia 113 Monoplegia 120 Paraplegia 124 Sudden Paraplegia 125 Spinal Hemorrhage 125 Acute Ascending Paralysis 126 Multiple Neuritis 128 Gradual Paraplegia 130 Spinal Congestion 131 Spinal Ansemia 131 Spinal Meningitis . •..'.....'.. 131 Myelitis 132 Spinal Scleroses 135 Tumors of the Cord 136 Keflex Paraplegia 137 Palsies usually Limited, though they may be General 138 Hysterical Paralysis 138 Rheumatic Paralysis 140 Lead Palsy . 141 Diphtheritic I'aralysis 141 Syphilitic Paralysis 142 Local Palsies 144 Facial Palsy "......,..'..... 144 Paralysis of the Nerves of the Arm 146 Bulbar Paralysis 147 Palsies connected with Marked Muscular Wasting 149 Progressive Muscular Atrophy 149 Infantile Paralysis 155 Ataxia 159 Locomotor Ataxja,. . ,, 159 Diseases of the Cerebellum 165 Tremor ....,,......, 1G6 Paralysis Agitans 167 Multiple Cerebro-spinal Sclerosis ,,..., 167 Functional Tremors 169 Spasms — Convulsions 171 Deranged Nutrition and Secretion 174 Acute Affections of which Delirium is a Prominent Syniptom 179 Acute Meningitis , , 179 Tubercular Meningitis . , 185 Cerebro-spinal Meningitis 189 Delirium Tremens 190 Acute Mania 192 Diseases Marked by Sudden Loss of Consciousness and of Voluntary Motion 194 Apoplexy ....,,., , 194 CONTENTS. 7 FAGE Sun-stroke 210 Catalepsy 212 Diseases marked by Convulsions or Spasms 214 Epilepsy 214 Chorea. ' . 219 Hysteria .;.........;......." 224 Tetanus 228 Functional Spasms ;..;................. 233. Diseases characterized by-Gradual- Impairment of the Metital Faculties with Paralysis- . 235 Chronic Softening 235 Tumor . 240 General Paralysis 246 Diseases characterized by Enlargement of the Head 249 Chronic Hydrocephalus 249 Hypertrophy of the Brain 250 Diseases characterized by Enlargement of Various Parts 251 Acromegaly . .- . 251 Diseases characterized by Paroxysmal Pain 252 Neuralgia in- General 252 Facial Neuralgia- . 254 Hemicrania 255 Sciatica , 256 CHAPTER III. DISEASES OF THE UPPER AIE-PASSAGES. SECTION I. DISEASES OF THE NOSE AMD ASSOCIATE OEOANS. General Considerations 260 SECTION II. DISEASES OF THE LARYNX AND TRACHEA. General CpnaideratioAS . ., 266 Acute Laryngeal A.ifections . , 274 Aeujie .Laryngitis. ■ 274 (Edema of the Larynx 277 Croup 278 Chronic Laryngeal Affections 286 Chronic Laryngitis 286 CHAPTER IV. DISEASES OF THE CHEST. General Considerations 297 8 CONTENTS. SECTION I. DISEASES OF THE LUNOS. PAGE Different Methods of Physical Diagnosis, and the Physical Signs of • Pulmonary Diseases 299 Inspection 299 Mensuration 300 Palpation 803 Percussion 303 Percussion of the Healthy Chest 309 Auscultation 310 Sounds of Kespiration in Health and in Disease 313 Changes in the Vesicular Murmur 314 Bronchial Respiration 318 New or Adventitious Sounds 320 Auscultation of the Voice 325 Combination of the Physical Signs, and the Examination of Patients affected with Disease of the Lungs 326 Principal Symptoms of Diseases of the Lungs 330 Dyspnoea 330 Cough 335 The Sputum 338 Hsemoptysis 345 Diseases in which Clearness on Percussion is met with 348 Acute Bronchitis 348 Chronic Bronchitis 352 Emphysema 356 Diseases in which Dulness on Percussion occurs 361 Phthisis 361 Acute Affections of the Lungs accompanied by Dulness on Percussion . 384 Acute Phthisis 884 Acute Pneumonia 388 Acute Pleurisy 404 Diseases presenting Dilatation of the Chest, Displacement of the Liver or Heart, and Dyspnoea 410 Pneumothorax . . . , 411 Chronic Pleurisy 415 Diseases in which Retraction of the Chest occurs 423 Chronic Pleurisy 423 SECTION II. DISEASES OP THE HEART. General Considerations 428 Examination of the Heart by the Different Methods of Physical Diagnosis 431 Inspection 431 Palpation 432 Percussion 433 Auscultation 435 CONTENTS. 9 PAGE General and Local Symptoms of Diseases of the Heart 445 Cardiac Dropsy 446 Derangement of the Circulation 446 Cardiac Pain 448 Palpitation 452 Functional Disorders of the Heart 453 Disorders characterized hy Palpitation, associated or not with Change of Rhythm 454 Organic Diseases of the Heart 460 Acute Diseases presenting Pain in the Cardiac Region ; the Symp- toms of a Disturbed Circulation ; and a Change in the Sounds of the Heart, or their Replacement by Murmurs . 460 Acute Endocarditis 461 Acute Pericarditis 468 Myocarditis 476 Chronic Diseases attended with Increased Extent of Percussion Dulness, but with Normal or almost Normal Heart-Sounds 478 Hypertrophy 478 Dilatation 482 Eatty Degeneration 484 Pericardial Effusion 488 Diseases of the Heart exhibiting more or less of the Signs and Symptoms of Enlargement of the Organ, and accompanied by Endocardial Murmurs 489 Valvular Aifections 489 Displacements of the Heart 505 SECTION III. TnoKAcic Anetjkism 506 CHAPTER V. DISEASES OP THE MOUTH, PHARYNX, AND OESOPHAGUS. Mouth 519 Fauces 522 Tonsillitis 522 Diphtheria , 524 Mumps 534 Chronic Sore Throat 535 Pharynx and CEsophagus 537 CHAPTER VI. DISEASES OF THE ABDOMEN. General Considerations 541 Methods and General Results of Physical Examination of the Abdomen 542 Inspection 542 Palpation 543 Percussion 544 Auscultation 550 10 CONTENTS. ' " ' SECTION I. , , , . DISEASES OF THE STOMACH. PAGE General Consideratrons 550 Loss of Appetite 565 Excessive Acidity of the Stomach 556 Flatulency 557 Nausea and Vomiting 558 Pain . 565 Diseases of the Stomach in which Pain and Soreness at the Epigastrium, and Vomiting, occur 571 Acute Gastritis 571 Chronic Diseases attended with Pain , Epigastric Tenderness, and Vomiting 574 Chronic Gastritis 575 Gastric Ulcer 576 Gastric Cancer 582 Dilatation of the Stomach 590 . SECTION II. DISEASES 01' THE INTESTINES AND OF THE PEKITONEUM. General Considerations 593 Alvine Discharges . . ; 593 Diseases attended with Paroxysms of Pain referred chiefly to the Middle or Lower Part of the Ahdomen, and not associated with Marked Tenderness or with Fever 596 Colic 596, Diseases attended with Pain and Marked Tenderness in the Umbilical Region or diffused oVer the Abdomen 606 Acute Enteritis 606 Acute Peritonitis 609 Chronic Peritonitis' : ; . . 621 Diseases attended with Pain and Tenderness in the Eight Iliac Fossa . . 622 Appendicitis .'.;.:;..;........ . 622 Disorders attended with Constipation, and' of which it is- a Prominent Symptom. ;............•.... 630 Intestinal Obstruction 630 Habitual Constijjation ;...;;.............. 641 Disorders in which Morbid Discharges from the Bowels occur 643 Diarrhoea g43 Dysentery 648 Intestinal Hemorrhage, or Melaena 651 Patty Diarrhoea 653 Diseases attended with Vomiting and Purging , . 653 Cholera Infantum , . , , , 654 Cholera Morbus 655 Cholera , , . 656 CONTENTS. 11 SECTION III. DISEASES OE THE LIVEB. PAGE General Considerations 661 Jaundice 662 Acute Diseases of the Liver attended generally with Slight Enlargement , . of the Organ, and with more or less, though rarely very much 7 - Jaundice 667 ^ Acute Congestion 667 Acute Hepatitis 667 Inflammation of the Gall- Bladder and Gall-Ducts 67B Acute Diseases characterized hy a Decrease in the Size of the Liver and by Deep Jaundice 676 Acute Yellow Atrophy 676 Chronic Diseases attended with Enlargement of the Liver, and with slight or no Jaundice 679 Chronic Congestion . 679 Chronic Hepatitis 681 Abscess of the Liver 682 Patty Liver 688 Waxy Liver 688 Cancer of the Liver 690 Hydatids of the Liver 697 Chronic Diseases attended with Decreased Size of the Liver, and with Abdominal Dropsy . . . . " 702 Cirrhosis 702 Chronic Atrophy of the Liver 709 SECTION IV. ABDOMINAL ENLARGEMENT. General Abdominal Enlargement 710 Ascites 710 Chronic Tyrhpanites . ' . 717 Partial Abdominal Enlargement 718 Abdominal Tumors • . 718 SECTION V. ABDOMINAL PULSATION. Aortic Pulsation 781 Abdominal Aneurism 732 12 CONTENTS. CHAPTER VII. ON THE URINE, AND ON DISEASES' OP THE URINARY ORGANS. PAGE TJrine 736 Color 740 Specific Gravity 740 Reaction 742 Changes in the Quantity of the more Important Constituents . . . 744 Presence of Abnormal Substances in the Urine 757 Sediments 782 Urinary Organs 784 Diseases of the Kidney of which Pain is a Prominent Symptom . 784 Nephritis 784 Nephralgia 785 Diseases marked by an Albuminous Conditition of the Urine, associated with more or less Dropsy 791 Acute Bright's Disease 791 Chronic Bright's Disease 798 Diseases associated with'Purulent Urine 814 Acute Cystitis 815 Chronic Cystitis 816 Abscess of the Kidney . 816 Pyelitis 819 Disorders in which a very large Amount of Urine is discharged .... 823 Diabetes 823 Chronic Diuresis 826 Disorders in which little or no Urine is discharged 828 Suppression of Urine 828 Eetention of Urine 829 CHAPTER VIII. DROPSY. Dropsy, according to its Seat and Extent 830 Dropsy, according to its Causation 832 Dropsy, according to the Eapidity of its Development 835 CHAPTER IX. DISEASES OP THE BLOOD-VESSELS. Diseases of the Arteries 836 Arteritis 836 Atheromatous Changes 838 CONTENTS. 13 PAGE Diseases of the Veins 839 Phlebitis 839 Diseases of the Capillaries 840 CHAPTER X. DISEASES OF THE BLOOD. General Considerations 842 Ansemia 855 Pernicious Anifimia . 857 Leukaemia 863 Addison's Disease 869 Pyaemia r • • 872 Septicaemia 876 Thrombosis and Embolism .' 877 Scurvy 884 Purpura 886 CHAPTER XL RHEUMATISM AND GOUT. Acute Rheumatism 889 Chronic Rheumatism 894 Gout 898 Rheumatic Arthritis or Rheumatic Gout 900 Rickets 902 CHAPTER XII. EEVERS. General Considerations 906 Continued Fevers 908 Simple Continued Fever 908 Catarrhal Fever 909 Typhoid Fever 913 Typhus Fever 929 Cerebro-spinal Fever • 937 Relapsing Fever 944 Periodical Fevers 948 Intermittent Fever 948 Remittent Fever 954 Congestive Fever 963 Yellow Fever 969 14 CONTENTS. PA6B Eruptive Fevers . . . , 976 . S.carlet Fever 976 .Measles. , 981 Rubella 985 Smallpox 988 Dengue 994 Erysipelas 996 CHAPTER XIII. Diseases oe the. skin. General Considerations . . . . . . ^ 1 . . . i 1 . . 1000 Erythematous Diseases 1 1003 Papular Diseases' '. I ............. ^ ........ . 1005 V.esiciilar Diseases .."........... 1007 Bullous "Diseases .."... 1010 Pustular Diseases ......'.'.'.'.... 1011 Squamoiis' Diseases' . . 1 1 ^ . . ; . . '. 1 . . ; 1 i . . . . . . . 1013 Maculie 1015 New Growths 1016 Hypertrophies 1017 Parasitic Diseases 1020 Altered Gland-secretions 1023 Nervous Affections, , , . 1025 CHAPTER XIV. POISONS AND PARASITES. Poisons 1027 Acute Poisoning 1027 Irritant Poisons . . 1028 Narcotic Poisoning 1032 Chronic Poisoning . . . . 1038 Parasites j ....... 1048 Vegetable Parasites 1049 Animal Parsisites 1050 Index , 1067 LIST OF ILLUSTRATIONS. FIG, 1. 2. 3. 4. 5. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18, 19, '20, 21, 22, 23 24, 25. 26, 27, 28. 29, 30, 31, 32 33 PAGE Sphygmograph of Marey ... 39 Dudgeon's Sphygmograph ... 40 Sphygmogram enlarged .... 41 Self-registering Thermometer . . 44 Seguin's Surface Thermometer . 44 Surface Thermometer, with coil at extremity 44 Temperature Chart in Simple Continued Fever 47 Temperature Chart from a Case of Remittent Fever 48 The Centres in the Human Brain 60 Right Homonymous or Lateral Hemianopsia 62 The .ffisthesiometer 78 Mathieu's Dynamometer .... 108 Laryngoscopes 268 Laryngoscopic Examination . . 269 Laryngeal Image, as seen in the Laryngoscope 270 The Stethometer 301 The Stetho-Goniometer .... 302 The Pleximeter 304 Percussion Hammer 306 The Ordinary Stethoscope . . . 311 Hawksley's Stethoscope .... 311 The Double Stethoscope .... 312 The Differential Stethoscope . . 312 Diagram illustrative of the Main Forms of Feeble Respiration . 315 Diagram illustrative of Rales . 321 Elastic Fibres of Pulmonary Tissue 340 A Spiral Magnified 340 Charcot-Leyden Crystals .... 341 Tubercle-Bacilli in Sputum . . 343 Tubercle-Bacilli (in colors) . . . 344 Casts from a Case of Plastic Bron- chitis 365 Appearance of the Chest in Em- physema 357 Beginning Infiltration in Phthi- sis 365 FIG. PAGE 34. Cavities in the Lung in Phthisis 367 35. Temperature Chart in Pneumonia 389 36. Diagram illustrative of Perfect Pulmonary Consolidation, such as happens in the Second Stage of Pneumonia 391 37. Temperature Chart in Broncho- Pneumonia 397 38. Diplococcus Pneumoniaa of Fraenkel 399 39. Pneumococcus (Diplococcus) of Friedlander 400 40. Roughening of the Pleura from Inflamma.tion 404 41. Large Effusion occupying the Left Pleural Cavity 405 42. Physical Signs of Pneumothorax 412 43. Topography of the Heart ... 429 44. Diagram showing the Points at which the Separate Valves maj' be listened to 436 45. Position of the Heart, and Dis- tention of the Pericardium with Fluid, in Pericarditis . , 469 46. Hypertrophied Heart, lying in its Position in the Chest .... 480 47. Dilated Heart, the Right Ventri- cle opened . . . , 484 48. Narrowing of the Aortic Orifice by Vegetations 494 49. InsufBcient Mitral Valves per- mitting Regurgitation of the Blood 496 50. Sphygmogram of Aortic Insuffi- ciency 498 51. Sphygmogram of Mitral Regur- gitation 498 52. Klebs-Loeffler Bacilli 625 63. Results of Abdominal Percussion 548 54. Sarcinse Ventriculi 561 65. Comma-Bacillus of Koch, from Culture in Blood-Serum . . . 658 56. Doremus's Ureometer 746 15 16 LIST OF ILLUSTEATIONS. FIG. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 70. 71. ?2. 73. 74. PAGE Greene's Ureometer 746 Crystals of Uric Acid 749 Mixed Urates 751 Earthy Phosphates in the Urine . 753 Calcium Oxalate Crystals . . . . 759 Albumin Test-Glaas 769 Pus-Corpuscles 779 Epithelial Casts and Cells from the Kidneys in a Case of Acute Bright's Disease 792 Fatty Casts and Epithelial Cells filled with Fat, as seen in Dis- charge from a Fatty Kidney • . 807 Hyaline or Waxy Casts from the Urine 809 Granular Casts, or Casts co^^ered with Disintegrating Epithe- lium and Granules • 810 Artificial Capillary of Malassez. Magnified 100 Diameters . . 844 Potain's Pipette 845 Graduated Moist-Chamber of Malassez 846 Blood-Mixture, as seen with the Square Micrometer Ruling of the Moist-Chamber of Malassez 847 Daland's Hsematokrit 848 Haemoglobinometer of Gowers . 852 Chart showing Blood Changes in Chlorosis 854 FIG. PAGE 75. Blood in Pernicious Anaemia . . 860 76. Temperature in a Case of In- fluenza 911 77. Temperature in Typhoid Fever . 916 78. Eberth-Gaffky's Typhoid-Fever Bacillus, from a Potato Culture 917 79. Spirilla of Relapsing Fever . . 947 80. Temperature in Tertian Inter- mittent Fever 951 81. Temperture Chart in Remittent Fever 955 82. Pigment in the Blood in Malarial Cachexia 960 83. Hsematozoa of Malaria .... 962 84. Temperature in Yellow Fever . 972 85. Temperature in Variola .... 990 86. Temperature in Varioloid . . . 994 87. Temperature Chart in Facial Erysipelas 997 88. Aoarus Scabiei 1021 89. Segments of Taenia Solium . . .1053 90. Heads of Tsenise 1053 91. Trichina in Recent Human Muscle 1057 92. Trichina Capsule with Shell-like Calcareous Deposits 1058 93. Encapsuled Chalky Concretions in Muscle, due to Trichinae . . 1059 94. Trichina Spiralis. Magnified 300 times 1061 MEDICAL DIAGNOSIS. INTEODUCTION. GENEKAL CONSIDERATIONS. The study of any complicated subject leads of necessity to its arrangement into branches. Closely connected as these are, and forming always parts of a whole, they are not only capable of distinct treatment, but frequently become more intelligible as they are so treated. This is made very manifest in investigating dis- ease. The extent of ground covered by the inquiry has rendered it imperative to map it out into various provinces, which, however intimately united, may be with convenience separately surveyed. One comprises the laws and facts common to individual affec- tions ; in another are gathered together all relating to their causes ; another embraces the consideration of their detection and the full recognition of their nature. It is the purpose of these pages to examine this department somewhat minutely, and especially that portion of it coming within the range of the practitioner of med- icine. In so doing it will become apparent how diagnosis, for such the distinction of disease is technically called, is partly a science, partly an art ; a science, because it comprehensively takes account of general facts, and of principles based on those facts ; an art, because it demands a cognizance of the means, and their application to arrive at the desired result. To consider, then, medical diagnosis in all its bearings, it will be necessary not only to hold up to view the morbid states met with in the examination of the sick, but also to inquire in what manner they may be most readily recognized and explored, and '! how their differences may be made available in the discrimination 2 17 18 MEDICAL DIAGNOSIS. of one ailment from another. In a study of this kind, an inves- tigation of symptoms plays unavoidably a prominent part. In truth, the detection of disease is the product of close observation of symptoms, and of correct deduction from these symptoms. The first requirement therefore for an accurate diagnosis is to learn to recognize morbid signs. But the art of observation this implies is not easy, and cannot be thoroughly acquired except by practice. No one aspiring to become a skilful obsei-ver can trust exclusively to the light reflected from the writings of othei-s : he must carry the torch in his own hands, and himself look into every recess. The knowledge obtained from reading is, however, serviceable in this way : it aids in overcoming one of the main difficulties at first experienced, — to know where to look and what to look for. There are in almost every affection some symptoms which can hai-dly escape the merest beginner; but also some which do not appear on the surface, and which to find taxes the skill of the experienced physician. And it is especially in this search after hidden signs that medical information as well as cul- tivated tact is demanded. Now, to recognize the manifestations of disease, whether they are or are not readily perceptible, we have to employ our eyes and ears, our sense of touch and of smell. Formerly we could go no further than these senses unassisted would carry us. But science has lent its aid, and furnished means by the help of which we can detect clearly what before we could not detect at all, or of which at best we caught only a glimpse. We now possess instru- ments of precision by which we ascertain with accuracy the size of organs and their play. With thermometers we tell the degree of heat of various parts of the body. Specific-gravity bottles, and other measures devised for the purpose, inform us of the relative gravity of fluids. The microscope gives at a glance insight into matters which the naked eye fails even to perceive, shows us crystals in secretions, enables us to count the corpuscles in the blood, and to detect minute and disease-causing speciflo organisms. The laryngoscope demonstrates the appearance and the movements of the organ of speech. The ophthalmoscope informs us of the state of the vessels in the brain. And chem- istry, with its marvellous teachings, is rendering our knowledge of many morbid states amazingly complete. Then the sagacity GENERAL CONSIDERATIONS. 19 of comparatively modern times has taught us to enlist the sense of hearing, and has demonstrated how a disciplined ear may detect the workings of disease in cavities into which the eye can- not penetrate. The effect of all these improved methods of study has been to give an immense impetus to clinical research, and to lead to the construction of a solid groundwork of experience in striking contrast with the looseness of former times. The advance in diagnosis thus attained forms, indeed, one of the most pleasing portions of medical history. When, by means of the aided or unaided senses, the symptoms of the malady have been discovered, the next step toward a diag- nosis is a proper appreciation of their significance and of their relation toward one another. Knowledge and, above all, the exercise of the reasoning faculties are now indispensable. The dailj' habit of investigating disease ; a scrutinizing study of the anatomical lesions ; chemistry, with its most searching analyses ; the microscope, with the wonders it reveals, — are all of little use, unless we have been taught the necessity of placing in connec- tion with one another the morbid signs they lay bare, and of considering in individual cases their respective value. Were it otherwise, the science of diagnosis would be simply a matter of memory. It is, however, this very analysis of symptoms and the lengthy process of induction attending it which make med- ical diagnosis so difficult and so unattractive to the beginner. He sees that by reflecting and reasoning on what are frequently but indirect manifestations he must find the seat and nature of disorders hidden from his view. Nor is it reasoning on the ascerta,ined facts alone that is required ; the premises may be but probabilities ; for, in truth, diagnosis deals at times with the logic of probabilities as much as with the logic of patent facts. Now, we are greatly aided in appreciating morbid signs, and in interpreting them correctly, by already existing knowledge. We look to landmarks which our predecessors have erected, and the gradually accumulated science of semeiology, rightly employed, furnishes the clue to the discovery of the disease. Thus the stores which medicine has laboriously collected during centuries can be used with advantage by all, and exist for the good of all. But an acquaintance with semeiology is far from being the sole guide to diagnosis, nor does it at once help to a recognition of the 20 MEDICAL DIAGNOSIS. malady. There are few symptoms in themselves distinctive ; and often a symptom may be due to one of several causes. Semeiology informs us of these different causes ; but to find out the precise meaning of the abnormal manifestation in an individual case, we have to draw our inference from all the signs encountered; to compare them with one another ; to seek out those that are in the background. We are thus arriving, step by step, at the explana- tion of the morbid appearances, the starting-point in deduction always being what is known of the affection the presence of which is suspected, and the symptoms of which we are contrasting with those before us. For the conclusion to be valid and exact, it is of course requisite that each part of the testimony have the proper position assigned to it. In reasoning correctly on symptoms, the same laws apply as in reasoning correctly on any other class of phenomena : the facts have to be sifted and weighed, not merely indiscriminately collected. And while this intellectual act is being performed, much collateral evidence is to be sought before a final judgment is given ; especially is it necessary to view the symp- toms with constant reference to the age, sex, and habits of the patient, and to the circumstances amid which the disorder develops. To accomplish all this effectually, the physician has need of much and varied knowledge. He must be master of something more than of the information supplied to him by semeiology. He must be an anatomist to pronounce with certainty on the seat of the malady ; a physiologist to appreciate the state of the great centres and the aberration of function. Above all, he must be a pathologist in the full sense of the term : he must understand the antagonism between diseases ; the frequency with which they coexist ; the influence of remedial agents on them ; and be cogni- zant of their natural history and of the general laws governing them, — for how else can he form an estimate of morbid action while in progress ? Then it is desirable that he should be awai'e of what are their current divisions and classifications. From what has ali-eady been represented, it is evident that he must also be a correct reasoner ; for even a good observer will, by bad reasoning, arrive at a faulty diagnosis ; just as sometimes a bad observer may, by the same process, blunder into the truth. There is, indeed, no end to the extent of knowledge which may be brought to bear in working out a conclusion regarding the char- GENERAL CONSIDERATIONS. 21 acter and seat of a malady. The habit of observation once ac- quired, information of the most varied kind will, by an accurate reasoner, be made tributary to the completeness of the diagnosis. Every fresh acquirement tends to enlarge our powers of insight. Just as in nature, the higher we ascend, the more fully lies the view before us. Having thus indicated the elements of a thorough diagnosis, we may next inquire in what way this is most easily arrived at when at the bedside. The main facts of the case on which the deductions are to be based are of course first elicited. We lay hold of these main facts, and especially of those that are the most direct signs of the morbid action. They are coupled together, and the inquiry is started as to what organ they indicate as the seat of the malady. This often has been already deter- mined by the very method of the examination ; and we therefore proceed at once to investigate the precise nature of the disorder by analyzing the symptoms and the previous history. Some- times, however, the site of the disease does not admit of being definitely fixed upon, or we can only in a general manner decide upon the function impaired. Again, as in idiopathic fevers, we may find no signs of local disease, — merely those of a general disturbance. In any of these instances clinical experience steps in to explain the phenomena as far as possible, and to inform us in what affections they occur. It may be only in one ; then the desired goal is at once attained. But, as above stated, there are few signs in themselves pathognomonic. It is therefore to be ascertained which one of the disorders is before us that special pathology teaches may yield the symptoms encountered. One of these is taken up. Its symptoms are placed side by side with those present. They accord in some respects, but not in all. Moreover, in searching for some of the phenomena which the supposed malady gives rise to, these are not found. The view is abandoned, and another taken up. It agrees in all particulars. The diagnosis is made. Yet, when the diagnosis is thus arrived at, we have still to determine, before it can be considered as com- plete and can be acted upon, whether or not any other morbid state exists, and to take into account the patient's general con- dition and his individuality. To cite a case in illustration. A person consults us for a cough 22 MEDICAL DIAGNOSIS. brought on by exposure. He has been ill for four or five days, having been previously in good health. "We notice, on examining him, that his breathing is hurried, and that he has fever ; the lower portion of one side of the chest is dull on percussion, and the respiration there is wanting ; the action and sounds of the heart are normal. The facts point to the lung or its covering as the seat of the malady. "We know, furthermore, from the his- tory and the febrile symptoms, that we have to deal with an acute affection. "What are the acute pulmonary affections ? . Acute bron- chitis ; acute phthisis ; acute pleurisy ; acute pneumonia. In all occur fever, cough, and disordered breathing. Is it acute pneu- monia ? No ; for, notwithstanding there is in this complaint, in addition to the general symptoms mentioned, dulness on per- cussion, the dulness is associated with a blowing respiration ; whereas in the case before us no respiration is heard. Let us look at the sputum, and see if it be tenacious and rusty-colored. It is not ; it is thin and frothy. But acute pleurisy may explain all the signs. The patient, too, when questioned, states that he had at the onset a sharp pain in his side ; and this, we are aware, takes place in pleurisy. The vocal vibrations, likewise, are no- ticed to be absent on the affected side of the chest, which, when measured, is found to be enlarged. This corresponds in all points with what happens in pleurisy in the stage of effusion. The dis- ease is, therefore, acute pleurisy in the stage of effusion. We finish the diagnosis by ascertaining the existence or non-existence of other maladies, and by taking note of the severity of the com- plaint ; that it has occurred in a young and robust person of good habits ; and that the symptomatic fever is very active. This process of arriving at an opinion is the simplest. It is one in which the investigation of the case is to some extent car- ried on while the deductions are being made. And it is astonish- ing how rapidly it may be performed by habit. The mind works unconsciously, and a decision is, to all appearance, formed intui- tively, which surprises the inexperienced by its readiness and pre- cision. This method aims, so far as the symptoms permit, at a direct diagnosis. But, in truth, it is often what is called differen- tial: that is, it takes cognizance of and dwells on the essential signs by which one disease can be discriminated from another resembling it. GENERAL COXSIDERATIOXS. 23 Sometimes, Instead of attaining the desired result in the manner proposed, we are obliged to judge of the nature of the malady entirely by finding out what it is not. The various diseases ca- pable of producing all, or even some, of the striking symptoms observed, are enumerated. They are one by one considered and set aside, until by this process of pure exclusion the mischief is bi'ought to light. Thus, to use again the example just given, we should have to assign reasons why the disease is neither acute pneumonia, nor bronchitis, nor acute phthisis, and in this way determine it to be acute pleurisy. But to pi'ove what a thing is by proving all that it is not, is a very tedious process, and we must be quite certain that really all morbid states which may give rise to the symptoms encouutered are thought of and inquired into ; otherwise our conclusion may be fallacious, though reasoned out in the most logical manner. Moreover, our knowledge of many pathological conditions is so imperfect that we are not fully cog- nizant of, or able at once to discern, the more characteristic signs ; nor can the symptoms be taken hold of and arranged in such a way as shall permit us to make nice distinctions without a lengthy and laborious plan of procedure. Owing to these drawbacks, diagnosis by exclusion is not, on ordinary occasions, much em- ployed, nor, indeed, is it to be recommended. Yet in difficult and obscure cases, where the accustomed pathway is blocked up, it may enable us to pass by obstacles otherwise insurmountable. But can we by this or by any other road always reach a certain diagnosis ? We cannot, and for several reasons. The patient may deceive us, wilfully or unintentionally. It may be necessary, for the confirmation of the opinion formed, to obtain an accurate his- tory of the case, and circumstances may render this impossible. The disorder may be so rare that its symptoms are not understood. There may be several lesions present, the signs of one masking or neutralizing the signs of the other. The first of the causes mentioned is a source of error difficult to guard against. To escape punishment, to avoid disagreeable duty, to excite compassion, to obtain a compliance with unreason- able wishes!, or sometimes from the mere love of deception, symp- toms may be stated to exist which do not exist, or may be imitated and artificially produced. Persons who thus feign disease are nu- merous. They are found in all occupations and in all classes of 24 MEDICAX DIAGNOSIS. society. They abound in the army and navy. Hysterical women and hypochondriacs help to swell the list. These, indeed, suffer mostly some inconvenience, but exaggerate it immensely, and, by deceiving themselves, end by deceiving, unless he be on his guard, their physician. On the other hand, disease actually in progress may be carefully concealed from motives of delicacy or from fear of the consequences. An incorrect diagnosis from want of a proper history does not, on the whole, occur often. Patients are generally very willing to give a full account of themselves and of their distresses. Some- times, however, the reverse happens. Pain or mental anxiety and sorrow may be wearing the body out while the sufferer obstinately persists in hiding the cause of his waning health. We meet also with individuals so stupid that the most elaborate cross-examina- tion fails to elicit anything like a connected history. Again, we may be unable to do so from the patient having lost the power of speech. A man is brought into a hospital unconscious. It is of the utmost importance to know how long he has been in this state, and what were his prior symptoms : unless some friend can supply the information, the most valuable diagnostic data are wanting. In the rarity of a disease we have a serious drawback to its recognition. This may occasion an error of diagnosis in a two- fold manner. The more distinctive symptoms may be so little understood, and the prominent features be so nearly identical with those of a malady with the manifestations of which we are well acquainted, that a conclusion of the presence of the latter forces itself almost immediately on the mind. Or, the disoi'der may give rise to phenomena wholly unknown, nothing but the autopsy revealing their true meaning. Every physician encounters such cases. It is true that the progress of science and the aggrega- tion of clinical facts are from year to year bringing them into a narrower circle. Yet, are there not still diseases, nay, groups of diseases, that have eluded discovery to the manifold means of research of the present day, as they have to the accumulated experience of the past? But the most serious obstacle to a precise diagnosis lies in the fact that frequently lesions coexist. Disease is a very complex state, and when one portion of the economy gets out of order, an- other is apt to follow. How close, for example, the connection GENERAL CONSIDERATIONS. 25 between affections of the heart and affections of the kidney ! Here it is comparatively easy to arrive at a conclusion, since we have the means of judging accurately of the condition of both organs. But there are instances in which it is very difficult, as when a part contiguous to one chronically affected is attacked with acute disease. A person applies for relief, presenting the symptoms of a severe local peritonitis. The inflammation spreads ; death re- sults. The exciting cause of the inflammation is discovered to be a structural alteration of one of the abdominal viscera, the signs of which were completely merged in the more marked signs of the recent inflammation. And this disguisement is effected not only by the supervention of another and more acute complaint, but also sometimes by the prominence of those remote sympa- thetic derangements which an affection of any viscus may produce. Thus, the disturbed action of the heart in dyspeptic persons throws at times the symptoms of the gastric malady into the shade. Yet it must be admitted that errors of diagnosis from this source are not apt to occur to the careful physician. A thorough examina- tion of the case is a safeguard against them. These, then, are the various causes which render a diagnosis imcertain, or wholly unattainable. Let us add to them one that does so temporarily. There are disorders the early manifestations of which are so much alike that it is next to impossible to tell with which of several we have to deal. In fevers this often happens. Here, however, a few days, or even less time, will almost always solve the difficulty. But not so in other diseases. It is only after a much longer period, and by careful watching of the patient, that the appearance or disappearance of a striking symptom, or the greater proniinence a hitherto indistinct sign assumes, inclines the scales toward one or the other of the affections between which judgment has been kept in suspense. In some such instances, the treatment becomes the touchstone of the diagnosis. Now it may be asked, Does this demonstrate that the diagnosis of a case is not necessary for its treatment? Not at all. It simply proves that we are sometimes obliged to aim at removing symptoms without understanding tlieir source. But it does not prove that if we understood their source we should not be better able to remove the symptoms. The physician who undertakes to relieve disease simply by attempting to allay its 26 MEDICAL DIAGNOSIS. symptoms, regardless of their cause, and without understanding their true relation and significance, is groping in the dark. His treatment is vacillating ; drug replaces drug ; alleviation is taken for a cure ; and the experience obtained is utterly untrustworthy. One great advantage, indeed, of attending carefully to diagnosis is, that it enables us to use remedies knowingly and with decision ; to appreciate what they are effecting ; to abstain from such as must be injurious. There is less needless meddling, more calmness; the treatment rises above the consideration of the moment, and takes into ^account what is for the patient's ultimate good. It is sometimes urged that the accurate detection of disease makes timid practitioners, and deprives them of confidence in medicines. More just is it to say that it shows how wide is the chasm between our acqvialntance with morbid conditions and our acquaintance with remedies; how far our skill to detect disease still outruns our power to cure it. There is undoubtedly, however, a danger which may arise from paying very minute attention to diagnosis. The study of it is so interesting, and capable of being conducted so entirely without reference to other points, and especially to the treatment of the complaint, that some minds are carried away, and, lost in the pur- suit of diagnostic knowledge, forget for what purposes chiefly this knowledge is profitable. Its main use is to enable us to fore- tell the course and probable issue of a malady, and to frame, with understanding, plans for its relief. Nor ought we ever to be unmindful how important it is, in basing the management of a disease on its diagnosis, to found that diagnosis on a general sur- vey of all the circumstances ; how necessary not to assign promi- nence to minor points ; and how the extent of the affection, the circumstances under which it has occurred, the sympathetic dis- turbances produced, and the vital state of the patient, belong, rightly considered, quite as much to the diagnosis as the recog- nition of the precise seat and exact anatomical character of the malady, and are, in truth, frequently its more important part. CHAPTER I. THE EXAMINATION OF PATIENTS, SYMPTOMS OF GENERAL IMPORT, AND SOME OF THE INSTRUMENTS EMPLOYED IN THE DIAGNOSIS. To elicit the facts of a case by a careful examination is, as has been stated, the first requisite for diagnosis. To conduct, however, a clinical inquiry with precision and facility, requires continual practice, and is rendered easier by following some well-digested plan. The advantage of adopting a method is clearly seen, if the attempts of a beginner be watched. He wanders in his search from one part of the body to another, attracted by different symp- toms in turn ; pointless question succeeds to pointless question ; and a conclusion, almost certainly erroneous, is finally jumped at, or an acknowledgment made of inability to arrive at any. Now, there are several ways which have been proposed to over- come this embarrassment. One of the principal consists in first questioning the patient with regard to his history. His age ; his occupation ; the diseases from his childhood up ; his habits ; his constitution ; the affections hereditary in his family, — are all minutely inquired into. After this the origin and progress of the existing disorder are traced, and the remedies ascertained that have been used against it. The present condition is then ex' plored ; each organ or each system being in turn interrogated. The investigation is now regarded as complete ; the facts are con- sidered, and the diagnosis, prognosis, and treatment determined. This method of examining is termed the synthetical or historical. The analytical reverses the order. The present condition is first ascertained, and subsequently the patient's history or anamnesis. Both of these courses have something to recommend them, and to both there are objections. The synthetical method is the more purely scientific ; but it is too full, and calls for too much labor, to meet the requirements of ordinary professional life. It is 27 28 MEDICAL, DIAGNOSIS. much better adapted for recording cases in the pursuit simply of pathological knowledge, and decidedly the best where the histoiy is obscure and the symptoms are ill defined. The plan which I habitually prefer is to take a general survey of the history and of the prominent symptoms, and, having thus obtained some clue to the part most likely to be affected, to explore this with care. For instance : we are brought to the bedside of a patient for the first time ; we inquire how long he has been ill ; how that illness began ; in what way he is now disturbed, — whether he has pain, or what is the main source of his annoyance. While questioning him, we are scanning his appearance, the position of the body, his movements, his manner of breathing. The hand is applied to the skin ; the pulse is felt ; the tongue is looked at ; the tem- peratm-e is taken. Partly from this examination and partly from the history, some organ is fixed upon to be specially investigated : say pain in the epigastric region and vomiting are complained of, — our attention is directed to the stomach. We explore this organ, its physical state and its functions. Then we look to the parts that are anatomically or physiologically most nearly related to it, which are, in the case cited, the intestines and the liver. The examination is completed by -taking heed of the condition of other portions of the body ; by reviewing the history of the case ; and by endeavoring to elicit fully such points as bear upon the diagnosis, which the mind, consciously or unconsciously, has already begun to frame. Then a balance between the symptoms is struck, tiie diagnosis is recast, modified, or extended, and the treatment is decided upon. There is some repetition in this plan, but it is the one which appears practically the most suitable. It has the advantage of bringing together the marked features of a case, and especially those most clearly indicative of the general or vital condition. But whatever scheme be chosen, it should, for us to become pro- ficient in it, be as constantly and closely adhered to as the varying circumstances of disease will permit. Yet to acquire thoroughly the habit of examining with accuracy and care, and also to obtain the full fruits of experience, it is indispensable to keep written records. This, too, should, so far as possible, be done according to a uniform design, since it both prevents us from overlooking important symptoms and enables cases to be more readily com- EXAMINATION OF PATIENTS, ETC. 29 pared. I subjoin a schedule that is based on the plan of exami- nation just mentioned. Date of Examination ; Name ; Age ; Color ; Place of Birth ; Present Abode ; Occupation or social state ; In females, whether married or not, number of children, and date of last confine- ment ; how many miscarriages. HiSTOKY. 1. History antecedent to present disease: Constitution and General Health — Hereditary predisposition — Previ- ous Diseases or Injuries or Taints — Habits and mode of life ; hygienic influences to which exposed, etc. 2. History of present disease : Its supposed exciting cause — Exposure to contagion — Date of seizure — Mode of invasion ; subsequent symptoms in order of suc- cession — Previous treatment. Present Condition of Patient. Height and Weight. 1. General symptoms : p . . f in bed — mode of lying , 1 out of bed — movements ; gait and station, of body ; . of countenance ; Skin ; Pulse ; Temperature ; Eespiration — as to frequency, character, etc. ; Tongue ; {appetite ; thirst ; condition of bowels ; General State of Urinary Secretion and Urinary Analysis ; Sensations of patient : pain, etc. Examination of special regions, parts, and functions, beginning with the one presumably the most aifected, and embracing, whenever practicable, microscopical examination of the blood and bacteriological studies. Aspect < 30 medical diagnosis. Diagnosis. Treatment. Remarks. The history is here placed first ; then the symptoms of general import, such as those furnished by the pulse, the tongue, and the temperature, are made to precede the examination of special regions. These general symptoms are of great value in the recognition of disease, and of yet greater value in determining its treatment. They are more than the mere physical signs of textural affections ; they indicate vital conditions, and partly from their importance, and partly from their not being linked to disease of any organ in particular, they demand a separate and detailed consideration. Position of the Body. — By noting whether the patient is in bed or out of bed, — ^how he lies, or how he walks, — a general idea may be formed as to the acuteness of an attack, the impairment of strength it has produced, and sometimes even as to its nature. Let a person who has been actively attending to his usual occupation be suddenly confined to his bed, and the inference that the disease is an acute and a severe one will be commonly correct ; certainly so, if no mishap to the organs of locomotion have necessitated a resort to the recumbent position. When the patient lies for a long time on his back, it is generally from exhaustion, or from paralysis, or it is owing to the pain which pressure or motion of any kind occasions. Such is the cause of the dorsal decubitus in peritonitis, and in rheumatism. Lying steadily on the back with a dispo- sition to slip down in bed is a form of dorsal decubitus witnessed in low fevers. Lying fixedly upon one side may, as a rule, be looked upon as an indication that the action of the lung of this side is impeded, and that the respiration has to be carried on with the other. The patient may be confined to bed, yet unable to lie down in it, on account of the distress in breathing to which the recumbent posture gives rise : he leans forward, or sits erect. This necessity of breathing in the upright position, or " orthop- noea," is a form of dyspnoea encountered especially in diseases of the heart, or where fluid is effused into the air-cells or into both pleural cavities. If a person is able to be about, his posture and movements be- come impoi-tant manifestations of his condition. The youncr and the strong walk erectly, quickly, and firmly ; the aged and the EXAMINATIOX OF PATIENTS, ETC. 31 weak, stoop: ngly, slowly, and with difficulty. In diseases of the spine the body is bent ; so, too, in affections of the larger joints of the lower extremities. When, after a fever or any other prostrating malady, the patient leaves his bed, he totters, moves slowly, and is soon obliged to rest : returning strength brings with it a quicker and steadier gait. In some diseases of the brain the movements are very uncertain ; in one-sided palsy the affected side lags, or its motions, if it can be moved at all, are laborious. Excessive and uncontrollable move- ments are observed in mania and in chorea; trembling motions in states of extreme debility, in shaking palsies, and in the de- lirium of drunkards ; irregular motions and positions chiefly in hysteria. The gait is always to be closely studied. "We find it of special significance in affections of the nervous system and of the muscles. It is very erratic, from side to side, in locomotor ataxia, and there is almost total inability to walk in the dark. In paralysis agitans the tremors are associated with a festinating gait, each stej) be- coming more rapid than the last, and a fall is only averted by seeking support. In spastic paraplegia the legs drag behind ; in walking each leg is rigidly brought forward, the toes having a tendency to catch the ground. In pseudo hypertrophic paralysis occurs a peculiar oscillating or waddling gait, from weakness of the extensors of the knee and hips ; there is also much difficulty in rising from the ground. In Thomsen's disease it may also be for some time impossible to rise from the floor, and the gait is at first impeded by tonic spasm of the muscles. Station, or the power of preserving an erect position while standing, is often as characteristic as the gait. It should be noted while tlie eyes are open, while they are shut, and while the feet are placed alongside each other with the heels and toes touching. Under both the latter circumstances the station is always less certain and the swaying of the body more marked. Tested with an instrument invented by Weir Mitchell,* Hins- dale f found in the normal man and woman the average sway, while the heels and toes were touching, to be about an inch in the forward and backward line, and three-quarters of an inch laterally. * Amer. Journ. Med. Sciences, 1887. f Ibid., April, 1887. 32 MEDICAL DIAGNOSIS. Children sway to a greater extent than adults. Closing the eyes increases the sway about fifty per cent. In locomotor ataxia station is much disturbed and the sway greatly increased ; so it is in disease of the middle lobe of the cerebellum. In the attacks of aural vertigo all power of standing may be lost. General Aspect— Expression of Countenance.— The eye notices rapidly whether the body is bulky or wasted, and whether the surface is discolored or otherwise changed. A bulky aspect of the whole body is the result of corpulency, or arises from uni- versal anasarca. In some acute diseases, too, a general tume- faction may take place, — for example, in the exanthemata. A partial increase, or a swelling, arises from the local extravasation of fluid or air into the cellular tissues. If air, the tissues crepi- tate under the finger ; if fluid, the skin pits under pressure. A swelling may, further, proceed from an inflammatory thickening, or from a tumor or any morbid growth. A diminution in bulk is a more frequent symptom than an augmentation. It may take place very rapidly, as witnessed in Asiatic cholera. More generally the wasting is gradual, and is an indication of defective nutrition. It occurs in the course of protracted fevers, and in most chronic diseases. In slowly fatal maladies, and in those attended with constant discharges, — for instance, in chronic diarrhoea, — the loss of flesh reaches its highest point. Emaciation is most readily recognized in the face. But it is not the only striking alteration observable in the countenance when health has failed. There may be pallor, sallowness, a livid hue of the lips, a puffy appearance of the eyelids, a flush on the cheeks. Now, these changes in the features, added to the ex- pression which pain or special trains of thought produce, make up that peculiar physiognomy of disease so pregnant with mean- ing. But I shall not attempt to describe in detail the cast or the play of features in the sick : the shades of expression are so nu- merous that they baffle description, and are to be learned only by continuous bedside experience. I shall merely set down a few broad facts which this experience teaches. Among the countenances most frequently met with is that of apathy and stupor. The eye is dull and listless ; the face pale, or flushed with fever. This look is common in fevers of a low type, EXAMINATION OF PATIENTS, ETC. 33 and is often combined with blackish accumulations on the lips, gums, and teeth. Unnatural fulness and congestion of the features are sometimes observed in enlargements of the heart, and oftener still in habitual drunkards. The same aspect is seen in apoplexy and in typhus fever. Local congestions on the cheeks and nose are met with in obstructive diseases of the liver, especially in cirrhosis, and in the endarteritis of old persons. A pinched expression is found when there is intense anxiety or pain, or a wasting malady at- tended with constant suffering. It is specially observed in acute peritoneal inflammation. When very marked, and accompanied by change of hue, it is the face which Hippocrates has so graph- ically described. In the great master's own words, "a sharp nose, hollow eyes, collapsed temples ; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended, and parched ; the color of the whole face being green, black, livid, or lead-colored." This is the physiognomy of approaching death, and generally its speedy forerunner, except in those cases in which the expression proceeds from want of food, from protracted vigils, or from excessive discharge from the bowels. The face of shock, with its great pallor, its anxious or frightened look, and its fixed or oscillating eye, often with a contracting pupil, is a face seen after severe injuries, and as such familiar to the sur- geon. But in many of its main traits it may be also met with in diseases that make a sudden and overwhelming impression on the nervous system ; for instance, it is at times encountered in cerebro- spinal fever and in cholera. An aspect serious and dull on one side, while the other side is in full play, is witnessed in some instances of hemiplegia, and in paralysis of the facial branch of the seventh nerve. The differ- ence in the cast of the features may escape observation when the face is in repose, but as soon as an attempt is made to laugh, it shows itself plainly. Besides these lineaments, which may be said to be common to several diseases, we read frequently in the countenance the signs of special disorders. A dusky flush on the face, if associated with rapid breathing, is almost a certain indication of inflamma- tion of the lung. Puffiness of the eyelids in a pallid person is 3 34 MEDICAL DIAGNOSIS. most apt to be expressive of Bright's disease. A bluish color of the lips shows plainly that the venous circulation is interfered with, or that the blood is but imperfectly aerated. The cyanosis is also recognized in the blueness of the nails and the duskiness of the whole surface. Then there is the chronic pallor of the ansemias with the pearly eye and the yellowish tinge of the pallor in chlorosis ; the straw-colored, anaemic hue of malignant disease ; or we note the jaundiced, melancholy look of an hepatic affection ; the downcast expression and mobility of the features in hysteria ; the thickened upper lip, delicate skin, and fair complexion of scrofula; the sallow countenance and peculiar notched teeth that indicate inherited syphilis; and the various traits which tend to mark not only the special diathesis, but also the peculiar temperament, with the morbid tendencies that belong to it. Skin. — By the state of the skin we can, to a great extent, judge of the activity of the circulation and of the character of the blood. Moreover, it is a fair index of the secretions, and of the condition of the system at large. In fever, along with the quickened circulation, the temperature of the skin is increased ; the attending dryness is produced by defective perspiration. When, after pressure on the skin, the blood returns slowly to the surface, it denotes a sluggish capillary circulation ; when rapidly, an active one. Coldness of the surface indicates a weakened capillary circulation, and is met with at the invasion of acute diseases, and when the nervous power is under the sway of some highly deleterious influence. If the heat of surface succeed a cold skin, we know that reaction has taken place, that the circulation has again become active. Protracted coldness, whether attended with dryness or with clamminess, is of evil augury : it implies seriously diminished vital force. The cutaneous covering is pale whenever the blood is poor and watery. If this be seriously vitiated and largely deprived of its fibrin, as in putrid fevers, black spots are seen, due to extrava- sation. Ofttimes the surface is overspread with eruptions, some of which bear a close relation to disorders of internal organs, while others are connected with febrile or general maladies ; and others, again, are owing to a disease of the texture itself. Tension of the skin is met with in acute affections accompanied by active excitement. In wasting and prostrating ailments, on EXAMINATION OF PATIENTS, ETC. 35 the other hand, the skin feels very relaxed and soft ; and in those producing rapid emaciation, it is inelastic and lies in folds. Pulse. — The study of the pulse has come down to us with the sanction of centuries ; and to feel the beat at the wrist is still, in the opinion of many, as indispensable to the understanding of a case as it was thought to be by the Arabs and in the Middle Ages. Yet the advance of science has shaken the belief in the paramount importance of the pulse. It has shown that, although a most valuable means of information, it is not exclusively to be relied upon, and has proved the many divisions and refinements of the physicians of by-gone days to be imaginary and useless. Indeed, were even all their distinctions founded in fact, -we have now better ways of judging of many lesions than by feeling the radial artery. The pulse enlightens us on the action of the heart, and on the state of the artery itself and of the blood. In a healthy adult a beat of some resistance is felt, recurring from sixty-five to seventy-five times in a minute. It becomes slower with ad- vancing years, though it may rise in the very aged. The pulse of infancy is from one hundred and tea to one hundred and twenty ; that of a child three years old, from ninety to ninety-five. Warmth quickens the pulse ; so do rapid breathing, forced expira- tion, and the process of digestion. In the recumbent position and during sleep it falls. For purposes of comparison, the pulse should be, so far as possible, taken under similar conditions. At the bedside we study in the pulse its frequency, its rhythm, its volume and strength, and its resistance. Increased frequency of the pulse denotes increased frequency of the heart's action, and arises from any cause that excites the heart. Hence exercise, rapid breathing, mental emotion, or rest- lessness will occasion the number of beats to exceed the average of health as readily as fevers or acute inflammatory diseases. In great debility, too, the pulse rises ; and the more depressed the vital condition, the higher the pulse becomes. In exophthalmic goitre the pulse is generally very frequent, and rapid heart action may show itself without any other appreciable abnormal state, as in tachycardia, a disorder in which the pulse may considerably exceed two hundred beats in the minute. Under the influence of suggestion the cardiac action may be made very much more rapid 36 MEDICAL DIAGNOSIS. or slower.* As a sequel of influenza there is often very rapid heart action. The heart may thus quicken from so many and such varied causes, acting temporarily or permanently, that in- creased frequency of pulse, taken by itself, has no significant diagnostic meaning. A slow pulse, too, happens in many different states, — in cold, in exposure to wet, in icterus, in protracted convalescence from acute disease. It is also produced by an intense and prostrating shock, or is found coexisting with pressure on the brain, with melan- cholia, with atheroma, with fatty heart. A permanently slow pulse is also met with in in-itative lesions of the cerebral centres, among them in spherical or pediculated thrombi, in altered state of the circulation in the bulb, and in injuries to the pneumo- gastric. It is not unusual in instances of very slow pulse, or brachycardia, to observe two or three abortive beats succeediug a strong beat. In some persons the pulse is naturally very slow. The rhythm of the pulse is often perverted. Instead of the beats following one another in regular succession, they are unequal, or one or two intermit. An irregular pulse occurs from digestive disorder, from gout, from lithsemia, from the excessive use of tobacco, or from debility and nervous exhaustion ; it is less fre- quently the indication of a cerebral or cardiac lesion. It is some- times a difficult beat to count; and we must be careful not to regard at once a pulse as irregular because it appears to intermit. The seeming irregularity may be caused by the fingers slipping from the artery, which they are very apt to do after they have been on the vessel for some time. Where every other beat is uneven in size, thus showing a beat of greater, followed regularly by one of lesser, altitude, though the rhythm may be regular, we have the pulsus aUernans. Where a beat is dropped, — in other words, where the heart-beat is not transmitted to the artery with sufficient force to be felt, — it is designated as an abortive beat. Two imperfect or abortive beats occurring in rapid succession, and followed by a long pause and generally by a distinct beat, form a linked beat. The volume and strength of the pulse are of much more im- portance than either its rhythm or its frequency. Volume and * Sgobbo-Nuovo Eivista, 1 , 1892. EXAMINATIOX OF PATIENTS, ETC. 37 strength are often associated, and are much alike ; but they are not identical. When the beat of the artery is large, we call it a full pulse. This is owing to the distention of the vessel with blood, — its complete expansion with every beat of the heart. A full pulse is, therefore, the pulse of plethora ; the pulse of the young and robust in health, or in inflammatory diseases ; the pulse in the early stages of fevers, or in obstruction of the capillaries. It is usually a pulse of power, just as its opposite, a small pulse, is usually the pulse of debility. Yet a full pulse may be pro- duced by the distention of an artery which has lost its tone, and which the finger easily compresses. Such a pulse, the " gaseous pulse," a pulse really of low tension, denotes exhaustion, and proves that a full pulse and a strong pulse are not always synonymous. Into the idea of strength something more than mere fulness enters. A strong pulse is a pulse heightened in all its natural characters. It has more fulness, but, in addition, more impulse, and less compressibility, than an ordinary pulse. A strong pulse, therefore, indicates activity of the contraction of the heart, and a normal, perhaps increased, tonicity of the arterial coats. It is found in active inflammations ; also in hypertrophy of the heart. Its opposite, a weak pulse, betokens want of force, often want of healthy blood. It is generally small as well as weak. Yet as the full pulse is not always strong, neither is the small pulse always weak. The small, choked pulse of peritoneal inflammation may be fine and wiry, but it is not a weak pulse. We also find a small pulse of high tension in mitral stenosis and in contracted kidney. The resistance or tension of the pulse is another valuable guide in the appreciation of morbid action. Is the pulse hard and resisting ? is it soft and compressible ? are questions on the solu- tion of which the application of remedies may hang. A hard, tense pulse denotes increased contractility of the arteries, and high-wrought power. Be the beat full or small, slow or frequent, it tells us that the blood is being driven with force along the arterial system. But it also tells us that the irritation has im- plicated the coats of the arteries themselves, or that there is ob- struction in the capillaries. A tense pulse is met with in active, violent inflammations, and sometimes, though not often, in states of extreme and continued excitement without inflammation. It 38 MEDICAL DIAGNOSIS. is almost needless to add that changes in the coats of the arteries may also be a cause of a hard and resistant beat, the common cause of the increased tension in elderly people. Where no local alterations are present, and where no acute symptoms explain the sympathetic disturbance of the heart and arterial system, the high arterial tension will be commonly found associated with hyper- trophy of the left ventricle, with interstitial nephritis, with gout or lithsemia, or with blood-poisoning. The opposite of the hard pulse is the soft or compressible pulse. This implies deficient impulsion, and loss of tone in the vessel ; it is the pulse of low fevers, of debility, of cardiac weakness. But it is also, when following a tense state of the artery, the pulse which denotes returning health, and danger passed. In some persons the pulse has naturally a low tension, just as in others it has a high tension. When the pulse is of low tension, and at the same time fre- quent, it may show double beats with each contraction of the heart. This dicrotic pulse is most often met with in fevers of a low form and preceding or during the continuance of hemor- rhages. The rebound is chiefly due to the oscillation of the column of blood in the arteries, and is very much influenced by their elasticity. With lowered tension and increased elasticity of the tubes, dicrotism becomes obvious, especially with a rapid cir- culation. In old persons, in whom the coats of the arteries are inelastic, dicrotism is but feebly marked. Such are the meanings attached to the various characters of the pulse. Yet they do not often present themselves thus isolated. The following are usually combined, and bear this explanation : A hard, full, frequent pulse occurs in active inflammations, and in most of the acute diseases of robust persons. A hard pulse, foil or smallj bounding or not, if unconnected with acute symptoms, leads to the suspicion of cardiac or of renal disease, or of an affection of the artery itself. A tense, contracted, and frequent pulse is met with in a large group of inflammations below the diaphragm, as in enteritis, peri- tonitis, gastritis. A frequent pulse, full or small, but not tense, is the pulse of most idiopathic fevers, and with marked low tension is also apt to be dicrotic. EXAJIINATION OP PATIENTS, ETC. 39 A very frequent pulse, but very feeble and compressible, is the pulse of marked debility, of prostration, of collapse. A pulse frequent, and changeable in its rhythm, is produced, for the most part, by perverted innervation in connection with gastric disorders, by tobacco, or by disease either of the heart or of the brain. The appreciation of these different kinds of pulses requires con- siderable practice. But even this scarcely teaches us to estimate Marey'e sphygmograpb attached to the wrist. Its tracings are shown by the wbiLe liues uu lao black background. the exact degree of the alteration of the beat, certainly not with sufficient distinctness to convey to others an accurate idea, or even to be able ourselves to compare one observation with another. To attain these desirable results, instruments have been sought for by means of which the pulse can be examined with precision, its finer shades of difference recognized, and its movements re- corded. The best of these instruments is the sphygmograph invented by Marey, which registers not only the frequency and regularity but the form of the pulse-wave, and which may be also used in the study of the cardiac impulse and of pulsatile tumors. Slight irregularities that wholly escape the finger are, through its aid, discerned with facility, and we tell at once in how far these irregularities belong to one beat or to a succession of beats. Double beats with each contraction of the heart, too, not appre- ciable to the hand, are easily detected. Indeed, the sphygmograph proves the phenomenon of dicrotism to exist in almost every per- son. The rebound may occur during the systole or the diastole of the vessel ; and instead of one, there may be four or five of the secondary pulsations. The mode of adjusting the instrument, and of proportioning the pressure of the spring, has something to do with the kind of 40 MEDICAL DIAGNOSIS. delineation obtained. To secure greater accuracy, Sanderson fixed the centre button at a definite pressure, and Mahomed added several serviceable contrivances, one of the chief of which is the causing of the amount of pressure employed to be accurately registered upon a dial. Still another modification, which, how- ever, really makes use of a different principle, the displacing power of the artery rather than its lifting power, has been made by Holden. The movement thus obtained is from side to side. A sphygmograph marking extremely fine tracings is that of Pond. A rubber diaphragm takes the place of the spring of other sphyg- mographs, and is fixed to the artery by means of a holder. A delicate needle -makes the tracing. The sphygmograph of Dud- Fio. 2. Dudgeon'd sphygmograph. geon (Fig. 2) is simple and very much employed. The system of levers is the same as in Marey's, but the slip of paper moves in a different direction. To show the tracing distinctly, smoked glass or mica, or paper smoked over a lamp or by burning camphor, is much used ; and the tracing may be preserved by dipping it in an alcoholic solu- tion of shellac or of benzoin, or of a varnish of benzoin and methylated spirit, in the proportion of one to six. On every tracing the amount of pressure employed should be noted. Mani- fold have been the suggestions to obtam the steadiest application EXAMINATION OF PATIENTS, ETC. 41 of the instrument to the forearm and the greatest development of the tracing. Lorain * has proved that raising the arm to a vertical position gives a much more ample trace ; and Richardson f shows that with the body in the horizontal line, the dicrotic wave be- comes more prominent. When we apply the sphygmograph for clinical purposes, we study in its tracing the line of ascent, the summit, and the line of descent. Each pulsation is composed of these three parts. Tig- 3- The line of ascent, the upstroke, tells us the manner in which the blood enters the vessels. The more rapid the flow, and the more quickly the artery distends, the more strictly vertical the line. The force, too, is indicated by this line, or rather by its height : hence '^ , , 1 j^ 1 1 Sphygmogram enlarged, — a, b, upstroke, when tne muscles Ot the heart con- or llne of ascent ; a, l, c, percusBion-wave ; tract powerfully, either from en- "' ^' '■ '"^"^ "' P'-^d"='-<'"'= *^^'': <'. «■/• ■*■ ^ ' ^ aortic notch ; e, /, g, dicrotic wave ; /, g^ largement or from overaction, the diastolic period. line is both vertical and high. Yet the strength of the ventricular contraction is far from being the only cause influencing the amplitude of the tracing. Indeed, as we may note in old persons, a large volume of the artery gives considerable height to the lines of ascent ; so does a long interval between the pulsations, or the obstruction of the vessel below the point where the observation is made. Low tension in the arteries or in the capillaries has the same efi^ect ; whereas when the passage in the ultimate ramification of the vascular system is difficult, the lever descends slowly by a convex line, and is soon again raised by the next pulsation. When the contraction of the heart is feeble, the line of ascent is not vertical or high, but oblique and short. In aneurisms of the thoracic aorta — indeed, in an aneurism interposing anywhere between the heart and the radial artery — an oblique and short upstroke is also met with. The line joining the summit of a series of pulsations, or the maxima of tension, is generally a straight line ; a similar imagi- * Le Pouls, Paris, 1870. t The Asclepiad, 1886. 42 MEDICAL DIAGNOSIS. nary line connecting the bases, or the minima, is apt to run par- allel to it ; but irregularity of pulsation leads to irregular lines, and the lower line may be irregular while the upper is straight. Irregularity of the base line is seen in marked dyspnoea. The summit of the pulsation informs us of the time during which the entrance of blood balances the onward flow. A pointed, dis- tinct summit-wave belongs to vigorous contraction of the heart- muscle. The summit may be a horizontal line of some length. This broadening of the apex happens in high and prolonged arterial tension, such as from the slow contraction of a strong heart, fulness of the vessels, or obstruction in the capillaries ; an extended plateau is also met with in induration or ossification of the arteries. In some instances we find a little hooked point preceding the usually transverse mark of the summit. This occurs by the rapid movement of the lever, and is generally a sign of regurgitation coexisting with obstruction at the aortic valves. In aortic narrowing of marked degree the summit-wave is indistinct or absent; the line of ascent is oblique and gradual, and may show a break near the summit. The line of descent is sometimes purely oblique, and the more rapidly the pressure is lessened in the arterial system, the more oblique is the line. It often shows a series of undulations. The first of these waves is called the tidal wave ; it is still part of the systole and onward flow of the blood ; the decided subsequent wave is specially called the dicrotic or great secondary wave. The closure of the aortic valves with the second sound of the heart happens just before the dicrotic wave ; the exact time is marked by the aortic notch ; the dicrotic wave represents the diastole of the heart. The tidal wave is large, but the dicrotism badly marked, in atheroma. In high arterial tension the dicrotic wave is also ill pronounced, and the line of descent is very gradual. In mitral narrowing, the line of descent is long, but is broken by small pulsations. The sphygmograph requires much care and practice in its use ; and with all the perfection of the instrument, its precise value for clinical research is still undetermined. I think it of much more avail in investigations on the exact action of medicines — where, indeed, it is of great value — ^than in aiding us materially in questions of diagnosis or in decisions on treatment. At all events, I do not EXAMINATION OF PATIENTS, ETC. 43 think that it supersedes the older and more usual means of research. Perhaps records of pulse-traces in which the amount of pressure has been carefully noted will enable us to judge more accurately than we can now of the state of the cardiac muscles in disease. An instrument aiming at even greater accuracy than the ordinary sphygmograph is the sphygmochronograph* It is similar in its construction to the sphygmograph of Dudgeon, but it enables us to measure the curves of the tracings, and to ascertain the exact time of each part. Normally capillanes do not pulsate. We judge of their dila- tation by the flush, of their contraction by pallor. But in certain pathological conditions they beat, as may be observed in the capil- lary flush. We may note the capillary pulsation in instances of chlorosis and of aortic regurgitation. The capillary flush has generally to be brought about artificially by pressure on the skin, the nails, or the lips. We can then perceive the pink changing in color with each pulsation, or disappearing after it. The most marked changes are observable at the periphery of the pink patch. In those rare instances in which the capillary pulsation is regur- gitant and of venous origin, as in tricuspid regurgitation, we find venous pulsation elsewhere, and the capillary pulsation precedes the radial beat. Temperature of the Body. — The thermometry of disease has become indispensable. The thermometer used for clinical pur- poses should be very sensitive, and requires to be from time to time compared with a standard one, and verified. It may be straight, or curved. The scale, extending from about 85° to 116° Fahr., ought to be uniformly graduated ; it should be divided so as to ex- hibit fifths of a degree. The most useful instrument is self-regis- tering (Fig. 4) ; a straight thermometer, generally short, for con- venience' sake, and having the mercury detached from the column. This detached part, or the index, is set by bringing it down below the lines of the scale by a rapid swing of the arm. After the ther- mometer has been in position for the required period, it is removed, and the end of the index farthest from the bulb records the tem- perature. A magnifying front allows the degrees to be easily read. * Jaquet, Zeitsehrift fiir Biologie, 1891 ; and Miilill, Deutsch. Arch. f. klin. Med., 1892, xlix. 44 Fig. 4. MEDICAL DIAGNOSIS. Fig. 5. Seguin^s Surface Thermometer, modified to be Belf - register ing. Surface Thermometer, with coil at ex- tremitjr. It may he, if necessary, kept in place by a thin elastic band. Self-Kegistering Thermom- eter, showing the index marking 99° shortly after an ohserration. EXAMINATION OF PATIENTS, ETC. 45 Very delicate but fragile thermometers, registering in a minute or less, have of late come into use. Metallic thermometers are neither so cleanly nor so trustworthy as those made of glass. As surface thermometers for localized thermometry various in- struments have been suggested. I habitually employ one which has the mercury in a fine coil at the expanded extremity, and which is self-registering. The ordinary self-registering clinical thermometer may be made use of, with the bulb fitted into a piece of cork. Whatever instrument be resorted to, we should first obtain the heat of a corresponding or analogous well part, and then leave the bulb for five minutes on the suspected abnor- mal structure. Better still is it to apply two instruments at the same time ; one on the sound, the other on the unsound side. In all observations the heat of the body, as ascertained in the axilla, should equally be noted. Thermo-electric apparatus have also been employed for surface thermometry, and certainly give very accurate results. But, with perhaps the exception of the instru- ment of Lombard,* they are not sufficiently portable or easily enough managed for general use. The SLurface temperature is, as a rule, lower by upwards of one or by several degrees than the general temperature. We find it so on the chest, on the abdomen, and on the head. The tempera- ture, too, is not on corresponding sides entirely the same, at least not on the head. There is almost always a slight inequality in the temperature of the two sides of the head ; Gray f demonstrates that Avhen at rest the temperature of the left hemisphere is the higher, which accords with Broca's statement. And the observa- tions of Amidon J have shown that excessive use of a group of muscles may generate heat in the cortical region presiding over them, sufficient to manifest itself to surface thermometers placed on the scalp. The mean temperature of a healthy man's head is fixed by Maragliano and Seppili, as the result of many observa- tions, at 36.13° Cent. (97.03° Fahr.) for the left side of the head, and 36.08° Cent. (96.9° Fahr.) for the right.§ These tempera- tures ai-e much higher than those given by Broca and Gray, which * " On the Kegional Temperature of the Head," London, 1879. f Chicago Journal of Mental and Netvous Diseases, 1879. X New York Archives of Medicine, April, 1880. ^ Translated in Alienist and Neurologist, St. Louis, Jan. 1880. 46 MEDICAL DIAGNOSIS. is accounted for by their having been taken in summer. Broca places the frontal region on the left side of the head at 35.43° Cent. (95.79° Fahr.), on the right at 35.22° Cent. (95.39° Fahr.); Gray's figures are somewhat lower. The parietal region on the right side is fixed by Broca at 92.8° ; by Gray at 93.6° on the right, and 94.4° on tlie left ; the vertical by Gray at 91.7°, and the occipital at 91.9° ; the whole side of the head by Broca at about 93° ; the entire head at places remote from theoe points at 93.5° by Gray.* As regards the abdomen, Peter f places the noriaal mean of the parietes at 35.5° Cent. (95.9° Fahr.), and the same observer re- cords the normal temperature for the chest-walls at about 36° Cent. (96.8° Fahr.). Certain diseases change the temperature locally. Thus, in neuralgia the heat near the painful points .may be markedly raised. So, too, is it sometimes in some parts of the surface in hysterical women. In hemiplegia the paralyzed limb may show a higher temjierature than the sound one. And over spots where there is inflammation or where decided tissue- change is going on there is a rise in local temperature. Weir Mitchell I has called attention to the manner in which posture affects surface temperature. It is, for instance, less by 0.4° C. to 1° C. on the dorsum and sole of the foot when standing than when lying down. But to return to general thermometry. The clinical thermom- eter may be put under the tongue or in the rectum ; but the most suitable site in adults is the axilla. The bulb is pressed into the armpit and kept in close contact with the skin for five minutes, except when the delicate minute thermometers are employed. The thermometer may be conveniently introduced just below the skin covering the edge of the pectoralis major muscle ; and, to insure exactness, the axilla should be kept well covered. The best posture, as Binger points out, is neither completely on the back nor on the side, but diagonally on the right or the left side. In all cases of importance, not less than two observations should be made daily, and, so far as possible, every day at the same hour. * New York Archives of Medicine, 1879, vol. ii. f Communication to the Academie de Medeoine, quoted in Medical Times and Gazette, Dec. 1879. J Medical News, Jan. 1894. EXAMINATIOi) OF PATIENTS, ETC. 47 BelAveen seven and nine o'clock in the morning, and about seven o'clock, or somewhat earlier, in the evening, are regarded as the most appropriate periods. If only a single observation be taken. Pig. 7. Name , Day of ilonth Dav of Disoase ^ 2 3 ^ 5 6 7 8 9 10 U 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 ME (IE HE IIEMESIE JIK ME JIK ME flIE J[E Sm ME ME ILE If H HE ME ME JIE ME ME ME ME ME ME ME MR MPlfE Iff *[[: MK ITP 110°: : I : I " z" YQf- - - "- - - i z ' \ ^i ;^r4^7/7- = - 1 r- 100-^ ^ '\ = V '- - ; : V\ ': '-- : : ;;=j =""^^4-^ ^ ^ ^"" Fulse lIcsiiiraliuTi Temperature clisirt in uimple continued fever. The initial stage, tlie stage in which the tempera- ture risea to its height, is here attained on the second day; the fastigium, the stage at which it remains, witli sliglit finctnations, at its lieiglit, lasts until thesixtli day ; the defervescence, the stage when the fever-heat falls, is rapid, by crisis, atid a subnormal point is, f»r a time, attained. it is best done in the late afternoon or in the evening. In every record of the temperature the pulse and the respirations must also be noted. For the purposes of record it is best to use always clinical charts. To be graphic, these should not be too elaborate. Fig. 7 is a simple model. It can be arranged for thirty days or upward ; by striking out the morning and evening marks, as many spaces as needed can be devoted to a case ; or by using, as we do at the Pennsylvania Hospital, a marking in red ink in addition to the black line in which the morning and evening temperature is recorded, as near as may be always at the same hour, the supple- mentary temperature can easily be traced (Fig. 8). Where we 48 MEDICAL DIAGNOSIS. wish also to show the pulse and the respiration graphically, the chart of Crozer Griffith is excellent. In discussing pneumonia, further on, one of these charts is shown. Fig. 8. xn — I — r — r — 1 — I — [ — 1 ' 1 — 1 ^ ^ ■^ ^ ■^ Sh ~ " , — a , — 3" i T , a .. ,^ ■^ .._ — _ . •)■ ' \ Oh , \=> "e injo" '"V a ~ -?tt- ^ ^ -J ■^ — 3 t ,„„o 1^ 103- 1 ■ / , / 'i I J £ ino*^ ^ 1 /y ; "^ ■ 1 ( ' jtn ^ 1 - 1 :: I 101^- = -! ^ "I I "^ ^ s 1 -J ~ , ^ s 1 S i - 1 I ^ , s / ■^ / \ \ a. /r ?^ l\ \ to / * -? 1 99- 11 -J 1 J 1 = \. 3/ — ^ \. nf s- \ 5 I \^ \o - S a \ "V" \ (O 1 V ^ ■^ ^ ^ H Iv jA ^ H u. / ^ < / ^ .2 — * » ^ c Tas ■'^ / - ;g 97- h / Wsease F 1 Pulse 96 ^."^ ??-fo ^'' I«84 «?'90 ««ai ,-' ^ss ./ "?.'' ^--'' ,,'' ,-"' ,,-' X' Resiiir. .-^20 ,'' ■^°2-2 ■^O'iS ,'-'' •:l*^26 ■1*22 ^^'' .'>54 •24,' ,-' _...-■' ^•'' Date Nov. 9 10 10 11 11 12 12 13 13 14 14 15 15 16 Temperature chart, from a case of remittent fever in a sailor at the Pennsylvania Hospital (No. 1570). The red Hues show the intermediary temperatures. In temperate climates the average heat of the body, as meas- ured in the axilla, is estimated at 37° Centigrade ; that of freshly- voided urine is about the same. Expressed in the scale used in this country and in England, the average heat of sheltered and internal parts of the body may be stated as 98.6° Fahr.* This, * It may te useful, for the sake of comparison, to recall the fact that one de- gree of Fahrenheit is equal to five-ninths of a degree of the Centigrade thermom- eter, and four-ninths of a degree of Eeaumur ; and also that the freezing-point EXAMINATION OF PATIENTS, ETC. 49 at least, is the case in the axilla ; in the rectum it is not quite 1 ° higher, and is very steady ; in the mouth it is somewhat lower. In the groin, where, in children, it may be most convenient to take it, the temperature is apt to be lower than in the axilla. The body temperature rises with the temperature of the air, and fluctuates slightly during the day, being in temperate climates, according to the most trustworthy observers, lowest between two and eight in the morning, and highest late in the afternoon. It is heightened by exercise and reduced by sustained mental exertion, and changes even when we are at rest.* But, as a rule, with the exception of very active exercise, no cause save disease induces a variation of much more than 1° ; even in the extreme heat of tropical climates the animal heat does not surpass 99.5°. Thus a temperature above this, or more than a degree below the average stated, when persistent, indicates some morbid action in the econ- omy. At all events, it does so in adults ; in very aged persons a temperature of 97° may still be normal ; Avhile, on the other hand, the range may be as high as in infants. In children, in whom the temperature, as a rule, is somewhat higher than in adults, the daily range is much greater. It falls rapidly in the evening, and is very much influenced by food and by crying. Immediately after birth the temperature is lowered ; and in the new-born it is about 99.8° to 100.4° in the rectum. It falls from early infancy to puberty. The rectal temperature of young children ranges between 99° and 99.7° ; under six years of age the mean is 99.4°. But, as already stated, there are great variations in childhood. The maximum is attained in the after- noon ; and in healthy children an evening fall is common. Dur- ing the first three or four months of life the temperature, Henoch of the first is placed at 32° ; that of the others at zero. To convert Centigrade into Fahrenheit, we multiply hy 9 and divide hy 5 ; to convert Keaumur, we multiply hy 9 and divide hy 4, and when above zero, in either case, add 32. To convert Fahrenheit above zero into Centigrade, we subtract 32, multiply hy 5, and divide by 9. * See an instructive paper by Garrod, on the Minor Fluctuations of the Tem- perature of the Human Body, Proc. Roy. Soc, May, 1869 ; an elaborate paper hy Jaeger, Deutsches Archiv fiir Klin. Med., Bd. xxix. ; Goodhart, Guy's Hos- pital Eeports, 3d series, vol. xv., particularly valuable as showing the variations during the prolonged application of the thermometer ; and Boileau, Clinical Thermometry in Hot Climates, Lancet, Aug. 4, 1888. 50 MEDICAL DIAGNOSIS. asserts, has, from slight causes of faulty nutrition, a marked tendency to go below the normal. A further point, too, to be taken into account in those of all ages is, that the temperature is somewhat influenced by food and stimulants. And these are the elements which make deductions from single observations or com- paratively slight changes untrustworthy. In high altitudes, as Keating * has observed, there is a tendency to hyper-pyrexia. In ordinary cases the pulse and temperature rise synchronously, and every degree above 98° Falir. corresponds with an increase of ten beats of the pulse. The fever temperature ranges from 100° to 106°. When it exceeds this, the patient may be looked upon as in great danger, except the rise be due to malarial fever. Under these circumstances it is rapid, occurring in a person who but a few hours before was healthy. In typhoid fever a tem- perature of 105° is a proof of grave disease. In some severe cases of yellow fever the heat in the armpit has been noted as 108°. t In pneumonia a temperature above 104° is a symptom of a very serious seizure ; so, too, is it in acute rheumatism a symptom either of danger or of some complication. Stability of temperature from morning to evening is a good sign ; the tem- perature remaining the same from evening till morning is a sign that the patient is getting worse. In convalescence the tempera- ture declines until it attains its norm, or even falls somewhat below this. If after the defervescence the thermometer again indicate a decided rise, it shows a return of the malady, or the supervention of some complication or new disorder ; and the per- sistence of even a slight degree of abnormal heat after apparent convalescence is a sign of imperfect recovery, or of the existence of some lingering secondary complaint. Further, in cases of low fevers, the skin, particularly of the hands and feet, may feel cool at the same time that the instrument in the axilla marks 104°. Specific forms of febrile diseases have their characteristic vari- ations of temperature. In measles, for instance, the temperature rises toward the breaking out of the rash, reaches its height with the period of eruption, and in the twenty-four hours succeeding it falls rapidly. In scarlet fever the thermometer marks 105°, or * International Medical Magazine, Dee. 1892. t Wragg, Charleston Medical Journal, vol. x. EXAMINATION OF PATIENTS, ETC. 51 upwards, at the beginning, and the heat only gradually subsides. Typhoid fever has its characteristic record ; so have the malarial fevers theirs. The temperature of tetanus rises to great heights before death. A temperature above 107° is almost certain to be the forerun- ner of a fatal issue. But recovery may take place. In a case of cerebral rheumatism under my charge * the thermometer marked 110° in the axilla, yet the patient got well. In an instance of injury to the spine after a fall, reported by Teale,tthe young lady lived though the temperature reached above 122° and ranged for days between 112° and 114°. A remarkable case has also been reported of hysteria and intercostal neuralgia, in which in one axilla the temperature registered 117° Fahr. and in the other 110°, but the patient recovered.| Galbraith § has reported a case in which the thermometer registered 151°, and Jones || that of a girl, fourteen years of age, in whom the temperature rose to over 150°. In neither instance was the extraordinary heat attended with evil r-esults. Duckworth's report T[ of a case in which the thermometer marked 228° (108.9° C.) is probably the highest on record. In all these extraordinary temperatures the possibility of deception prac- tised by hysterical patients must be borne in mind. The tempera- ture may be temporarily very high from emotion. I saw this once in a frightened child which had previously had but slight fever, and E. S. Tait has reported the same in the puerperal state.** On the other hand, the thermometer may show a depression in temperature below the normal. The body heat often falls at the beginning of acute peritonitis. It is low after severe loss of blood, or if exposure to cold happen in alcoholic intoxication, during convalescence from acute diseases, and in melancholia. It is de- pressed by various poisons, and has been observed down to 93.9° in carbolic acid poisoning.f f It is low in the insane. It may be * See Amer. Jour, of Med. Sci., Jan. 1875. f Transact. Clinical Society of London, vol. viii. J Philipson, London Lancet, April, 1880. ^ Journ. Amer. Med. Assoc, March, 1892. II Memphis Medical Monthly, Oct. 1891. T[ Archives of Gynaecology, New York, Oct. 1891. ** Ohst. Soc. Transact , 1884. tf Baumler, in Quain's Dictionary of Medicine. 4 52 MEDICAL DIAGNOSIS. only a fraction above 89° in the axilla in cholera. From any other cause it rarely, even in extreme collapse, sinks below 92°. Though having its widest range of applicability in fevers, in other than febrile states, too, the thermometer assists greatly in diaignosis and prognosis. It is invaluable, in many instances, in discriminating between functional and organic affections. It aids in the study of apoplexy, of palsies, and of hysterical affec- tions, and tells the true story in cases of feigned disease. It also enables us to judge whether increased frequency of pulse be due to fever or to debility ; and it indicates that sweating which is not preceded by a previous elevation of temperature is the result of exhaustion and not of fever. There is a continuous rise of the heat of the body in all cases in which a deposition of tubercle is taking place actively in any of its organs, and more especially in the lungs ; while, on the other hand, I have noticed that in can- cerous affections the heat of the body is but little influenced, and is sometimes even below the normal standard. Tongue. — When a patient is told to put out his tongue, it is not to see whether this organ is the seat of disease, but because experience has taught that the tongue is a mirror, more or less perfect, of the condition of the digestive functions, and that it reflects the complexion of the nervous power and of the blood, and the state of the secretions. To judge of these varied circum- stances, we have to examine the tongue in regard to its move- ments, its volume, its dryness or its humidity, its color, and its coating. The movements of the tongue are impeded and tremulous in all conditions of the system attended with exhaustion. It is pro- truded slowly and with difficulty in fevers of a low type, and in nervous disorders Avhlch are accompanied by marked debility. The action of the muscles is seriously impaired in paralysis. In hemiplegia one side is crippled, and the tongue turns toward one of the corners of the mouth. When imperfect articulation is associated with difficulty in moving the organ, it commonly announces a serious cerebral lesion. The volume of the tongue is changed by its own diseases ; more rarely by the condition of the system at large, or by disturbances of the abdominal viscera. Yet a swollen or a broad and flabby tongue, on the sides of which the teeth leave their marks, is some- EXAMINATION OF PATIENTS, ETC. 53 times found in chronic a'.lments of the digestive organs, and as the result of the action of mercury, and of certain poisons. It is further observed in some affections of the brain, or as a conse- quence of a disturbed circulation attending diseases of the heart, and in distempers, like the plague, typhus, or scurvy, in which the blood is much altered. The tongue is sometimes observed to be swollen on one side only in consequence of catarrhal inflam- mation. This hemiglossitis affects the left side, and is supposed to be of neurotic origin.* Loss of substance of the tongue, es- pecially on its borders, is mostly due to syphilis. The ulceration is often associated with fissures. Dryness of the tongue indicates deficient salivary secretion. In acute visceral inflammations, and still more frequently in febrile states, especially in the exanthemata and in typhoid fever, the tongue is dry ; it may be so dry as to cause the papillae to become prominent and the whole organ to appear roughened. This condition is one which, in acute diseases, is always to be dreaded, especially if the tongue be, in addition, of a dark color, glazy, or furred or fissured ; for it is then a proof not only of generally ai-rested secretions, but also of depraved blood and of ebbing life-force. Yet a fissured tongue is not, by itself, indic- ative of great and imminent danger ; it may occur in chronic affections of the liver, or in chronic inflammation of the intes- tines ; and in some persons it is congenital. In estimating dry- ness of the tongue we must not overlook the fact that this may happen from persistent openness of the mouth, as during sleep, from obstruction of the nasal passages, or from coma. Among chronic diseases the tongue is most apt to be' found dry in dia- betes. A dry, incrusted, brown tongue is due to a continuous crust on and between the papillae, which is filled with parasitic growths. It occurs in states of prostration with lowering of nutrition and tendency to sinking. Dickinson has calculated that a dry tongue is present in about fifty per cent, of fatal cases ; more than any other it foretells death.f The opposite of dryness, humidity, is, unless excessive, a favorable sign. It is extremely so if it succeed dryness, because it is a proof that the secretions are being re-established. * Dyce Duckworth, Liverpool Med.-Chir. Journ., July, 1883. f The Tongue as an Indication in Disease, London, 1888. 54 MEDICAL DIAGNOSIS. There is a rare disease of the tongue known as xerostomia, occur- ring in women after middle life, in which the dryness of the tongue is so extreme that it may prevent speaking or swallowing. The tongue is cracked like alligator skin, and looks like raw beef.* The colm- of the tongue is subject to many variations. It is re- markably pale whenever the blood is watery and deficient in red globules. It is exceedingly red and shining in the exanthemata, especially in scarlet fever. The tongue is also very red if inflam- mation have attacked its substance, or the fauces, or the pharynx. It is bluish and livid when there is an obstruction to the flow of the venous blood or deficient aeration, as in some structural dis- eases of the heart and in dangerous cases of bronchitis or of pneu- monia. A. red, smooth tongue is a sign of failing nutrition. A tongue black in spots, the discoloration particularly marked about the middle of the dorsum, the papillae enlarged, indicates a con- dition of parasitic origin. As important as the color of the organ are the color and form of its coating. In health the tongue has hardly a discernible lining ; disease quickly gives it one. In inflammation of the respiratory textures, at the beginning of fevers, in disorders of large portions of the abdominal mucous tract, the epithelium accumulates, and the tongue has a loaded, whitish appearance, due to excess of white epithelium on the papillae with the inter- vals also more or less filled up. The coat is apt to be yellowish in disturbances of the liver, and of a brown or very dark hue when the blood is contaminated. But we must be sure, in draw- ing our inferences, that the abnormal aspect is not due to the food partaken of, or to medicine. Its color is also modified by the character of the occupation. Thus, as Chambers tells us, there is a smooth, orange-tinted coating on the tongues of tea-tasters. A local cause sometimes gives rise to a thick, opaque coat. For instance, decayed teeth may produce a yellow sheathing on one side. Affections of the fauces also occasion a deep-yellow hue. Again, there are many healthy persons who M^ake up every morn- ing with their tongues covered, more especially at the back, with a heavy coating, which wears off" after a meal. * See reports of cases in Sajous' Annual of the Univ. Med. Sci., vol. i. 1891, C-1. EXAMINATION OF PATIENTS, ETC. 55 In some diseases the epithelium, which is either formed in ex- cessive quantities or not thrown off, collects between the papillae, leaving them uncovered and prominent. This is especially noticed in scrofulous children. When the epithelium is sticky and ad- herent, it winds itself chiefly around the filiform papillae, elon- gating them and giving to the surface of the organ a furred ap- peai-ance. Although this kind of tongue, as almost every other variety, is met with now and then in persons who are not ill, yet it may generally be looked upon as denoting disease. It occurs sometimes in chronic diseases of the abdominal viscera, but much oftener in grave acute maladies. The tongue, on the other hand, may be bare of its epithelium or imperfectly covered with it. We meet with this in certain instances of scurvy, or in cases of chronic diarrhoea and dysentery with great prostration, in which the tongue is often found to be red, smooth, and dry, or in attend- ance on cachexias, as the malarial. Again, a denuded tongue is common in scarlet fever, and not infrequent in typhoid fever. In scarlet fever it has a strawberry look. This is sometimes also seen in pneumonia. To sum up, before leaving the subject, the manifestations afforded by the tongue which are indicative of danger. They are, tremulous action ; great dryness ; a livid color ; a very red, shining, or raw aspect ; a heavy coating of a dark or black hue ; a glazed, brown tongue. Any change from these to a more natural look bears a favorable interpretation. The state of the digestion and the character of the discharges have so close a connection with the nutrition of the body that they become important general symptoms. But, for the sake of convenience, their value will be inquired into while discussing the diseases in the recognition of which they occupy the foremost place. A few words here, however, on the sensations of patients. Sensations of Patients. — Sick persons are subject to many disagreeable feelings. They complain of chills, of heat, of lan- guor, of restlessness, and of uneasiness ; but their most constant complaint is of pain. Now, pain may be of various kinds ; it may be dull or gnawing ; it may be acute and lancinating. In its duration it may be permanent or remitting. A dull pain is generally persistent. It is most often present in congestions, in subacute and chronic inflammations, and where gradual changes 56 MEDICAL DIAGNOSIS. of tissues are taking place. It is the pain of chronic rheumatism, and shades off into the innumerable aches of this malady. The only acute affections in which it is apt to exist are inflammations of the parenchymatous viscera and of mucous membranes. Acute pain is in every respect the reverse of dull pain. It is usually remittent, and not so fixed to one spot. It is met with in spasmodic affections, in neuralgia, and, with extremely shai-p and lancinating pangs, in malignant disease. Pain varies much in intensity ; it is sometimes so extreme as to cause death. "We have to judge of its severity partly on the testimony of the sufferer, partly by the countenance, and partly by the attending functional disturbances. The latter are not to be overlooked, for they enable us, to some extent, to appreciate whether the torments are as great as they are represented to be. The seat to which the pain is referred is far from being always the seat of the disease. A calculus in the bladder may produce dragging sensations extending down the thighs ; inflammation of the hip-joint gives rise to pain in the knee ; disorders of the liver occasion pain in the right shoulder. Pain felt at some part remote from that affected is either transmitted in the course of a nerve involved, or is sympathetic. The same abnormal action does not always create the same kind of pain. Inflammation, for instance, causes different pain as it involves different structures : the pain from an inflamed pleura is not the same as that from an inflamed muscle. Speak- ing generally, the tissues themselves seem to determine the form of pain more certainly than does the precise character of the morbid process. Thus, pain in diseases of the periosteum and bones, no matter what may be the exact nature of the malady, is mostly boring and constant ; in the serous membranes, sharp ; in the mucous membranes, dull ; and in the skin, burning or itching. Pain produced by pressure is called tenderness. It indicates increased sensibility, and is most constantly associated with inflam- mation. Yet tenderness may be present without inflammation ; the tenderness, for example, of the skin in hysteria. Commonly it is combined with pain occurring independently of pressure ; but a part may be tender and not painful. CHAPTER II. DISEASES OP THE BRAIN AND SPINAL COED, AND OP THEIR NERVES. Before entering upon a consideration of the affections of the nervous system it is proper to recall a few salient points con- nected with its structure and functions indispensable to a recog- nition of its derangements. We have constantly to bear in mind that there are in its composition nerve-cells composing ganglia, which are for the most part originators, and nerve-fibres, which are for the most part conductors, and, besides, a peripheral termi- nation of these conductors, which forms a peripheral nervous sys- tem, chiefly concerned in receiving and distributing impressions. In the brain and spinal cord are the principal nervous centres which originate and control, and of the brain especially our knowledge of the subject of localization and special function of particular points has become so extended that it is made the basis of accurate diagnostic knowledge, which has of late years assumed the greatest practical importance. Cerebral Localization. Either for his own purposes or to co-operate with the surgeon, the physician must often satisfy himself of the exact seat of the lesion, and a knowledge of the centres in the brain is a necessity. The methods by which, in animals, the locations of the cere- bral centres have been determined have been principally those of electrical stimulation and the ablation of limited areas of the cortical gray matter. It has been thus ascertained that in the monkey the centre for the movements of the head as a whole is placed most anteriorly ; extending from that part of the frontal lobe non-responsive to excitation — which is about opposite a point between the posterior and middle thirds of the superior frontal 57 58 -MEDICAL DIAGNOSIS. convolution — ^to the arm-area, which, on the convex aspect of the hemisphere, abuts the face-area at its inferior border. The arm- area next occupies a somewhat irregularly shaped territory, com- prising a space of the mesial surface directly posterior, bounded behind by the trunk-centre, and stretching upon the -convex sur- face below the leg-area across the whole space of the ascending frontal and ascending parietal convolutions, to the interparietal sulcus. The trunk-centre upon the inner aspect occupies but a limited space, and is bounded posteriorly by the leg-centre, which is situated at the head and about the superior termination of the Kolandic fissure. The face-centres occupy the space about the lower termination of the Rolandic fissure,- between the precentral and Sylvian fissures. It has been found that these large centres are compound, that subdivisions control individual muscles or movements, and that the general order is such that upon the median aspect the centres arranged from before backward control successively the muscles of the head, shoulder, arm, trunk, leg, and feet. This is also true of the arrangement upon the convex or external surface of the hemisphere, the most anterior being those of the face. In man almost all peripheral movements have their cerebral reflex centres located with more or less exactness in certain cortical areas, and with more or less definite topographical relations to others. In correspondence with this law there seems to be another governing the position of the centres of the most specialized and differentiated muscles, whereby they are su])erposed upon those of the larger muscles and groups, of which they are in reality exten- sions, refinements, or specializations. Strong stimulus of a sub- centre will implicate a larger area and result in movement of larger related muscles. The centres for movements of the trunk and head as a whole are not so clearly determined. But in a general way the arrange- ment of the cortical motor centres in man preserves the same plan and order as in the monkey. The facts in the case of man are chiefly the results of clinical and pathological investigation, and in consequence some indefiniteness still prevails; <■ The localization of human cortical centres is indicated in the annexed sketch. It should not be forgotten that in all such diagrammatic representations the picture represents the fact but DISEASES OP THE BRAIN AND SPINAL COED. 59 poorly. The two halves of the same brain are unlike. More- over, there is never any hard and fast line dividing one centre from its neighbor. If they do not actually overlap, the centres certainly pass into one another by indefinable gradations. The strength of the stimulus, as has been stated, modifies the definite- ness of limitation, and many facts go to show that the unaffected hemisphere has often a certain power of substitution, whereby it can take up the function of its injured fellow. Certain muscles, indeed, appear to be rej)resented bilaterally in each hemisphere, whilst, on the other hand, there is, at least in the case of articulate speech, a location of the unique controlling centre singly upon one side or the other according as the person is right-handed or left-handed. As in the monkey, the centres for voluntary motion of the opposite side of the body cluster about the fissure of Rolando. Upon the mesial surface the same order of arrangement from before backward is preserved, but there is less certainty as to the definite areas of the head and trunk. Externally, about the upper limit of the Eolandic fissure, and seated in the highest part of the motor region, is the leg-area, extending posteriorly to a somewhat indeterminate point of the superior parietal lobule, and inferiorly occupying the upper third of the ascending frontal and ascending parietal convolutions. It is almost certain that the centre for the foot is at the junction of the highest frontal and ascending frontal convolutions. The shoulder- and arm-area includes the middle third of the ascending frontal and ascending parietal convolutions, extending higher up the ascending frontal convolution. The centre for the muscles of the trunk is supposed, in accord- ance with the experiments of Horsley and Schaefer, to be on the inner surface of the hemisphere. The centre for the neck region Munk and Wernicke located in the frontal lobe in front of the middle of the anterior central convolution. In the lower third of the ascending frontal, perhaps extending to the ascending parietal, are located the centres of control of the facial movements ; the centres of the lips and tongue lie at the lowest part of the ascending frontal. The centres for the move- ment of the head and eyes are not established. In the latter space, and extending into the posterior portion of the third left 60 MKDICAL DIAGNOSIS. DISEASES OF THE BRAIN AND SPINAL COED. 61 frontal convolution, lies the centre for articulate speech, lesion of which causes motor aphasia. In connection with the subject of aphasia we may note that a separate centre is required to cor- respond to the clinical fact of psychic inability to write, — agrajjhia. Yet the location of this centre is not clearly established. There are, then, the two kinds of motor aphasia produced by lesions of the corresponding centres, which are called by some " aphemia," or simply motor aphasia, and "agraphia." But our complex power of thought-expression is made up of two other elements that are sensory ; there must be psychical comprehension both of the heard and of the seen word. The centres intermediating these functions have been made out with some approach to defi- niteness. Lesions of the first temporal convolution produce word-deafness, or inability to comprehend the meaning of words though not deaf to other sounds. In the same way, word-blind- ness, or inability to understand the import of written or printed words, follows injury of the angular gyrus. In reference to the cortical visual centre there can be little doubt that it is located in the occipital lobe, and especially in the cuneus. The production of hemianopsia from lesions of the oc- cipital lobe, in accordance with the conclusions of Seguin,* is shown in the accompanying diagram (Fig. 10.) Complete cortical blind- ness may be considered as a bilateral hemianopsia. The macula is also represented in the cortex. Dimness of sight in the oppo- site eye, with, as a rule, concentric diminution of the field, or crossed amblyopia, depends upon a lesion in the angular gyrus. The centres for audition, smell, and taste are not absolutely de- termined. The auditory centre is most likely in the middle of the first temporo-sphenoidal convolution and related to the audi- tory nerve of the opposite side. The centre for smell is very probably on the medial surface of the temporal lobe at the ante- rior extremity of the uncinate convolution and in connection with the auditory nerve of the same side. The cortical centre for taste is most uncertain. The location of the centres of tactile or cu- taneous sensation is also in dispute, but it appears probable that, if not identical with, they are at least contiguous to those of the motor functions of corresponding parts. f A geographical centre, * Journ. Nerv. and Ment. Dis., 1886, No. 1, and Nov. 1887. t See Dana, Journ. Nerv. and Ment. Dis., Oct. 188:i. 62 MEDICAL DIAGNOSIS. a centre for determining locality, is claimed to have its seat in the occipital lobe, near the visual centre. The psychical, or mental, processes have as their centres those parts of the cortex that have Fig. 10. V Bight Homoxtmous oe Latebil IlEaiAMOPSiA, from Lesion of the Left Visual Centbb OF THE Coktex OK LEFT Oi'Tlo Tbact.— ^, dark left nasal lialf-field from blind temporal half of retina; vl', dark right temporal half-field from blind na^al half of retina ; B, left eye; B', right eye ; C, C, left and right optic nerves, composed of the crossed bundles of fibres ; D, D', left and right crossed bundles ; E, E', left ancj right occipital lobes ; F, F, left and right posterior cornua ; a, G', " optic radiation" of Gratiolet ; H, H', optic chiasm ; I, I', angular gyrus ; E, region of optic thalamus, geniculate.body, and quadrigemiiial bodies, collectively termed the primary optic cen- tres ; M, M\ cunens of the occipital lobe, the cortical visual centre. The left cuneus and optic tract are shaded, tu show lesion of these parts and the influence of the lesion upon the retinse. not been found to possess any special motor or sensory function, and particularly the prefrontal lobes. It is often a matter of much importance, especially with refer- ence to brain surgery, to determine on the skull the seat of the underlying cerebral centres. Broca, Horsley, and Eeid have specially investigated the subject, and from their and other researches we are sure of these facts : Under the frontal bone lie almost the entire frontal, middle, and about three-quarters of the upper frontal convolutions. The temporal bone covers the temporal lobe, except its anterior ex- tremity and its posterior fifth. The occipital bone covers the DISEASES OP THE BRAIN AND SPIKAL CORD. 63 greater part of the occipital lobe ; the remainder of the cortex is beneath the parietal bone. The ascending frontal convolution starts somewhat lower than beneath the anterior inferior angle of the parietal bone in front of the prolonged line of the fissure of Rolando. In front of the precentral sulcus, the lower half of which is parallel to and behind the coronal suture, lies the root of the lower frontal ; the root of the ascending parietal is behind the ascending frontal. The upper end of the fissure of Rolando corresponds to a point half an inch behind the middle of a line measured from the root of the nose upward to the occipital protu- berance, and the fissure extends obliquely downward and forward, at an angle of 67°, to within a short distance of the fork of the Syl- vian fissure. The fissure between the middle and lowest frontal convolutions is under the temporal ridge. The central convolu- tions are about an inch on each side of the fissure of Rolando ; the centres for the leg, arm, and face lie on each side of the fissure. The angular gyrus is immediately behind the most prominent portion of the parietal eminence. The first temporal convolution is over the ear and mastoid process below the Sylvian line. This line is determined by drawing a line from the external angular process of the frontal bone to a point three-quarters of an inch below the most prominent part of the parietal bone. Sensory Centres, and Conducting Paths. The sensory centres and the conducting paths by which tlie fibres unite the various parts of the brain, whether sensory or motor, and of the spinal cord, are not so definitely made out as the brain-centres are; particularly uncertain are we as to the course of the sensory paths in the medulla, pons, and peduncle. The sensory centres for the muscular sense and the sense of touch are supposed by Horsley and others to be in layers of cells in the motor cortex. But the centres for sensory impression are also claimed to be the hippocampal convolution and the gyrus for- nicatus, and, generally, the occipital and tempero-sphenoidal lobes. Volitional impulses originate in the motor cortex, and pass by converging fibres through the white substance of the hemi- sphere to the internal capsule, thence beneath the optic thalamus, to enter the crus cerebri, and through the pons, reaching the medulla, where the larger number of fibres cross to the opposite 64 MEDICAL DIAGNOSIS. side of the cord to form the lateral or crossed pyramidal tract. The smaller fibres that continue onward form the anterior or direct pyramidal tract; these decussate in the cord at various levels. This constitutes the upper segment of the motor path of Gowers, which terminates in the ganglion-cells of the anterior horns of the cord. The lower segment consists in the fibres that originate in the efferent processes of the ganglion-cells and pass to their peripheral distribution in the muscles. The fibres for the so-called cranial nerves leave the pyramidal columns as they approach the level of their nuclei on the opposite side of the medulla, to reach which they cross the median line somewhat in advance of the decussation of the remainder of the pyramidal tracts. A lesion in any part of the upper segment of the motor path, between the cortical cells and the ganglion-cells of the anterior horns, is followed by descending degeneration in the pyramidal tracts. The resulting paralysis is attended with increased reflexes, unchanged electrical reactions, and little or no wasting of the muscles. A lesion in any part of the lower segment, between the gray matter in the cord and the terminations of the nerves in the muscles, gives rise to paralysis characterized by wasting, qualita- tive electrical changes, and impairment or abolition of the reflexes. Sensory impressions reach the brain through the posterior roots of the cord, passing by the posterior and lateral columns in several tracts, most of which decussate in the cord. There is reason to believe that the paths for common tactile im- pressions, for painful impressions, for the conveyance of thermal impressions, and of the muscular sense, are distinct ; that for the first coursing through the posterior column, those for the second and tliird through the antero-lateral ascending tract, and those for the last tlirough the postero-median column and the direct cerebellar tracts. Lesions of the peripheral sensory segment are attended, in addition to the impairment of sensibility, with abolition of the related reflexes. Lesions of the cord involving the posterior and lateral columns are attended with ascending degeneration in the postero-median and postero-external columns, the direct cerebellar and the antero-lateral ascending tracts. The sensory fibres for the muscular sense are supposed not to decussate in the cord. DISEASES OF THE BRAIN AND SPINAL COED. 65 Spinal Localization. A centre for spasm is thought to be in the medulla at its junc- tion with the pons, and is carried by the vagus ; the cardio-inhibi- tory centre is in the medulla; the respiratory centre is in the medulla between the nuclei of the vagus and accessories ; the vaso- motor centre is in the medulla ; so is the sweat centre in the medulla, with subordinate spinal centres. The following facts will prove useful in localizing or determin- ing the extent of a lesion of the spinal cord : Paralysis of the small rotators of the head and of the depressors of the hyoid bone points to involvement of the first and second cervical nerves ; paralysis of the le%'ator anguli scapulse to involvement of the third cervical ; paralysis of the sterno-mastoid, of the upper neck-muscles, and of the upper part of the trapezius to involvement of second, third, fourth, and fifth cervical ; paralysis of the diaphragm to involvement of the fourth and fifth cervical ; paralysis of the serratus, flexors of the elbow, and supinators of the forearm to involvement of the fifth and sixth cervical ; paralysis of the shoulder-muscles to involvement of the fourth, fifth, and sixth cervical ; paralysis of the extensors of the wrist and fingers to involvement of the sixth and seventh cervical ; paralysis of the extensors of the elbow, of the flexors of the wrist and fingers, and of the pronators of the forearm to involvement of the seventh and eighth cervical ; paralysis of the lower neck-muscles and of the middle part of the trapezius to involvement of the sixth, seventh, and eighth cervical and first dorsal ; paralysis of the mus- cles of the hand to involvement of the eighth cervical and first dorsal ; paralysis of the intercostals to involvement of the dorsal nerves from the first to the tenth ; paralysis of the lower part of the trapezius and of the dorsal muscles to involvement of the dorsal nerves from the second to the twelfth ; paralysis of the abdominal muscles to involvement of the dorsal nerves from the seventh to the twelfth, and also the first lumbar ; paralysis of the cremaster and flexors of the hip to involvement of the second and third lumbar ; paralysis of the extensors of the knee, of the adductors, extensors, and abductors of the hip to involvement of the fourth and fifth lumbar ; paralysis of the lumbar muscles to involvement of the second, third, fourth, and fifth lumbar nerves ; paralysis of 66 MEDICAL DIAGNOSIS. the peroneus longus, the flexors aud extensors of the ankle to in- volvement of the fourth and fifth lumbar and first sacral nerves ; paralysis of the flexors of the knee to involvement of the fifth lumbar and first sacral ; paralysis of the intrinsic muscles of the foot to involvement of the first and second sacral ; paralysis of the perineal and anal muscles to involvement of the third and fourth sacral nerves. Loss of sensibility on the scalp points to involvement of the first, second, and third cervical nerves ; on the neck and upper part of the chest to involvement of the second, third, fourth, and fifth ; on the shoulder to involvement of the fourth and fifth ; on the outer aspect of the arm to involvement of the fifth and sixth ; on the radial aspect of the forearm and hand and on the thumb to involvement of the sixth and seventh; on the inner aspect of the arm, on the ulnar aspect of the forearm and hand, and on the tips of the fingers to involvement of the seventh and eighth cervical and first dorsal ; on the front of the thorax to in- volvement of the dorsal nerves from the first to the tenth ; over the ensiform cartilage to involvement of the sixth and seventh dorsal ; on the abdomen to involvement of the dorsal nerves from the seventh to the twelfth, and also the first lumbar ; at the umbil- icus to involvement of the tenth dorsal ; on the upper part of the buttock to involvement of the twelfth dorsal and first lumbar ; in the groin and on the scrotum to involvement of the first and second lumbar ; on the outer, anterior, and inner aspect of the thigh to involvement of the second, third, fourth, and fifth lumbar nerves ; on the inner aspect of the leg to involvement of the fifth lumbar ; on the lower part of the buttock, on the posterior aspect of the thigh, and on the anterior, posterior, outer aspect of the leg and foot to involvement of the fifth lumbar and the first, second, and third sacral ; on the perineum and about the anus to involve- ment of the third, fourth, and fifth sacral ; and on the skin be- tween the coccyx and anus to involvement of the fifth sacral and the coccygeal. Loss of tlie scapular reflex points to involvement of the fifth, sixth, seventh, and eighth cervical and first dorsal nerves ; of the epigastric reflex to involvement of the fourth, fifth, sixth, and seventh dorsal ; of the abdominal reflex to involvement of the dorsal nerves from the eighth to the twelfth, and also the first DISEASES OF THE BRAIN AND SPINAL CORD. 67 lumbar nerve ; of the cremaster to involvement of the first, sec- ond, and third lumbar ; of the knee-jerk to involvement of the second, third, and fourth lumbar ; of the gluteal to involvement of the fourth and iifth lumbar and the first sacral ; of ankle-clonus to involvement of the fifth lumbar and first sacral ; and of the plantar to involvement of the first, second, and third sacral nerves. Let us now look at the derangements of the nervous system. But first let us examine a few symptoms and morbid states having , a general significance rather than a specific connection with any malady. DERANGED INTELLECTION. The great instrument of the intelligence, the brain, manifests its ailings, whether primary or merely symj^athetic, by derange- ment of thought of every conceivable degree and kind, — from dulness and confusion of the intellect to its utter perversion and prostration. When one intellectual function is disturbed, generally all are, or soon becoms so ; yet we may find impairment of judg- ment and of imagination without deterioration of memory or of the powers of attention. One of the most marked signs of mental infirmity is a disordered memory. This is especially encountered in chronic cerebral diseases, or in such nervous affections of un- certain seat as epilepsy. Another signal of mental derangement is loss of judgment, or rather loss of power to appreciate the logical sequence of ideas ; still another is depression of mind, or its op- posite, exaltation. All these abnormal conditions may happen in acute as well as in chronic maladies, but they are more striking in the latter, and become of more aid in the diagnosis ; and they may or may not be joined to appreciable textural changes. To the psychologist their significance is very great, as they are often the premonitory symptoms of that departure from mental health which terminates in confirmed insanity. In acute disturbances of the brain, whether functional or or- ganic, we meet with these striking phenomena connected with disordered intellection ; delirium, stupor, coma ; and with these we may consider insomnia. Delirium. — This is a wandering of the mind, manifesting itself by the expression of ill-associated thoughts, of the incongruity of which the patient is not conscious. It most frequently occurs in those of susceptible nervous system, and is, in consequence, more 68 MEDICAL DIAGNOSIS. common in the young than in the old. It is almost invariably united with restlessness, and increases as night approaches. The character of the delirium is various. There is iirst the quiet delirium, of a low or passive type. The patient mutters incoherent words, moans without any assignable reason, or lies silent, with his eyes open, his thoughts preoccupied with his vague illusions, and taking no notice of what goes on around him in the external world. If strongly aroused, he gives a rational answer, but not a long or a connected one, for he soon returns to his dreams and his ever-changing hallucinations. He picks at his bedclothes, moves in bed, and may even try to leave it, although he is easily prevented from so doing. Then there is a delirium of somewhat more active type, still, on the whole, quiet ; the patient wanders, yet not boisterously. He is irritable, and often does not show that his mind is disturbed, except in some one particular, — in irascibility about trifles, or in expressions and modes of thought foreign to his nature. An active, fierce delirium presents different characteristics. The patient is wild, noisy ; he sings, screams, gets out of bed ; his face during the excitement becomes congested ; the eye is bright, often fiery. Now, all these forms of delirium occur in many different mala- dies, and are far from being of necessity linked to an organic cerebral affection. Nay, not even the most violent kind of mental wandering is positively indicative of a lesion of the brain ; at least, not of such a lesion as can be determined by any of our present means of investigation. As a rule, we find the low, quiet de- lirium in conditions of vital exhaustion, particularly in those depressed states of the nervous system which are connected with quickened vascular action, and with a deterioration of the blood, as, for instance, in the low fevers. The fierce delirium may, however, be associated with prostration or depraved blood. Thus, the delirium of pneumonia is sometimes of a violent kind, owing to the maddening effect of the ill-oxygenated blood on the brain. In most of the ordinary fevers the delirium is of a moderate type ; in inflammatory diseases of the brain and in acute mania it is fierce. The delirium of ursemia is apt to be active. If the delirium be due to cerebral disease, it is associated with headache ; the head- ache of pyrexia generally disappears with the onset of delirium. DISEASES OF THE BEAIX AND SPINAL COED. 69 Delirium is not difficult of recognition ; yet we must be careful not to confound with it night terrors, those troubled dreams to which ailing children are so liable, and which occasion confusion of thought on first awaking, and until consciousness is fully aroused. Delirium is most likely to be mistaken for insanity. There is this palpable diiference : an insane person is commonly in good health in all save his intellect ; a delirious person is ill, and exhibits evidences of his illness besides his delirium. It is true that, when the patient is first seen, doubt may arise ; but it is not generally of long duration. In the mania appearing oc- casionally after epileptic fits, or taking their place, there may be doubt until we obtain a clear history. Most perplexing are the cases in which insanity follows or attends inordinate drinking. But this is a subject which we shall discuss in reviewing mania a potu. Another perplexing group of cases is furnished by the occur- rence of that singular form of delirium which is met with at times in acute diseases, especially in fevers, and which, as it is apt to be associated with insufficient nutrition, has been called the delirium of inanition, or of collapse.* Its outbreak is sudden, like an attack of mania, but it is found to be combined with a feeble pulse, with a skin bathed in perspiration, with cold hands and feet, — in a word, with the signs of great prostration or of collapse. The seizure happens usually early in the morning, and is unex- pected, for it occurs commonly at the end of the febrile state, and when the condition of the skin and pulse bespeaks convalescence. The exhausted nervous centre betrays itself in the sudden mental wandering, which has generally this characteristic, — there is but one fixed delusion, and this one connected with the subjects which have most engrossed the mind before the illness. The seizure lasts from six to forty-eight hours, and at its termination the patient is apt to awake out of a sleep with a calm mind, re- membering, perhaps, his hallucination as a vivid dream. There may be more than one attack, but this is not common ; and the duration is materially abridged by opium and by the employ- ment of stimulants and nourishment. The form of delirium * See "Weber, Medico-Chirurg. Transact., 1865 ; Becquet, Arch. Gen. de Medecine, 1866 ; also the Clinical Lectures of Chomel and of Trousseau ; Nothnagel, " Anaemia of the Brain," in Ziemssen's Cyclopsedia. 70 MEDICAL DIAGNOSIS. under consideration is not simply a sequel of febrile conditions. It may also succeed exhausting discharges and drains from the system, or inability to obtain or to digest the proper amount of food. Thus, it may happen in malignant diseases of the stomach ; also in mere gastric irritability and persistent vomiting. The most marked instance of this kind of mental wandering I have encountered was associated with functional gastric disorder, which prevented enough food from being retained. In this patient the hallucination was on one subject, — a business matter which had been annoying him greatly just before his illness became decided. Delirium is at times simulated. This differs from real delirium by the absence of all other signs of illness, and by the sameness of the mental wandering. In a case of feigned delirium I met with, the man whined when spoken to, and pretended to rave ; but his ideas always ran on the same subject, and he was very solicitous about his food, and about other matters of which a delirious person takes no notice. Delirium is more or less con- tinuous ; once delirious, a patient remains so for some time, and until the exciting cause Subsides. In this respect hysterical de- lirium is exceptional ; it does not last long, or it intermits and then reappears. Stupor. — A blunted state of mind, a partial, drowsy uncon- sciousness, constitutes the phenomenon called stupor. The patient lies in a deep slumber, from which he cannot be roused save with great difficulty, and when roused he answers reluctantly and briefly, and soon resumes his heavy sleep. The expression of his face is dull, yet now and then a ray of intelligence, excited by some object which attracts his attention or by some pleasant reverie, flits across his features. Stupor is met with in several cerebral affections, and seems to be chiefly owing to a congestion of the brain. It is frequently seen in typhoid fever, immediately after an epileptic fit, or as the result of narcotic poisons, and is, in these states, also probably due to cerebral congestion. It may fiirther be due to sedative drugs. But there is nothing pathognomonic about it in these various conditions, nothing by which we can judge positively of its origin. Coma. — Coma is complete loss of consciousness : perception and volition are alike suspended, and there is an appearance DISEASES OF THE BRAIN AITO SPINAL CORD. 71 of the profoundest sleep. The face wears a confused look ; the pupils are sluggish, often dilated ; the mouth is open, the tongue dry. Sensation may be blunted, but is not destroyed ; nor is motion, for the patient moves when his skin is pinched or tickled. Coma always betokens a serious disturbance of the functions of the brain. It is often witnessed in cerebral lesions, as from pressure from blood or fluid in brain-substance or in ventricles, more rarely from tumors, abscesses, or thrombosis. The most complete coma is seen in apoplexy ; it comes on quickly, and is attended with noisy respiration and a slow pulse. Another form of coma, scarcely less complete, is caused by narcotic poison- ing ; it, however, does not appear suddenly, and when from opium is associated with contraction of the pupils. Profound intoxica- tion with alcohol induces coma, but the attendant symptoms, as a rule, make the association clear. The coma of fevers and of acute diseases, whether cerebral or not, is also gradually produced, but, unlike that due to the toxical effect of opium, is ordinarily pre- ceded for days by insomnia, by delirium, and by other signs of cerebral disturbance. The coma of epilepsy is recognized by its following epileptic seizures. In Bright's disease, among the nervous phenomena, of which coma as well as stupor and delirium may happen, the loss of consciousness is apt to occur subsequently to either of the two other morbid phenomena, and its cause is made manifest by finding albumen and tube-casts in the urine, and by the general evidences of uraemia. Ursemic coma may, however, come on suddenly and pass off suddenly. It is, as a general rule, associated with low temperature and dilated pupils. Coma also sometimes occurs in connection with diabetes. Under such circumstances examination of the urine will reveal the pres- ence of sugar, perhaps also of acetime and of diacetic acid. Sometimes a person appears to be comatose when his intellect is but little disordered. He may be paralyzed, and not have the power to communicate his ideas, from crippled articulation or in connection with aphasia. This state is distinguished from coma by noting that the patient's attention is always directed to the questions asked him, nay, that he strives to answer them, but cannot ; and that generally he has lost control over the muscular movements of one side or of both sides of the body. Coma must not be confused with syncope, which depends upon cerebral an- 72 MEDICAL DIAGNOSIS. ffimia, and is usually of brief duration, and, except feeble heart action, is unattended with noteworthy symptoms. Insomnia. — The deprivation of sleep is a concomitant of cere- bral congestion and of the earlier stages of cerebral inflammation. But a person may be sleepless from excessive pain, from exhaus- tion, from grief, from mental excitement or fatigue, or from the too free use of coffee or of tea ; sometimes insomnia is engendered by habitually working late at night. However, in several of these states congestion, of active or passive character, is, in all likelihood, the immediate cause of the wakefulness. Insomnia often precedes or attends delirium, as appears in typhoid fever. Among purely nervous affections it is most marked in delirium tremens. It is a very troublesome symptom; but, occurring in so many abnormal conditions, it cannot be looked upon as having a distinct and specific diagnostic value. DEEANGED SENSATION. The signs of perverted or impaired sensation are numerous. They may either be due to an alteration of the general sensibility or be the signals of a derangement of a nerve of special sense. Let us look at a few. Hypersesthesia. — An exalted sensibility of surface nerves, — of those of the skin, the mucous membranes, or even of those of deeper-seated structures, — in other words, a hypersesthesia of these parts, is a symptom of importance ; not so much, perhaps, on account of the light thrown by it on any particular disease, as because its presence makes it requisite to determine its origin and to separate its phenomena from those of inflammation. We may, as a rule, distinguish the peripheral sensitiveness from the tender- ness of subjacent inflammation, by its extension over a larger surface ; by deep pressure producing no more pain than a light touch ; by the absence of signs of functional disturbance of the part involved apparently in inflammatory disease ; by the uni- formity of the painful sensation, no matter how long the duration of the disorder, though the sensitiveness exhibits distinct inter- missions and exacerbations. Hypersesthesia is not closely connected with organic diseases of the brain or of the spinal cord. Indeed, it is in them not common, nor, as a rule, highly developed. By far the most usual causes DISEASES OF THE BRAIN AND SPINAL CORD. 73 of hyperesthesia are impoverished blood and hysteria ; therefore conditions which bespeak lowered vital and nervous power. Sometimes hypersesthesia is produced by rheumatism or by gout, by lithsemia, or by disturbance of the function of the kidney. It is further met with in epidemic influenza ; in hydrophobia ; in inflammations in internal cavities involving the ganglia of the great sympathetic ; after the use of ergot and of opium ; and in some diseases of the skin. It also attends paroxysms of neural- gia, as witnessed in the exquisite sensitiveness of the skin during an attack of tio douloweux ; the painful spots, too, in the course of local neuralgias are, when not the result of neuritis, hyperses- thetical. Hypersesthesia attends the irritative stage of inflamma- tion of sensory nerves from whatever cause. The seat of the heightened sensibility is ordinarily i? the skin, in the distribution of the cutaneous nerves. Yet hypersesthesia may affect the nerves of the special senses, manifesting itself, for instance, by intolerance of light or of sound. But this variety of hypersesthesia need here be but alluded to, as we shall presently look more fully at the signs of disturbance of these nerves. Of the minute anatomical changes in hypersesthesia we know nothing. The physiological basis for the increased sensation may be either in the peripheral nerves, or in the irritability of a cerebral centre or of the conducting fibres of the spinal cord, especially of those of the posterior columns. When a painful sensation is more acutely felt than normal, it is called " hyperalgesia." Sensibility to pain is most readily tested by a pinch or a prick, or by a wire brush with the faradaic current. Let us now look at hypersesthesia in connection with affections of the nervous system, especially with those of the brain and cords. HypercBsthesia is general and combined with signs of organic disease. — We find this in tumors pressing upon the pons Vai'olii and corpora quadrigemiua, or in alterations or injuries of the posterior columns of the cord and those producing irritation in the coarse of the conducting fibres, in some cases of cerebral meningitis, and in spinal meningitis in which the posterior nerve- roots are implicated. We have in all these conditions a hyperses- thesia more or less, extensive, and combined with other striking evidence of nervous disease, often with pain. But, in making up our minds as to the cause of the extended hypersesthesia, the sen- 74 MEDICAL DIAGNOSIS. sitiveness in diffuse neuritis, in general neuralgias, and in reflected irritation to the posterior columns, especially in hysterical sub- jects, must always be remembered. Hyperoesthesia is limited to one side. — An injury, or, at its beginning, a degeneration of only one posterior column, will give us increased sensibility on the same side as the lesion. Limited hypersesthesia belongs much more closely to spinal than to cere- bral disease. We also find it in connection with special neural- gias, and the sensitive skin shows augmented electrical sensibility. In some instances of limited as well as of more extended hyper- sesthesia nothing abnormal can be detected, and the disorder must be, with our present knowledge, set down as a neurosis, one con- cerning which it remains uncertain whether it be of central or of peripheral origin. Ansesthesia. — Loss of sensation, or anaesthesia, is of various degrees. It may be complete or partial, — a perfect absence of sensibility, or its mere benumbing. Not to speak of its meaning when displaying itself only in the organs of the special senses, we find it in diseases of the brain ; in several of the neuroses ; after large doses of Indian hemp, of lead, of arsenic ; we see it ushering in attacks of neuralgia ; accompanying or preceding cutaneous eruptions, such as elephantiasis or pemphigus ; in hys- teria, in syphilis, in rheumatism ; and as the result of diphtheria, of pressure on nerve trunks, of peripheral neuritis or nerve irrita- tion, and of disturbances of circulation and faulty blood conditions. In the mucous membranes, too, it may exist, in consequence either of the general causes just mentioned, or of some purely local irritation ; and it may affect the muscles. But it does not attack these structures nearly as often as it does the skin : indeed, when we speak of anaesthesia without qualifying it, we mean that of the cutaneous nerves. In the parts affected with anaesthesia the nutrition is less active, and there is a feeling of numbness. The temperature is diminished, and, if the impaired sensibility be at all general, the patient is not susceptible to alternations of heat or cold. Frequently the circulation in the skin is retarded, occasion- ing a perceptible lividity and discoloration of the surface ; or there are coexisting trophic changes, such as glazing of the skin, and grayness of hair. The electrical sensibility is diminished, as is made very manifest by the use of the wire brush with either DISEASES OF THE BEAIN AND SPIXAL COED. 75 the faradaic or the galvanic current. In hysterical anaesthesia this is a particularly striking feature. Loss of sensation has a much more constant connection with organic affections of the nervous centres than increased sensi- bility, which, however, may precede it. In the insane, especially in monomaniacs, anaesthesia is common, and ordinarily very ex- tended : so, too, in general paralysis. Indeed, with few excep- tions, an extended anaesthesia points to an affection of the nervous centres. It may in these organic cases be both general and very complete. * Localized anaesthesia may usher in acute attacks of cere- bral disease, and sometimes exists for years before any marked cerebral symptoms are perceived. Thus, a case of apoplexy was observed by Andral f in which deficient sensation was noticed at various portions of the thorax for a long time previous to the loss of consciousness ; another in which the tips of the fingers were benumbed, and felt continually as if they had been subjected to intense cold. Forbes Winslow | mentions instances in which cir- cumscribed conditions of impaired sensation were the premonitory symptoms of softening of the brain ; the defective feeling being manifested in some cases in the skin, in others in the tongue and fauces. If the defective sensibility be owing to a spinal malady, it is generally found in the lower extremities, and coexists with paral- ysis. Anaesthesia of spinal origin is usually indicative of the sensory conducting paths, principally in the posterior columns, having been disturbed or altered ; when about the body, as in transverse dorsal myelitis, there is mostly present a zone of hyper- aesthesia above the zone of anaesthesia. A limited area of anaes- thesia, Allen Starr § has demonstrated, is caused by a limited lesion in the spinal cord, and the situation and shape of the area of anaes- thesia tell us the level of the lesion. In hysterical paraplegia, in paraplegia from hypnotic suggestion, or that following railroad or other injuries, the line of lost sensibility is, as Charcot || has shown, very significant ; it excludes the genital organs. * As in a case reported by Winter, quoted Schmidt's Jahrb., 1883, No. 1. •j- Clinique Medicale, tome v. J Obscure Diseases of the Brain, p. 549. i Am. Journ. Med. Sci., July, 1892. II CEuvres completes, iii. 76 MEDICAL DIAGNOSIS. In accordance with the well-known law of the decussation of sensitive impressions in the cord, disease, if only of one posterior half, is followed by lost sensation on the opposite side of the body. One-sided anaesthesia, affecting even the face up to the middle line, is sometimes met with in hysterical subjects as the result of ovarian irritation, or after typhoid fever,* and, though presumably cerebral, the pathology is unsettled. Hysterical hemiansesthesia is generally on the left side, and associated with tenderness over the ovary. But strictly-limited one-sided anaes- thesia is more apt to be found in a distinct brain lesion, and the particular affection occasioning the " hemiansesthesia" is disease of the white substance just outside of the optic thalamus, of the posterior part of the internal capsule, on the side of the brain opposite to the side of the body which shows the anaesthesia, or damage to the iibres which conduct sensation through the pons or the crus. A lesion involving the upper part of the pons may give rise to " crossed anaesthesia," — namely, loss of sensibility upon the same side of the face and upon the opposite side of the body. Hemiansesthesia is a uot uncommon symptom between the attacks of hystero-epilepsy. Complete hemiansesthesia may be also associated with functional palsy. f Whatever the clinical association, the insensibility is generally complete as to touch, pain, temperature, and electricity. Taste, smell, and hearing are also abolished on the one side, and the eye on the anaesthetic side loses its acuteness of vision and of perception of color. Color-blindness is complete or partial; J the degree of deafness corresponds with that of the cutaneous insensibility.§ A localized form of anaesthesia happens now and then in conse- quence of an affection of the fifth nerve. The extent of loss of sensation depends much upon the part- of the nerve at which the cause of disturbance is seated. The skin of the nose and cheek may become devoid of sensation ; the reflex movements of the mus- cles of the face may cease ; the conjunctiva, or the whole surface of * Calmet, Bulletin de la Societe Medicale des Hopitaux, 1876. t Wilks, Guy's Hospital Keports, 1883. J Fere, Archives de Neurologie, Nos. 8 and 9, 1882. J Walton, Brain, Ja..uary, 1883. DISEASES OF THE BRAIN AND SPINAL COED. 77 the eye, or one-half of the tongue, may be deprived of sensibility. Only one of these phenomena, or all conjointly, may be encoun- tered, according as part of one, or one, or all of the branches of the fifth nerve are affected. Sometimes, as Romberg proves, irigeminal anaesthesia is of rheumatic origin. When it is com- plicated with disturbed functions of adjoining cerebral nerves, it may be assumed that the cause is seated at the base of the brain. Anaesthesia is sometimes the result of reflex action. It may thus arise in disorders of any of the viscera, and from an irrita- tion of any sensitive nerve. It has, for instance, been observed in both lower limbs in sciatica.* But in many of these instances of supposed nerve irritation there is really a neuritis. Diminished or lost sensibility to touch generally goes hand in hand with diminished or lost sensibility to pain, but the sensibility to pain may be augmented. This " anaesthesia dolorosa" is most commonly met with in multiple neuritis, and in spinal meningitis and myelitis from pressure. Very often numbness and other altered sensations are com- plained of, and yet the whole is subjective ; when tested, anaes- thesia is not found. In endeavoring, indeed, to form an opinion of the existence or the completeness of anaesthesia, we do not trust to the patient's statements. We touch the part lightly with the finger or a feather while his eyes are shut, and the skin is pinched or a pin used to ascertain the extent of the impaired sensation. Or we resort to means by which we can make accurate comparisons ; and one of the best is to pursue the method employed by Weber, which consists in determining how closely the points of a pair of compasses sheathed with cork may be approximated on the skin and yet be felt as two distinct points. An instrument for the same purpose, called the " aesthesiometer," was invented by Sieveking (Fig. 11), and is very much the same as the lighter one of Brown-Slquard now in common use. An instrument combining the principle of the beam compass with that of the mathematical one has been contrived by Ogle,t and one with ivory points, by Manouvriez.J The points of the aesthesiometer, * Brown-Sequard, Central Nervous System, Tenth Lecture, t Beale's Archives of Medicine, vol. i. J Archives de Physiologie, 1876. 78 MEDICAL DIAGNOSIS. whether blunted or sharp, should be put down lightly and simultaneously, and parallel with the dii-ection of the cutaneous Pig. 11. The seBtheEjiumeter. nerves ; at all events, the same relative direction should be pre- served in making comparative estimates. To understand any results obtained regarding the tactile sense, it is necessary that we should be aware how this differs in some parts of the body. Most works on physiology contain an account of the researches of "Weber and of those who have prosecuted the inquiry he started ; yet a few of the conclusions may be here ad- vantageously mentioned. At the tip of the tongue two points can be readily distinguished when separate from each other only ^ of an inch, or half a Paris line, 1.5 mm. ; at the palmar surface of the third phalanx the limit is one line ; on the palmar surface of the second phalanx, two lines, the same on the red surface of the lips ; on the palm of the hand, the cheek, and the extremity of the great toe, five lines ; on the back of the hand, at the knuckles, eight lines ; at the lower part of the forehead, ten lines ; on the skin over the patella and the dorsum of the foot, eighteen lines ; over the middle of the arm, the thigh, and over the spine, thirty lines ; on the back, 60 mm. is common. But these observations are found to vary somewhat even in healthy persons, some being able to distinguish at a shorter distance than others. Besides the impairment or loss of tactile discrimination, the ahered sensibility may show itself in the loss of the faculty of feeling pinching, pricking, and other acts which excite pain, " anal- gesia ;" or in insensibility to tickling ; or in the want of apprecia- tion of heat or cold ; or in the loss of the sensation which attends muscular contraction, whether produced by the will or by an DISEASES OP THE BRAIN AND SPINAL COED. 79 electrical current. Now, it is of interest in individual cases to note which particular kind of sensibility is affected, though, as yet, we are not in possession of sufficient facts to draw, from the absence of one form of sensibility or the other, any positive conclusions as to the seat or character of the disease. In affections of the base of the brain the patient feels three points instead of the two of the sesthesiometer.* In sclerosis of the cord the sensation is retarded rather than lost.f A form of perverted sensibility, which may or may not be associated with anaesthesia, consists in the sensibility being more or less perfect, while there is doubt as to the side touched ; indeed, the touch is commonly felt at a corresponding part of the other limb. This allochiriaX is generally found in association with organic spinal disease ; but it may also manifest itself in hysteria. A sufficient explanation of the erroneous reference of impressions Is wanting. In a case recorded by Ferrier § the reversal showed itself also in the reflex reactions. Tickling the sole of one foot caused retrac- ■ tion of the other ; tickling the inside of one thigh produced flexion of the other. Occasionally a single sensory impression is per- ceived as tMo or more ; this is known as " polytesthesia." Sensibility to temperature has a close connection with sensi- bility to pain ; but not always. There may be crossed paralysis of the thermal sense, while other senses are undisturbed. || Some- times the temperature sense is exaggerated or diminished, or much pervei'ted, and cold objects feel hot, and the reverse. Then points may be found in the skin where only cold, others where only heat, is appreciated. To test heat, a heated s})oon or a test-tube filled with hot water is the readiest means ; to test cold, a sponge that has been dipped in cold water or a piece of ice is best. Muscular ancesthesia has been mentioned. It is closely con- nected with the power we possess of estimating weight, the " mus- cular sense ;" and the loss of ability of perceiving differences in small weights, or the impairment of the sense of muscular move- ment and effort, is its most common form. It is really distinct from the sensitiveness of tlie muscles to pressure or to electrical stimulation, which may be also wholly wanting. The loss of the * Brown-Sequard, Archives de Physiologie, t. i. No. 3. f V'llpi^ij 'bid. i Obersteiner, Brain, July, 1881. ? Brain, October, 1882. II Case reported by Weir Mitchell, Trans. Assoc. Am. Phys., vol. vii. 1892. 80 MEDICAL DIAGNOSIS. power of appreciating muscular contraction, as well as the defi- ciency of sensation, is most readily tested by the use of the faradaic current ; the contraction of the muscles produces no feeling. Muscular ansesthesia is frequently combined with inability to determine the posture of a limb when the eyes are closed ; it may or may not be associated with cutaneous anaesthesia. It is not uncommon in hysteria and in locomotor ataxia. Here the loss of the appreciation of the position of the limbs and of the sense of muscular effort are the usual varieties. When the muscles are completely paralyzed, the muscular sense cannot be tested. The muscular sense has been localized by Allen Starr and McCosh at the junction of the superior and inferior parietal convolutions, be- hind the posterior central convolution.* In testing for the muscular sense, the eyes of the person on whom the test is made should be kept closed, and objects used should be of uniform size. To detect the difference in weight, and thus the re- sistance to contraction, Gowers f recommends leather balls contain- ing weights from two drachms to two pounds. The weights are ■ placed in a bag, suspended by a string to the parts to be tested. Farsesthesia, — This is a perversion of sensation, not an ex- altation. It does not disclose itself by pain and tenderness, but in itching, in formication, in unnatural feelings of various kinds, such as the feeling of tingling, of pins and needles, of goose-flesh, of thrilling, of flushing, of the trickling of cold water, of shock- like sensations, of a sense of tightness, as in the girdle pain. It is generally purely subjective, though it may be influenced by touch. A form ofparsesthesia is acroparcesthesia. This is chiefly characterized by numbness of the extremities. It is encountered in women at the menopause, and in those who do washing, scrub- bing, sewing or other needlework. It may be also found in men, and by some is believed to be a neurosis, by others a neurltis.J The alterations of sensibility discussed manifest themselves chiefly in connection with external impressions. Let us now look at some abnormal sensations which are not objective, but subjec- tive, — arising independently of external impressions. Headache and vertigo are of this character. * Anier. Journ. Med. Sci., Nov. 1894. f Diseases of the Nervous System, vol. i., 2d ed., 1893. X Sinkler, Medical News, Aug. 1894, p. 178. DISEASES OF THE BRAIN AND SPINAL CORD. 81 Headache. — In every case of headache we must first ascertain that the pain really originates within the cranium, and that it is not owing to supra-orbital neuralgia ; to rheumatism of the scalp ; to disease of the bones ; to periostitis, syphilitic or otherwise ; or to affections of the ear. To accomplish this is generally not difficult. An inquiry into the history of the case, the locality of the pain, and its augmentation on pressure in most of the disorders named, furnish evidence which decides the source of the cephalalgia to be external to the cranium. Another possible cause of headache, always to be kept in mind, has been made clear by the labors of eye-surgeons. It occurs in persons who have headache more or less intense, with abnormal sensations in the skin of the scalp, and at times vertigo and spasm of the eyelids and occipito-frontal muscle. The near use of their eyes increases their distress. When the eye is carefully examined, an optical defect is found, especially hyperopia or astigmatism. Again, we may have defective vision, with sleeplessness and severe headache, dependent on decayed teeth, and disappearing with their removal.* Having settled that none of these conditions are present, we have to determine the probable cause of the headache, — a question the solution of which depends frequently more upon the symptoms attending the pain than upon its character. But let us glance at some of the common causes and characteristics of intra-cranial headache. Headache is a rarely absent symptom of disease of the brain. In acute inflammation it is generally agonizing, and, while subject to exacerbations, continuous ; it is associated with fever, with vom- iting, although the tongue remains clear, and with delirium. In abscesses of the brain, in softening, and in similar affections which run a chronic course, the headache is less violent, and only occasion- ally paroxysmal ; it is usually accompanied by signs of disturbed intellection and of deranged motion. In tumor of the brain the headache is apt to be severe and paroxysmal, but intellection is not at first much affected. In congestion of the brain the pain is dull, increased by stooping or lying down, by long sleep, and by bodily or mental fatigue ; its concomitants are a flushed face, throb- * Case reported bj' Ogle, Medical Times and Gazette, Aug. 1872. 82 MEDICAL DIAGNOSIS. bing of the arteries of the neck, an eye-ground, as seen with the ophthalmoscope, in which the vessels, especially the veins, are turgid, and a heated head, with increased temperature, as shown by the surface thermometer. A form of congestive headache, apt to be relieved by bleeding at the nose, is often seen in young people at the age of puberty : the attacks are brought on by running or other violent exercise. In diseases of the meninges, especially those of a chronic character, the pain is constant and fixed, and sometimes very sharp. The latter kind of pain when persistent is significant either of disease of the membranes, or, at least, of parts of the superficial structure in contact with them, and is usually felt at the place on the head which corresponds to the seat of the lesion within the skull. Generally there is in menin- geal affections coexisting heat of forehead, with signs of local vascular excitement. Nervous or neuralgic headache is most common in women, es- pecially in ansemic women. It is unremitting and very severe, yet of short duration ; but after it is over there is great lassitude, and even some local soreness. It is not attended with rise of tem- perature, or with any signs of disturbance of the brain, except at times with a confusion of vision and an inability to carry on a connected train of thought. Anything that agitates the nervous system produces an attack; stimulants and food often relieve it. To the class of headache under consideration may be referred many cases of megrim or migraine. But migraine, sick headache, or hemicrania, has ordinarily certain symptoms which set it apart. The pain is usually at- tended by nausea and vomiting, is generally at first one-sided, and is accompanied, or more often preceded, by visual disorder, such as a bright spot gradually enlarging. The disturbance of vision begins suddenly, lasting perhaps for half an hour before the headache begins, and is at times associated with tingling on one side, with difficulty in speech and confusion of ideas. The headache often begins in the temple, and is very severe ; it spreads over the head, it may extend to the neck, or may leave the side originally affected to become agonizing on the other. There may be soreness of the head with the pain, and there is often pallor of the face, and a contraction of one pupil. Coldness of the extremities is not uncommon, and the patient vomits bile. This DISEASES OF THE BRAIN AND SPINAL COED. 83 bilious vomiting ofteu terminates the attack, which comes on only in paroxysms. Migraine is frequently met with in gouty or lith- £emic persons, and the urine is of high specific gravity, and contains an excess of uric acid and urates, though, during the attack itself, no such increase may be met with. Sympathetic headache is found mainly in connection with dis- orders of the alimentary tube and of the uterus, and is often worse in the morning, before food has been taken. Headache may be dependent upon various poisons, whether generated in the system or introduced from without ; for instance, in diseases of the kidney, particularly Bright's disease, the reten- tion of a large quantity of urea in the blood becomes the source of persistent pain in the head. In torpidity of the liver, in lead poisoning, in opium-eaters, in drunkards, after the use of strych- nine or of large quantities of quinine, headache is common ; and it is very likely that in persons with faulty assimilation certain ptomaines give rise to the headache. In studying headache as a symptom, we must always note what influence position and movements of the head have on the pain : whether, for instance, stooping, swinging the head from side to side, or rising rapidly from the horizontal to the erect posture affect it, and cause it to be combined with vertiginous or other abnormal sensations. In headache connected with organic disease of the brain the pain is increased by whatever increases the blood- pressure, — by stooping, by coughing, by any effort. The site of pain bears no very definite relation to the site of lesion, except the lesion be near the surface. With severe paroxysms of pain vomit- ing often occurs. Headache increased by the erect posture and relieved by lying down bespeaks an ansemic condition of the brain. Vertigo. — This is a transitory feeling of swimming of the head, a sense of falling, or illusory movements of external objects. The sensation is apt to occur whenever the circulation within the cranium is disturbed, and is often symptomatic of a disease of the heart, liver, kidneys, especially Bright's disease, or of an affection of the stomach, or of gout or lithsemia ; or it accompanies anaemia, or follows long-continued and ejihausting discharges. In the de- fective blood-supply to the brain produced by arterio-sclerosis the vertigo is attended by signs of the morbid process in other parts 6 84 MEDICAL DIAGNOSIS. of the body, and the tense pulse, increased blood-pressure, and accentuated second sound of the heart explain the cause of the giddiness. Extreme slowness of pulse, and a sensation of fall- ing in a given direction, as in M6niSre's disease, are not infre- quent.* Vertigo may attend any disorder of the brain. The cerebral form is recognized in part by the absence of those affections of other organs which would induce the dizziness, — and among these we must not forget eye-strain and local palsies of the muscles of the eyeball, — in part by its being joined to an almost constantly present sense of uncertainty in movement, to headache, and to further signs of an encephalic malady. Moreover, it is usually objective in character : surrounding objects appear to the patient to move, not he himself; and, unlike the subjective vertigo so common in mere sympathetic .disturbance of the brain, closing the eyes relieves it. The most common form of vertigo, not arising from brain affection, is the so-called stomachal vertigo. It is apt to come on in paroxysms, sometimes in the middle of the night or in the early morning, and is associated with a dull, heavy ache in the head, and with more or less gastric disturbance, often following indiscretion in diet. Yet the tongue may be clean, and the diges- tive disorder so slight that it is only by the after-symptoms, by the relief afforded by attention to diet, and by remedies acting on the digestion, that we clearly make out the cause of the vertigo. Between the attacks the patient is free from the affection; though there are cases of more chronic kind, in which a certain amount of giddiness is present for long periods with only comparatively short intervals of freedom. Here food and stimulus are apt to relieve the giddiness, which exists often with symptoms not of violent indigestion, but of delayed and slow digestion, and may become aggravated into a severe attack if the stomach be for a long time empty. In the gastric vertigo there is no loss of consciousness. The pathology is obscure. Woakes f has endeavored to establish a direct nervous communication between the stomach and the * Grasset, Vertige Cardio va^culaire, Paris, 1890; Church, Medical News, June, 1892. f Deafness, Giddiness, etc., 1879. DISEASES OF THE BRAIN AND SPINAL CORD, 85 labyrinth to explain the vertigo. Others regard the irregularity in the cerebral • circulation produced by the gastric disorder, aa- semia or hypersemia, as the cause. Very -similar to gastric vertigo is the vertigo of malassimila- tion in connection with lithoemia. The history of the case, the state of the urine with reference to uric acid, the striking change which follows diet and treatment that alter the formation and elimination of uric acid, distinguish lithsemic vertigo. Another form of vertigo of eccentric origin is that associated with partial deafness or ringing in the ears. Again, there may be an aifection of the internal ear, the semicircular canals of the laby- rinth especially being the seat of an inflammation, and the vertigo set in suddenly. Its onset is apt to be associated with vomiting, with suddenly-developed tinnitus, with pain produced in the affected ear by the slightest noise, and with symptoms of apoplexy or a fainting condition. Such cases, to which M6ni6re particularly has called attention, at times very speedily terminate fatally. But the acute seizure, which is by far the most common beginning of the aural vertigo, may leave behind giddiness and a persistent unsteadiness in standing and walking, or a tendency to go for- ward or backward, or a reeling gait, which, with the intense vertigo, the vomiting, the persistent noises in the ears, the unim- paired consciousness, and the deafness, become very valuable signs of M6ni6re's disease. The deafness shows especially in defect of power of hearing vibration conducted through the skull. It is often one-sided, generally on the side of the marked tinnitus, and never absolute. Again, it may be noticed that there is deafness for certain gi'oups of musical sounds, which Knapp accepts as proof that the disorder has extended to the cochlea. In some instances the patient has a tendency to turn to one side or to walk round and round in a circle ; and he is always miser- able, although his general health suffers but little. The dis- turbance of the equilibrium is not always present ; there may be disturbance of hearing without it. The vertigo is generally the most prominent symptom of the disease, and persistent vertigo * not epileptic in character or obviously associated with an organic brain affection is nearly always aural. The dizziness is very apt to be severe, to come on in paroxysms, and to be excited by some effort or movement. It becomes associated with pallor. 86 MEDICAL, DIAGNOSIS. with faintness, with vomiting, and in part it remains even be- tween the paroxysms. During these the roaring in the ears may- or may not be increased, but signs of eye-disturbance are very apt to show themselves. The disease may result from any process that involves the labyrinth and the nerve-endings. It is more common in men than in women, and is very rare in young persons. It may come on after cold and exposure, or originate in gout or in syphilis. It has also been observed in men working under ground and breathing compressed air.* All cases of aural vertigo do not set in suddenly ; some are slight, others are very severe and do not cease until the hearing is totally lost. Many cases progress slowly to recovery. Aural vertigo in its milder forms may be met with in affections of the ear, that have had their origin in catarrhal inflammation travelling along the Eustachian tube. To return to vertigo connected with cerebral or cerebro-spinal disease. There is a kind which Trousseau especially has described. The abnormal sensation is very short in its duration, but severe ; the patient momentarily loses all consciousness. The vertigo recurs at uncertain times : while actively engaged, sometimes while in bed and half asleep. The head feels heavy after an attack, and the mind is temporarily stupefied ; otherwise the health is good. This type of vertigo is dangerous. It is often the precursor of epilepsy, and after a time becomes associated with convulsions. Another kind of vertigo is that which arises from overworh of the brain. At times giddiness is the only symptom of disorder, essential vertigo, and is present for many years, the patient enjoy- ing otherwise excellent health. I have known a number of such instances in which the tendency appeared to have been inherited. If it do not break out until late in life, it is a matter of more serious concern. In laryngeal vertigo f there is a close connection with epileptic seizures. The chief symptoms are tickling or burning in the larynx, followed by vertigo, loss of consciousness, and spasmodic movements in the face and limbs. The larynx is healthy ; but in * Curnow, Lancet, T894, No. 3715, p. 1088. f Gasquet, Practitioner for August, 1878 ; Charcot, Progrds Medical, No. 17, 1879. DISEASES OF THE BEAIN AND SPINAL COED. 87 a case observed by Sommerbrodt a polypus existed, the removal of which cured the affection. Somewhat allied to vertigo is the condition known as astasia- abasia, the most marked characteristic of which is difficulty in standing and walking. Consciousness is not lost, but sometimes there is a sense of giddiness. The affection is most common in persons past middle life, especially if gouty and with degenerated vessels. It has also been observed in hysterical patients. Besides headache and vertigo, there are various unnatural sen- sations, such as a feeling of momentary unconsciousness without giddiness ; a feeling within the cranium of weight, of consti'ic- tion ; the feeling described as a rush of blood to the head ; ocular spectra, and other false perceptions of many kinds and of every gradation. But I shall do no more than advert to this subject, and shall now consider some of the morbid phenomena of the special senses, particularly of the senses of sight and hearing. DEEANGEMENT OP SPECIAL SENSES. Vision. — The sense of vision may be exalted, impaired, or per- verted in disorders of the brain, whether organic or functional. It is exalted in inflammation ; impaired, even totally lost, in soft- ening, in tumors, in apoplexy, and during violent hysterical at- tacks simulating apoplexy. Perversions of the sense of vision are more frequent than its abolition, and probably more peculiar to cerebral affections. They are of all kinds, — some of great con- sequence, others of but little. Muscee volitantes, or the appear- ance of spots and various small objects floating before the eye, have the latter significance ; for they may happen in almost any form of cerebral disturbance, also in ansemia, in cardiac maladies, in the neuroses, and in states of nervous exhaustion. They are simply the shadows of vitreous opacities or retinal vessels upon the retina, and have nothing to do with anything but the local condition, which is without significance. Of other manifesta- tions of deranged sight, such as illusions, ocular spectra, and phantasms, I shall only state that they are more common in sick headache, and in derangement of the mind, temporary or per- manent, than in recognizable organic disease of the brain. Yet they are found in affections of certain parts of the brain ; for in 88 MEDICAL DIAGNOSIS. disease of the posterior lobes, as Hughlings Jackson has observed, colored vision and optical illusions are frequent. The appearance of the eye is often of as much significance as the derangement of sight. In some cerebral maladies the eye has a fixed stare ; in others the eyelids are constantly moving : but the latter is a sign more frequent in chorea, local spasm, and hysteria. Great brilliancy of the eye is oft«n noticed in menin- gitis and in insanity. Derangements of the ocular mechanism may be the result of remote causes, or, themselves primary, may become the starting- point of disorder elsewhere. In the first case their study is val- uable to the general diagnostician as indicative of the seat, nature, or stage of many diseases in other parts of the system ; in the second case the diagnosis as well as the therapeutics of the dis- tant and related disease is dependent upon the appreciation of the ocular derangement. It thus becomes evident that the abnormal- ities of the visual mechanism are of the highest importance in many systemic affections, particularly in disease of the cerebro- spinal system, where it is always necessary to inquire as to de- rangements of the eyes and their significance. Let us first briefly consider the idiopathic derangements of the eye that induce derangements elsewhere. Both in origin and in result these are essentially functional. So far as relates to the eye they consist chiefly either in abnormalities of refraction, classed under the general head of ametropia, and comprising hyperopia, astigmatism, myopia, and presbyopia, singly or combined ; or in incoordination of the external ocular muscles, commonly called insufiiciency. The results of ametropia and muscular insufficiency are conveniently called eye-strain; and the symptoms of these conditions must not be neglected by the physician, especially in view of the fact that eye-strain generally evinces itself not so much in ocular or visual symptoms as in functional nervous derangements often far removed and apparently disconnected. For example, it is a well-established fact that eye-strain is prone to produce headache, especially in young women aftsr the age of puberty. These headaches are usually frontal, but may also be occipital, less frequently of the vertex or diffused. Eye-strain is at times the starting-point of choreic symptoms, and even of DISEASES OF THE BRAIN AND SPINAL CORD. 89 genuine chorea. Cases have been reported * by trustworthy ob- servers showing that the same cause may produce functional gastric derangemente, hysteria, melancholia, and even epilepsy. The lesson is obvious that when these or other functional affec- tions do not yield to direct treatment, or when their origin is not otherwise explainable, we should at once proceed to exhaust the possibilities of a reflex neurosis due to ocular abnormality or to some other peripheral irritation. Hyperopia and hyperopic astigmatism are much the most frequent sources of eye-strain, and by the aid of a mydriatic, followed by tests with the trial-lenses, the diagnosis of the ex- istence and amount of the defect may be made. In the neu- rotic, or in those with intercurrent affections and weaknesses, the smallest amount may become the source of irritational strain. Muscular insuflSciency is the next most frequent cause of ocular irritation, and its existence is at once and easily detected by a simple test. The correct diagnosis of its amount demands the officfes of one specially skilled. Simple myopia produces no strain, but myopic astigmatism, and presbyopia, may sometimes cause it. Turning now to the consideration of those changes in the ocular mechanism which indicate effects and symptoms of disease elsewhere, we find that disease in almost any part of the organism may give indications of its nature and location in the eyes. These symptoms, either singly or combined, are of a threefold nature : Changes in the external appearances and visible to the naked eye. Changes in the fundus oculi, or eye-ground, as revealed by the ophthalmoscope. Defects of vision as shown by the subjective report of the patient. The first and last set of symptoms require no very considerable special training to study, but the use of the ophthalmoscope does demand it, and often to such a degree that many are unfortunately compelled to forego invaluable knowledge. I. Among the external ocular abnormalities of the eyes visible * For example, Clinical Illustrations of Keflex Ocular Neuroses, by Gould, Amer. Journ. Med. Sci., January, 1890. 90 MEDICAL DIAGNOSIS. to the examiner, exception must of course first be made of such local diseases as have no systemic relations, such as ecchymoses, congestions or inflammations of the lids and conjunctiva, trachoma, glaucoma (with an unusual hardness and anaesthesia of the eye- ball, impaired vision, dilated pupil, etc.), cataract, congenital anomalies, etc. Herpes zoster ophthalmicus, a peripheral neu- ritis of the ophthalmic branch of the fifth nerve, is a dangerous and painful malady, often, if not always, owing to local causes. Exophthalmos is either due to local disease or is present as one of the main symptoms of the affection called exophthalmic goitre. A case recorded by Hale White * seems to locate the focal lesion in the medulla, in the central part of the floor of the fourth ven- tricle, near the nucleus of the sixth nerve. Next in importance is a class of diseases due to external in- fection that generally points to a source of contagion elsewhere in the organism. Cases of localized tuberculosis of the conjunctiva have been reported wherein the handkerchief has perhaps carried the bacillus to the eye. Gonorrhceal ophthalmia is a constantly recurring disease in ophthalmic practice ; but the most frequent and frightful is the ophthalmia of the new-born, — ophthalmia neonatorum, — due to infection during labor with the vaginal dis- charges of the mother. It is said that the greater part of the blindness of the world is due to this wholly preventable disease. Affections of the conjunctiva or lids may have their origin in diseases of the adjacent skin or mucous membrane, and extend to the eyes by simple contiguity of structure. There is reason to believe that a close connection may frequently exist between hay- fever, catarrhal and other diseases of the nasal mucous membrane, and similar conditions of the conjunctiva. Arcus senilis, a ring of grayish tissue-change about the corneal limbus, betokens generalized atheromatous or fatty degeneration, chiefly arterial or cardiac. Interstitial or diffused keratitis is nearly always the result of inherited syphilis. In rubeola, scar- latina, smallpox, and erysipelas, the external ocular structures may be injured or destroyed by the same causes that produce the skin-lesions, or by extension of the disease to the eyes from the skin. * Brit. Med. Journ., March 30, 1889. DISEASES OF THE BRAIN AND SPINAL COBD. 91 Of the remaining affections of the external parts of the eye indicative of general or internal disease, the most important are those pertaining to the muscles of the eye or movements of the globe. They easily fall into two groups, — those of the external and those of the internal muscles. Strabismus, or squint, may be due to local causes, such as in- juries, or cold, etc., but it usually arises from a lack of equal or bal- anced power among the twelve external muscles, and to ametropia and anisometropia. The distinctive subjective characteristic of squint is double vision ; but so numerous are the possible combi- nations that it is often difficult, if not impossible, to tell just what nerves or muscles are implicated, and the exact seat of the lesion. In examining for strabismus we observe whether the eyeball is tm'ned inward or outward. In paralysis of the external rectus we have ordinarily an internal or convergent squint, in paralysis of the internal rectus an external or divergent strabismus. In palsy of the superior rectus there is inability to raise the eyeball in a proper manner above the horizontal level ; inability to lower it below indicates palsy of the inferior rectus. Strabismus due to local causes must be distinguished from true paralytic squint due to more centrally located lesions. It must also be distinguished from spastic action of the muscles caused by irritative intracranial injuries. In both the latter cases there is a conjugate or common movement of both eyes to one side or to the other, called conjugate lateral deviation ; the head often shares in the lateral movement. In spastic irritative lesions of the cortex the eyes are turned from the side of the injury ; in paralytic or destructive lesions they are turned toward it. The eyes, as it has been said, look at the lesion in paralysis, away from it in spasm. The symptom, however, owing to its frequently temporary existence, and also to the fact that it may arise as an indirect symptom, must not be relied upon except in conjunction with others and when continuing at least for several weeks.* The seat of the lesion may be in the cortex, the internal capsule, or the pons ; in the latter case the * The direct symptoms are those intimately dependent upon the lesion of a part ; the indirect or distant symptoms are those due to disturbances of circu- lation, to pressure, to the reflex or inhibitory eifects at other points than the seat of injury. The less marked the cerebral symptoms, the more probable is it that the paralyses are direct. 92 MEDICAL DIAGNOSIS. symptoms are direct and the deviation of the eyes is the reverse of that given above : the eyes in paralysis look away from the lesion ; in spasm, toward it. If in lesions of the pons the sixth nerve nucleus be included, there is, of course, paralysis of the external rectus, so that the corresponding eye cannot be rotated outward past the middle line, whilst the other eye cannot be ro- tated inward past the middle line. This associated movement of the other eye will not be impaired if the injury to the sixth nerve be between the nucleus and the globe. Owing to the peculiar position of its nucleus and the long course of exit of the sixth, nerve, its exclusive paralysis is the most frequent of single nerve palsies. It is peculiarly liable to paralysis from indirect or pressure causes, but if connected with paralysis of the opposite side of the body and with other symptoms of brain disease, it clearly points to a lesion of the pons. In consequence of the close anatomical relations of their nuclei, palsies of the sixth and facial nerves are frequently asso- ciated. Other nerves originating in the pons are, of course, liable to implication in varying degrees. Next to the sixth the third nerve is the one most often paralyzed, and, in proportion to the numbers of twigs involved and the completeness of their palsy, is there a probability of a lesion at the base of the brain, though the location can be rendered certain only by a study of associated palsies and symptoms. The various paralyses of the external ocular muscles are usually attended with double vision, diplopia. Ptosis may exist either with or without involvement of other third-nerve branches, but in any case the value of the droop of the upper eyelid as a localizing symptom is somewhat indeterminate. If of one eye alone, ptosis usually indicates a cortical lesion, unless due to evidently local causes. In paralysis of the third nerve we have, besides the ptosis, dilatation of the pupil of rnod-. erate extent. Inability to close the eyelids is associated with paralysis of the facial nerve. As regards the nature of the lesion, the ocular symptoms gen^ erally give little definite indication, and, at all events, must be considered in relation with others and with the history of the case. Abnormalities of the pupils are understood by remembering that DISEASES OF THE BRAIN AND SPINAL CORD. 93 the third nerve controls the contractile mechanism and the cer- vical sympathetic the dilating mechanism. Hence an unusual diminution or increase of either innervation, especially of .the first, causes alterations of the pupils at once. Irritative cerebral lesions thus produce contraction, whilst lesions which destroy cere- bral function produce morbid dilatation. The state of the pupil in tumors, hemorrhage, and inflammatory conditions of the brain may thus furnish us with most serviceable indications of the extent and destructiveness of the injury. "When but one pupil is abnormal, the rule above given serves to indicate lesion of the corresponding half of the cerebrum, irritative or paralytic according to the degree of the injury. Yet one-sided contrac- tion, like one-sided dilatation, may also be owing to tumors at the root of the neck. Hemorrhage or effusion into the pons or lateral ventricles, when small or irritative, produces contraction ; but if large, permanent dilatation. Certain drugs, such as opium, contract the pupil ; belladonna and chloral dilate it. We also find dilatation of both pupils in chlorosis. If the foot be pricked, the pupils dilate, provided the iris be uninjured and the sen- sory columns be intact. In epileptics this reflex excitability is greatly diminished.* The pupillary reaction to light may be useful in diagnos- ticating the location of a lesion, whether beyond the corpora quadrigemina or not. If beyond, the pupillary reflex will be retained, despite the loss of sight. Lesions of the spinal cord and of the sympathetic nerve produce results the reverse of cerebral disease : irritative lesions dilate, paralytic lesions con- tract. In this connection the Argyll -Robertson pupil — the light-reflex lost, the accommodative reflex retained, of a myotic pupil — is of value as indicating, often early, sclerosis of the pos- terior columns of the cord. When hemianopsia is due to disease of the optic tract, the pupil fails to react to the stimulation of light reflected upon the blind half of the retina ; contracting, how- ever, if the lesion be situated in the cerebral hemisphere. Paral- ysis of the accommodation may exist independently of pupillary involvement, and its significance is that of paralysis of other branches of the third nerve. Paralyses of many or of all the * Lawson, West Kiding Reports, vol. iv. 94 MEDICAL DIAGNOSIS. muscles of both eyes, ophthalmoplegia, is usually due to a .esion of the nuclei of the supplying nerves. II. Abnormal changes in the fundus of the eye may be of great diagnostic value, and in almost every case of circulatory or ner- vous disease the ophthalmoscope gives valuable hints concerning the general disorder. This is rendered exceptionally true by the fact that these changes are most frequently symptomatic, and, with few exceptions, do not arise from local disease. We should invariably examine with the ophthalmoscope the eyes of patients suspected of having disease of any part of the eerebro-spinal nervous system. Changes in the eye, indeed, often occur early enough to be the first certain sign of disease, and this, too, without any impairment of sight ; on the other hand, lesions indicating cerebral or other organic aifection have been found in cases in which failure of sight was alone complained of, the cause being unsuspected. But particularly is the ophthal- moscope valuable in enabling us to differentiate organic from functional affections. It tells us of extension of congestion or of inflammation of the brain to the internal structures of the eye, or of the amount of resistance offered to the circulation within the cranium. This resistance may either arise from a marked " coarse" lesion, or may make itself felt through the sympathetic nervous system. The changes in connection with organic disease have been ob-. served chiefly in the retina, the optic disk, and the choroid. In using the ophthalmoscope for medical diagnosis we pay particular attention to these structures; especially do we note the disk, its color and size, and the pigment around its edges, the region of the macula, the size and appearance of. the arteries and veins, whether diminished, enlarged, or tortuous, whether there are exudations or hemorrhages in the course of the vessels, and in what part of the eye-ground the patches are most marked. Hypereemia, or increased redness, is due to local causes ; and the fundus-changes in myopia, astigmatism, retinitis pigmentosa, and some forms of choroiditis are also to be excepted. In diseases of the blood and the blood-making organs, the indications are re- markably clear. Retinal hemorrhages are a common concomitant of such general diseases as albuminuria, diabetes, anaemias, cardiac valvular disease^ arterial atheromatous and fatty degenerations. DISEASES OF THE BRAIN AND SPINAL COED. 95 chronic malaria, and other febrile conditions. Embolism of the central artery of the retina, causing unilateral blindness, points to cardiac valvular disease. There is a grayish discoloration about the macula, with a central cherry-red spot. Poverty of the blood, simple ansemia, is at once recognized by the trans- parency of the blood-columns, and leuksemia and pernicious an- aemia produce characteristic changes in the eye-ground, especially the last, with retinal oedema and hemorrhages, disk -discoloration, arterial pallor, and venous distention. Albuminuric retinitis is not invariable in albuminuria, but, when present, renders the prognosis more serious. The typical fundus-changes consist in an early stage of haziness of the papilla and central part of the fundus, slight hemorrhages, and faint grayish discolorations. Later, white dots or splotches are grouped about the macula, or, flame-like, radiate from it. Striate hemorrhages are scattered over the fundus, the papilla is cedematous, and its limits are obscured. The ophthalmoscopic signs of diabetic retinitis are very similar to the last. Visual disturbances, however, do not, in either case, stand in any exact ratio to the defects of the eye-ground. Atrophy of the optic nerve, recognizable by the whiteness or discoloration of the disk, failure of vision, even to blindness, etc., may sometimes seem to have no remote causes, but is commonly associated with, or a result of, diseases or lesions of the spinal cord or the brain, toxic substances in the blood, papillitis, etc. Papillitis, optic neuritis, " choked disk," is a symptom of most decided diagnostic value. The picture is easily recognized, con- sisting in a swollen red disk, the edges and vessels of which are obscured by a "woolly," striate blurring extending to the adja- cent retina. This condition is always symptomatic, and in the large majority of cases points to tumor of the brain, though other intracranial diseases may produce it. From papillitis, however, nothing can be argued as to the nature or location of the tumor or other affection. Its existence — and it is often not a late symp- tom — at once demands careful inquiry and energetic treatment. This is particularly true because unimpaired vision may coexist with even a severe papillitis. Optic neuritis has been observed after measles and scarlet fever, also after malaria and typhoid fever.* * "White, Journal of the Am. Med. Assoc, Oct. 1893. 96 MEDICAL DIAGNOSIS. Choroidal inflammations are chiefly distinguishable by the striking color and pigment changes of the fundus. Plastic cho- roiditis is commonly secondary to meningeal affections and pros- trating fevers ; purulent choroiditis, to local or general infection or septicsemia. Disseminated and central choroiditis, or choroido- retinitis, is frequently the result of syphilis. The choroid is peculiarly liable to become the seat of tuberculous growths. III. Passing now to tlie consideration of purely subjective visual derangements, it becomes highly necessary to determine first whether such defects are due to refraction-errors, insufficiencies, and other local causes, or if they are secondary and symptomatic. Unless other indications are present, the complaint of headache, especially if frontal, weariness or pains of the eyes after near-woi'k, affec- tions of the lids and conjunctiva, conjoined with general irri- tability and functional gastric derangements, almost invariably indicate eye-strain as primary. Simple inability to see distant objects clearly, without other symptoms local or general, indicates myopia. Amblyopia, due to the excessive indulgence in tobacco or alcohol, has but a single objective sign : an unusual pallor of the temporal portion of the papilla. There is deterioration of visual acuity, to which subnormal color-perception may be added. Amblyopia sometimes occurs also as a manifestation of hysteria and in associa- tion with migraine. It has further been observed as a symptom of intoxication with quinine and iodoform, or after sexual excesses ; or the defective acuteness of vision shows itself as a day-blind- ness or as a night-blindness ; or takes the form of contracted fields of vision, or of color-blindness. Marked visual deterioration of a single eye should lead to inquiry for extra-local causes. It may be due to disease of the corresponding optic nervfe. When ame- tropia has been excluded and the above-described ophthalmoscopic signs are wanting, the cause must be sought in disease of other organs. Paresis, and even paralysis of the accommodation, and visual failure, are not infrequent as reflex neuroses from peripheral irritation of other parts. Cases of abnormalities of dentition and other dental troubles producing such visual defects have been frequently reported. Menstrual difficulties, masturbation, the influence of pregnancy and lactation, may sometimes account for obscure ocular troubles. Hemeralopia, night-blindness, due to DISEASES OF THE BRAIN AND SPINAL COED. 97 deficient nutrition of the general system, has been traced to insuffi- cient food.* Modifications of the color-fields have been found chiefly in hysterical patients. The field for red and green, always the narrower, shows the restriction most markedly. The most important ocular sign of cerebral disease, and one invariably pointing to intracranial affection, is hemianopsia, or loss of vision of the halves of the fields. The most common variety is that called homonymous lateral hemianopsia, in which the loss is either of the temporal half of one eye and of the nasal half of the other, or vice veisa, a vertical line nearly through the centre being the dividing line. There are three other forms of hemianopsia, called temporal, nasal, and altitudinal, in which the half-fields are respectively the two temporal, the two nasal, with the dividing line, as previously, perpendicular, or the two dark half-fields are the upper or the lower halves, with the dividing line horizontal. These three varieties are seldom met with, and, from the peculiar anatomical relations of the optic chiasm or commissure, are readily recognized as the results of lesions of this part, either at one side or the other, above or below. Ho- monymous lateral hemianopsia always indicates lesion beyond the chiasm. If the hemianopsia be "relative," — involve only a part of the perceptions of light, form, and color, the three con- stituent factors of ordinary vision, and believed to have special subcentres or strata in the general visual centre, — it must neces- sarily proceed from a partial lesion of the common visual centre situate in the cuneus of the occipital lobe.f But if the hemi- anopsia be absolute, — with complete loss of light, form, and color sense, — the lesion may be either one affecting the entire visual centre of one side, or one rendering wholly functionless the fibres of one radiation, intei'nal capsule, or optic tract. If the latter were the case there would almost certainly be other intercurrent or general symptoms, such as paralysis of other cra- nial nerves, hemiansesthesia, some form of aphasia, or hemiplegic symptoms. A symptom of great value in locating the lesion of * See article by Kubli, Archiv fiir Augenheilk., June, 1887, who describes three hundred and twenty cases occurring during the Eussian church-fasts. f Seguin limits the centre to the cur.eus ; Nothnagel makes it include also the posterior portion of the superior occipital convolution. 98 MEDICAL DIAGNOSIS. hemiaHopsia is the bemiopic pupil. Convergence of a narrow cone of light upon the insensitive half of the retina yields no pupillary reflex if the lesion be in the optic tract ; if the pupil, under such stimulus, contract, the lesion must be beyond the tract. The intracranial affection giving rise to the hemianopsia may be of malarial origin, and it and the associate cerebral symp- toms will disappear under active antimalarial treatment.* Mind-blindness, physical vision, but failure to realize the psy- chical import of the things seen, sometimes a symptom of gen- eral paralysis and obscure cerebral disease, indicates a cortical lesion in the occipital or occipito-temporal lobe, near by if not conterminous with the visual centre. Hearing. — As regards the sense of hearing, the same may be said as of vision. It, too, is perverted and impaired in various cerebral affections. Yet, to be certain that the cause of the diffi- culty is cerebral, the ear must first be examined with reference to any physical imperfection ; and in doing so we may by means of the otoscope get an idea of the vascularity of the drum, and be led from this to infer the condition of the vessels of the brain. We must also examine the throat and the condition of the Eustachian tube, for catarrhal inflammation extending to the mid- dle ear may give rise to a form of aural vertigo. Great acuteness of hearing and intolerance of sound are gen- erally symptoms of extreme nervous irritability, or of beginning cerebral inflammation. Deafness may be owing to softening of portions of the brain ; but Ferrier tells us that it is not met with in destructive lesions of the cortex. Deafness is also found as a temporary and by no means unfavorable symptom in the continued fevers. Imaginary sounds and ringing noises in the ear, or tinnitus annum, are frequent accompaniments of cerebral disorders. But the latter is encountered in so many different conditions — in dis- eases of the cerebral vessels, in congestion of the brain, in M6- nifere's disease, in affections of the heart, in ansemia — that it is a sign of little moment ; and, in truth, its most usual cause is local, — namely, an acciunulation of wax in the meatus. * See my paper on Malarial Paralysis, with eye examinations by Harlan, in International Clinics, vol. iii., Ser. I., Oct. 1891. DISEASES OF THE BKAIN AND SPINAL COKD. 99 DERANGED EEPLEXES. Derangement of the reflex action plays a most important part in the study of diseases of the nervous system. Each action is brought about by a sensory nerve that conveys the impression to the centre, by a motor nerve that transmits the impulse from the centre to the periphery, and by a reflex centre between the two in the spinal cord connecting the roots of the sensory and motor nerves, which with them forms the "reflex arc." The reflex centre is to some extent under brain control. There are two forms of reflexes to be especially studied, — the cutaneous or superficial, produced by stimulating the skin, and the deep reflexes, the muscle or tendon reflexes, evoked by tapping muscles or tendons. The superficial may be almost everywhere excited by tickling or gently stimulating the skin. The most usual ones to be noted are the reflex of the sole of the foot, the plantar reflex ; and that of the palm of the hand, the palmar reflex. The former, when nor- mal, attests the integrity of the reflex arc at the lower end of the cord ; the palmar reflex, contraction of digital flexors by tickling the palm, indicates a normal state of the reflex arc through a greater part of the cervical enlargement. Other superficial re- flexes which may be mentioned are the cremaster reflex, the drawing up of the testicle excited by stimulating tlie front and inner side of the thigh, and originating in the cord at a point between the first and second lumbar pairs ; the gluteal reflex, the contraction caused by irritating the skin over the buttock, and showing the integrity of the cord at the fourth and fifth lumbar nerves ; the abdominal reflex, a contraction in the abdominal walls caused by scratching the skin on the side of the abdomen, and depending on the action of the cord from the eighth to the twelfth dorsal nerve ; the epigastric reflex, an epigastric dimpling produced by stimulating the side of the chest in the fifth or sixth intercostal space, and indicating integrity of the cord from the fourth to the seventh pair of dorsal nerves ; the scapular reflex, a contraction by stimulation of the scapular muscles, and bespeaking the integ- rity of the reflex arc at the level of the upper two or three dorsal and lower two or three cervical nerves ; the erector spinal, show- ing itself by stimulating the skin along the border of the erector 7 lOO MEDICAL, DIAGNOSIS. spinal muscle, the contraction of these muscles showing the healthy state of the cord in the dorsal region. Other reflexes of indeter- minate utility are the erector spince reflex, a local contraction of these muscles produced by stimulation of the skin along their border, proving that the reflex arc is intact in the don-al region of the cord ; the platymia reflex, dilatation of the pupil upon pinch- ing the platysma myoides muscle ; the jaw-jerk or clonus, rarely present in health, elicited by suddenly depressing or tapping with a hammer on the inferior maxilla, when clonic movements of the lower jaw are produced ; the peroneal reflex, a stroke upon these muscles when in tension, or when the foot is bent inward, causing a reflex movement. To these may be added the tendo AcUllis reflex or front-tap contraction, described by Gowers, a reflex con- traction of the gastrocnemius when the muscles upon the anterior part of the leg are struck, the leg being extended and the foot flexed by the hand upon the sole. It is considered a delicate test of heightened spinal irritability. Among cranial reflexes, the more noteworthy are the iris-contraction upon exposure of the retina to light; the eyelid-closure {rom. irritation of the conjunc- tiva ; the pharyngeal, laryngeal, and palatal reflexes (cough, swal- lowing, etc.) from irritation of these parts ; and nasal reflexes, as in sneezing. The aural reflexes are of some value in appreciating disease of the cervical part of the cord.* In disease these super- ficial reflexes are often absent. Thus, disease of one cerebral hemisphere diminishes or destroys them on the other side, the paralyzed side of the body. In pregnancy all reflexes are increased. The superficial reflexes are much influenced, increased or diminished, by psychical causes.f The reflex phenomena connected with the tendons give us the best illustration of the so-called deep reflexes. The tendon of the patella is the one most readily studied ; and if, the body being bent forward, we strike abruptly the tendon of the patella just below the knee-cap, after rendering the ligamentum patellES tense by flexing the knee at a right angle while one knee-joint rests upon the other, a sudden contraction takes place in the quadriceps femoris muscle, and the foot is jerked upwards. When very slight, the knee-jerk is most readily elicited by a tap with the percussion * Amer. Journ. Med. Sci., Dec. 1888. f Jeiidrassik, Deutsch Arcliiv f. klin. Med., April, 18! 4. DISEASES OF THE BRAIN AND SPINAL COED. 101 hammer. This reflex is due to a muscle reflex action dependent upon the spinal cord. The knee-jerk is found in health, and is markedly increased in disease of the pyramidal tracts, in heightened irritability of the gray substance of the spinal cord, in many tumors of the brain, in cerebro-spinal sclerosis, in lateral sclerosis, after epileptic seiz- ures or unilateral convulsions, in spinal irritability.* It is absent in locomotor ataxia, even at an extremely early stage of this affection. It is also abolished in affections of the anterior srrav cornua, in infantile paralysis, in destructive lesions of the lower part of the cord, in advanced stages of pseudo-hypertrophic paral- ysis, in alcoholic paraplegia, and, temporarily at least, as pointed out by Hughlings Jackson, in meningitis and in instances of emphysema and other maladies in which the blood has become venous to an extreme degree,t and disappears in certain general constitutional affections, as in diabetes and in diphtheria.J I have also known it very exceptionally to be absent in healthy persons, in one instance in three brothers. The biceps reflex is developed by tapping the tendon of the biceps. This leads to contraction of the biceps muscle. Its meaning is the same as that of the knee-jerk. Tapping on the front of the wrist gives rise to contraction in the flexors of the fingers ; striking the tendon of the triceps above the olecranon causes contraction in the triceps. This is especially marked in the irritable muscle of the early and late rigidity of hemiplegia. Another deep reflex is the jseri- osteal. It is produced by tapping the bones of the forearm or leg, which gives rise to active contraction of the muscles, and indicates a disease of the spinal cord, especially amyotrophic lateral sclerosis. In some instances of disease the reflex phenomena are produced on the side opposite to the one acted on. These crossed reflexes are not unfrequently met with in posterior spinal sclerosis, and are not merely associated contractions. A secondary stimulation of a motor centre in the opposite side of the cord has been suggested as the cause in a case of transferred patellar tendon reflex. § A tap on the tibia near its middle generally induces contractions of * Hughlings Jackson, Med. Times and Gaz., Feb. 1881. t Brit. Med. Journ., 1892, No. 1614. X Marie et G-uinon, Revue de Med., July, 1886. § McLane Hamilton, Archives of Medicine, New York, Dec. 1883. 102 MEDICAL DIAGNOSIS. the quadriceps femoris ; and it is often followed by contractions of the quadriceps. of the opposite leg when both the pyramidal tracts are diseased.* The phenomenon called reinforcement of a reflex may have its use and significance in the diagnosis of doubtful or obscure cases. In testing the muscular power of the hand by the dynamometer, it is well known that when one hand is fatigued it has greater power if the other hand be forcibly and synchronously clenched than if acting alone. In the same way it has been shown that any reflex is heightened by coincident muscular exertion of other parts than those being tested. Thus, if a desired reflex be weak or diflicult to elicit, it may be brought out by muscular tension of some other member or part of the body. Strong sensation of the skin a• ^ „ , , , ,.,, — False and true croup, in children. > Specific affections— Syphilis, tuberculosis, lepra, diphtheria, erysipelas, typhoid, etc. 274 MEDICAL DIAGNOSIS. Chronic Organic Diseases. Inflammation of the mucous membrane of a part, or of the whole — Chronic laryngitis in its various forms — Abscess. Destruction of the cartilages. Growths and tumors of various kinds. Ulcers, simple and specific. Affections of the Nerves. Spasm of the larynx. (Laryngismus stridulus.) J>Jervous aphonia. < Chorea of the larynx. Nervous aphonia. \ I'u^««°°«'l. °^ P^^rely nervous aphonia. t. Paralysis of the muscles of the vocal cords. Acute Laryngeal Affections. Acute Laryngitis. — In its mild form, acute laryngitis is neither an uncommon nor a dangerous disease. In its severe form it is much more uncommon, and very much more dangerous. When it is slight, it occasions simply hoarseness ; a feeling of tickling and irritation in or near the larynx ; a trifling, though annoying, cough, or rather a constant disposition to clear the throat, more than a cough ; and, owing in a great measure to a coexisting inflammation of the fauces, some difficulty in swallow- ing. The disorder passes ofl" in the course of a few days. When the inflammation is violent, and especially when it in- volves the submucous tissues, the symptoms are much aggravated, and life is in peril. The respiration becomes seriously impeded ; with each breath a wheezing or whistling noise is heard. There is but little expectoration ; and the cough is distressing and pain- ful, and has a harsh sound. The voice is hoarse, or sinks into a scarcely audible whisper. The patient knows the seat of his disease : he feels that it lies in the windpipe, and complains of this being tender when pressed, and of a feeling of constriction in the throat. There is difficulty in swallowing, and fever, with a full pulse and flushed face. If the case advance unchecked, the countenance becomes distressed and pale, the lips bluish, the pulse irregular, and death sets in with all the signs of deficient aeration of the blood and of strangulation. The disease in its graver form runs a very rapid course. If in a few days after its commencement no improvement show itself, DISEASES OF THE LARYNX AND TRACHEA. 275 life does not last long". Sometimes death takes place on the first day of the attack. It rarely waits for the sixth. (Edema of the laryngeal mucous membrane is often the consequence of the in- flammation and the cause of the danger. The marked symptoms of the perilous complaint prevent it from being overlooked, and render its discrimination easy. There is fever with dyspnoea in the acute pulmonary affeotions ; but the voice remains unaltered, and they exhibit physical signs which acute laryngitis does not, — they show rales, or abnormal respira- tion-sounds ; while in laryngitis the murmur of the lungs is that of health, although it is sometimes enfeebled by the impediment in breathing, or obscured by the shrill sound which issues from the larynx. We find difficulty in swallowing and some hinderance in breathing in tonsillitis ; but inspection of the oral cavity imme- diately detects the source of the disorder. There is difficulty in swallowing in pharyngitis, but there is not embarrassed breathing, or a peculiar voice, or cough, and the fauces appear dusky and injected, while they are but slightly affected in laryngitis, unless the inflammation of the larynx have supervened upon that of the throat. Croup resembles acute idiopathic laryngitis most nearly ; but it is as rare in the adult as acute laryngitis is in the child, and, as we shall presently see, obvious differences in the symp- toms exist. An affection of the larynx cocurring only in winter, laryngitis hiemalis, has been described by Mulhall, in which the secretions form adhesive crusts, producing difficulty in speaking, or more often aphonia. This is to be diagnosticated from laryngitis sicca, which is a part of a general process, and follows pharyngitis sicca and atrophic rhinitis. There is a peculiar form of inflammation of the larynx, diffuse cellular laryngitis, a diffuse inflammation of the cellular tissue, with lymph or pus infiltrated in the submucous tissue, to which attention has been called by Henry Gray.* It is a formidable affection, which bears a strong likeness to erysipelatous laryngitis, but, what is not by any means constantly the case in this disorder, the symptoms begin in the fauces and larynx ; and, wholly unlike erysipelatous laryngitis, the submucous tissue is primarily attacked, * Holmes's System of Surgery, vol. iv. 18 276 MEDICAL DIAGNOSIS. and the neck becomes greatly swollen from' the effused products around the larynx, trachea, and oesophagus filling its cellular tissue. The disease begins with chills, soreness of throat, and fever, soon succeeded by a hacking cough, by dyspnoea, by a dusky hue of the fauces, by enlargement of the tonsils and of the glands in the neighborhood of the jaw, and by great difficulty in swallowing. As the complaint proceeds, the neck increases greatly in size, the fever assumes a low type, and the patient either sinks gradually or dies asphyxiated, perishing sometimes rapidly from a speedy increase of the laryngeal tumefaction. A form of cedema of the laryngeal mucous membrane exists, due to submucous effusion of a myxoid substance which occurs in the course of influenza, and to which Seller has applied the term myxoid oedema; there are aphonia, swelling, and severe localized pain. The diagnosis is chiefly made by considering the history of the case, and the symptoms, which are not so acute as in ordi- nary oedema. Other forms of inflammation of the larynx to which attention has of late years been called are hemorrJmgic laryngitis, an acute catarrh of the larynx, attended by bleeding from the inflamed membrane, and laryngeal rheumatism. This generally happens in persons of rheumatic diathesis, is attended with considerable pain, and may or may not be associated with other signs of rheumatism.* There are cases in which laryngeal symptoms are marked, and cases without them. Roos reports f several instances of rheumatic angina that terminated in attacks of general rheumatic arthritis. The principal features of rheu- matic angina are excessively painful deglutition, redness and swelling of one or both tonsils ; the disease is of slow de- velopment, and occurs with or without abscess-formation. It has been suggested that the joint affections are really secondary manifestations, pseudo-rheumatic in character, and that the polyarthritis belongs to the category of attenuated pysemic in- fections. H. L. Wagner has found articular rheumatic affections following follicular amygdalitis, in which bacterial investiga- tion showed that the synovial fluid obtained by tapping the joint * Archambault, These de Paris, 1886. f Eevue de Laryngologie, etc., 1895. DISEASES OF THE LAKYNX AND TRACHEA. 277 contained the same micro-organisms as were found in the dis- eased tonsil.* Following inflammation or ulceration of the larynx, various irregularities may occur as the result of cicatricial contraction, or adhesions between the cords, which may be studied with the aid of the laryngoscope. There are usually alterations in the voice, with attacks of dyspnoea simulating asthma, and impairment of general nutrition. (Edema of the Larynx. — The danger of acute laryngitis of any kind is much aggravated by the precise seat of the disease. When the inflammation takes place immediately around the glottis, and causes a serous fluid to transude, cedematous laryn- gitis, the peril is greatly increased. The inspiration is audible, noisy, hissing, and labored ; there is a distressing sensation of constriction or obstruction in the windpipe, and the patient makes repeated efforts, by swallowing or by hawking, to clear his throat of the substance which seems to be clogging it. His difii- culty of breathing is intense, and occurs in frightful paroxysms, sometimes of a quarter of an hour's duration, in which strangu- lation appears to be imminent ; and, indeed, often he does perish by strangulation. This grave disease, oedema of the larynx, sometimes follows an extension of the peculiar inflammation of the throat in the ex- anthemata, or is of erysipelatous origin, and it occasions death quickly, and amidst great suffering. But the oedema may arise without preceding acute inflammation, whether this be specific or not. It may result from long-continued pressure on the trachea or larynx, or in exceptional instances occur in connection with Bright's disease. Again, an effusion of serum may cause death suddenly in a person who has been laboring under a chronic laryngeal disorder.f Such cases of oedema of the larynx are dis- tinguished from those produced by active laryngeal inflammation by the absence of fever, of local tenderness, and of marked diffi- culty of deglutition. It is true that, if the cedematous affection * Rheumatic Aifections of the Body due to Tonsillar Disease, Trans. Amer. Laryngol. Assoc., 1894. t As in tubercular laryngitis, which may be complicated both with acute and, more frequently, with chronic oedema. See an interesting paper on the connection in Archives de Physiologie, No. 6, 1882. 278 MEDICAL DiAGJsrosra. ensue upon a chronic inflammation of the larynx, tenderness and an impediment in swallowing may be observed. But the history of the malady and the non-existence of fever leave little room for error. The diagnostic sign proposed for oedema of the larynx — the swelling of the epiglottis, as ascertained by the touch — cannot be relied upon, because this swelling does not always exist to an obvious degree, and, even when it does exist, is not readily deter- mined by the finger. In the acute eases of cedematous laryngitis the laryngoscope shows a bright-red mucous membrane j some- times the tumid epiglottis presents the appearance of two round red swellings. It is generally erect and tense. The oedema, in rare instances, may be altogether below the glottis. Group. — Croup is inflammation of the larynx and trachea ; but it is something more. It is a spasmodic action of the muscles of the larynx, which spasmodic action gives rise to much of the peculiar cough, the stridor, and the paroxysms of dyspnoea, so characteristic of the disease. As croup is thus an afiection com- posed, as it were, of several distinct elements, it differs somewhat according as one or the other of these elements preponderates. Thus, the inflammation may be comparatively slight, yet the spasm play a very prominent part; or the inflammation may be very severe, and result in the formation of a false mem- brane. To the first class belongs the disorder known as false croup, catarrhal croup, spasmodic croup, spasmodic laryngitis; to the second, the true or membranous croup, and diphtheritic croup. False or catarrhal croup. — This is one of the most common diseases of childhood. Its seizures happen chiefly at night ; and the child that has gone to bed well, or perhaps fretful from teeth- ing, or with a slight catarrh, wakes up suddenly in a state of alarm, breathing with difficulty. It coughs with violence at short intervals, and the cough is noticed to be loud and ringing and hoarse ; and so are the voice and the cry. Each inspiration is attended with that shrill, " croupy " sound which, once heard, is never forgotten. The face is flushed, the pulse frequent, and the temperature but little above the normal. The paroxysm continues in this manuer for about an hour ; the breathing then becomes quiet, the child falls asleep, and rests well until toward DISEASES OP THE LARYNX AND TRACHEA. 279 morniug, when the attack is apt to be renewed. The little patient may, however, escape this altogether, and keep well ; or else the paroxysm recurs the next night, or for several nights in succession. In the intervals the voice and respiration are natural, there is little or no fever, little or no cough. Yet sometimes a cough occurs, during the day, which has every now and then a croupal sound ; the voice, too, is slightly hoarse. Catarrhal, or false croup, most frequently follows exposure. It is very rarely fatal. The laryngoscope shows marked congestion with swelling of the mucous membrane and copious muco-puru- lent secretion. Cases in which the inflammation is extensive and severe, without having led to a plastic exudation, and in which the inflammation is apt to be chiefly subglottic, approach in their persistency and in the character of their symptoms very closely to true croup. Indeed, one form of the complaint may run into the other, warranting the assumption that they are not two dis- eases, but only two forms of the same disease. Spasmodic croup may be a symptom of abuormalities, such as of hypertrophies or of adenoid growths in the nose or pharynx, and, if persistent, should suggest a digital or rhinoscopic examination. The main element in the production of the symptoms of false croup is undoubtedly spasm of the glottis. But laryngismus strid- ulus, as laryngeal spasm or spasm of the glottis is called by many, is a neurosis which, while it may complicate any affection of the larynx and trachea, may also exist independently, from central, or direct, or reflex, causes of irritation. The laryngeal spasm may, therefore, form a distinct disorder, which differs from catar- rhal croup by the absence of all inflammation and by several circumstances which proclaim its non-identity, such as its usual connection with rickets, and its frequent association with other convulsive symptoms, — with distortion of the face, rolling up of the eyes, spasmodic contraction of the hands and feet, and general convulsions. Laryngismus and tetany are often associated ; indeed, by many laryngismus is looked upon as the laryngeal expression of tetany. The Trousseau sign of tetany — pressure upon the large arteries and nerves of a limb developing a paroxysm of tetany — is said to be never absent in the laryngo-spasm.* * Escherich, address before the Tenth International Congress. 280 MEDICAL DIAGNOSIS. Some cases of supposed purely nervous laryngeal spasm in children are undoubtedly symptomatic of laryngeal growths, or of paralysis of intrinsic muscles, and are really attacks of dyspnoea due to laryngeal obstruction. Laryngoscopic exan)ination should be made in severe cases, even though an anaesthetic be required, as in Scanes Spicer's method. Laryngismus stridulus is an affec- tion of children under two years of age. Crying may bring on the attacks, the child dying of suffocation or during convulsions. In some cases mentioned by Mackenzie, the attack assumes the form of a sudden, almost soundless, spasm that does not relax until life is extinct. As in croup, the seizures are apt to take place at night. Gen- erally the child has been fretful from teething, or from gastric or intestinal irritation, when suddenly an attack of difficult breath- ing occurs, accompanied by several loud, crowing inspirations, and by an appearance of the most manifest distress and of threat- ening suffocation ; yet the paroxysm is not associated either with cough, or with fever, or with an altered voice or a materially changed cry. A fit of this kind may be repeated twenty or thirty times a day. It may terminate fatally in a short time ; usually, however, the paroxysms are spread over weeks, or even over a longer period. In addition to the frequent combination with other convulsive symptoms, the protracted duration of the disease, and the absence of febrile disturbance, of hoarseness, and of cough, point out the distinction between laryngeal spasm and catarrhal or spasmodic laryngitis. From bilateral palsy of the vibrators of the glottis, laryngismus is readily distinguished by the great and persistent difficulty of breathing in this affection. Laryngeal spasm also occurs in the laryngeal crises of tabes ; the absent knee-jerk and the ataxia tell us its meaning. In the adult, glottic spasm produces symptoms to which the name of laryngeal vertigo has been given ; the attack comes on suddenly, the patient gasps for breath and becomes unconscious and asphyxiated. In such cases attendant disease of the pharynx often affords the explanation of the symptom. True or membranous croup. — True croup is a formidable affec- tion, in which there is inflammation that results in the formation of a false membrane. The plastic exudation is found lining the DISEASES OF THE LARYNX AND TRACHEA. '281 larynx, extending at times into the trachea or down into the bronchial tubes. The symptoms of this dangerous malady are : the same brazen cough, the same stridulous breathing, as in false croup, a decided change in the voice, dyspnoea, and fever. But all these symptoms do not show themselves at once, and generally only attain their intensity after ordinary catarrhal croup has existed for a few days. High fever — the temperature ranging from 103° to 104°, or upwards — and difficulty in breathing are manifest, and, al- though they exacerbate and remit, only cease when the disease ceases. There is much thirst, no appetite ; but what is taken is readily enough swallowed. The voice, changed almost from the onset, becomes hoarse and whispering, and, as the disease ad- vances, often totally suppressed. The child remains in this condition for several days : restless, with its head thrown back, its respiration labored, and the croupal sound never completely disappearing. The great efforts at getting air into the lungs through the obstructed windpipe give rise to inspiratory recessions, seen at the supra-sternal not«h, above the clavicles, and at the epigastrium. Sometimes solid masses of mem- brane are coughed up. Finally, the cough stops altogether ; the intervals between the paroxysms of dyspnoea are effaced ; the countenance becomes livid ; the skin loses its sensibility ; the extremities grow cold ; and, unless relief be affijrded, either by medicinal means or by an operation, the little sufferer dies coma^ tose or suffocated. The fatal termination is not unfrequently hastened by an intervening attack of bronchitis or of pneumonia, — a fact which teaches us not to neglect examining the lungs in cases of croup, so as to be sure that no disease is there silently running its course with its symptoms masked by the tracheal malady. The application of a stethoscope to the larynx or trachea does not give us much information as to the exact seat and the extent of the affection of the windpipe. Still it is not without value. It may enable us to judge of the position of the exudation, for we may occasionally hear a vibrating sound, as if a membrane were being tossed to and fro by a current of air. In a case that came under my notice some years ago, this sign was perceived with great distinctness at the lower part of the trachea and toward the 282 MEDICAL DIAGNOSIS. comraencement of the left bronchial tube ; and, at the autopsy, at exactly this point was found a thick layer of membrane lying unattached in the tube. Laryngoscopic examinations in croup are difficult of accomplishment ; but, when successful, they demon- strate deep-red infiltrated subglottic tissue with muco-purulent incrustations; or exudation upon and immobility of the vocal cords, and the arytenoid cartilages held together by false mem- brane in the interarytenoid space.* Auscultation of the lungs, by showing to what extent the air is still capable of entering them, furnishes us with a clue to the degree of the laryngeal obstruction. Membranous croup is a disease not apt to be mistaken. Yet we must be cautious not to attach too much weight to any one of the symptoms ; we ought rather to judge of the existence of the dis- order by their grouping. But when we take the symptoms coUec- . tively, — the ringing cough, the peculiar respiration, the dyspnoea aggravated in paroxysms, the changed voice, the fever, the expec- toration ; when we regard the comparatively short duration of the disease, — there is, with the exception of the ever-present question of the diphtheritic origin, but one interpretation of the phenomena possible. It is, of course, of the utmost consequence to distinguish be- tween spasmodic laryngitis ot false croup and membranous croup. The main difference consists in this : in the former, the invasion is usually more sudden ; there is little fever, or this disappears with the paroxysm ; and so do the croupal breathing, and, to a great extent, the hoarse voice and the loud, barking cough. The disorder lasts rarely more than two or three days, the attack usually occurring at night ; whereas in true croup the duration is seldom less than from four to six days, the disease progresses steadily, and the voice and respiration show at all times the nature of the affection. Then in the latter we may find expectoration of false membrane. This is, indeed, the most absolute proof; yet the absence of membrane in what is coughed up or vomited is not a positive sign that the case is not one of membranous croup. The membrane may be retained in the larynx ; and we meet, in- deed, with instances in which it is impossible without a laryngo- * Pieniazek, Arch. f. Kinderh., x. 5. DISEASES OP THE LARYNX AND TRACHEA. 283 scopic examination to say whether the inflammation has or has not produced a plastic exudation ; whether, in other words, the case is a severe one of false croup, or one of membranous croup. The disorders, excluding diphtherias, which, next to false croup, are most likely to be mistaken for the formidable malady under consideration, are : acute laryngitis, oedema of the larynx, retro- pharyngeal and retrolaryngeal abscesses. Acute laryngitis in its ordinary form, such as we see in adults, is a very rare disease in children. Acute catarrhal laryngitis is in them closely connected with the phenomena of spasmodic croup ; and the croupy symptoms, the changed voice, the barking cough, the paroxysmal dyspnoea, the slight or absent difficulty in swal- lowing, tell us what we are dealing with. In membranous croup these signs also are intensified, and we are apt to have high fever. A form of laryngitis, however, happens in children, which is very liable to be considered as croup : it is the secondary laryngitis of the exanthemata, especially of variola. Attention to the history of the case, and to the circumstance of the inflammation having spread from the throat downward, will go a great way toward forming a correct opinion of the disease. Yet the diagnosis is sometimes one of extreme difficulty. (Edema of the larynx resembles croup, in its severe or its mem- branous form, in the dyspnoea, the fits of suffocation and of coughing, the altered voice, and the noisy inspiration. It resem- bles it further in the fact that most of the symptoms do not dis- appear in the intervals between the paroxysms. Here is certainly a strong likeness. But the cough has not the croupal, brazen sound; expiration is comparatively unembarrassed; there is no fever, unless the oedema occur in the course of an acute affection ; and, above all, oedema of the glottis is a disease of adults. Again, the history of the case often guards against error, for oedema of the larynx happens frequently, perhaps most fre- quently, in those who have been long laboring under chronic, or ulcerative laryngitis ; it is also seen from the toxic effects of iodide of potassium. In cases in which we are able to use the laryngeal mirror, the peculiar oedematous look of the parts is readily recognized. Retropharyngeal abscesses share with croup the dyspnoea, the 284 MEDICAL DIAGNOSIS. stridulous respiration, and the altered voice. They do not, how- ever, share with it the peculiar cough ; and, further, in croup there is not the difficulty in swallowing, or the evident tumefaction and stiffness of the neck, nor can a tumor be recognized by the touch, as it can be when an abscess is seated behind the walls of the pharynx. Moreover, the dyspnoea and the voice present some- what different characteristics. In the case of abscess, the former is greatly augmented or paroxysms of it are brought on by at- tempts at deglutition ; it is always preceded by dysphagia, is increased by pressure against the larynx, and is aggravated by the horizontal position. In croup, the patient seeks relief by throwing his head back, and, although he loses his voice and speaks in a hardly audible whisper, still the words are sufficiently distinct ; while an abscess gives a nasal or guttural tone to the voice, that makes it impossible to understand what is being said. Rdrolaryngeal abscesses following inflammation of the areolar tissue of the retrolaryngeal space present dyspnoea, attacks of suffocation, and cough like those of croup, and run, moreover, generally an acute course ; but they also present dysphagia and severe pain, occasioned by pressing on the thyroid cartilage.* Abscess of the larynx bears a strong resemblance to retro- pharyngeal abscess, and may be, like it, mistaken for croup. Abscess of the larynx in its acute and primary form is not a frequent disease : rare in adults, it is still rarer in children. No swelling can be detected in the pharynx to account for the pain, the cough, the difficult breathing and impeded swallowing ; but on close observation it is found that the larynx projects, and that there is induration at the posterior margin of the thyroid carti- lage. The neck is not markedly swollen, as in diffuse inflamma- tion of the cellular tissue. "With the laryngoscope, we observe a circumscribed swelling, red at its base, and often yellowish at its apex. We do not find, as we so commonly observe in croup, that both inspiration and expiration are interfered with; the latter, indeed, may be both unembarrassed and noiseless. Abscess of the larynx may have unsuspected causes. Poli f * Goix, Archives Generales de Medecine, Oct. 1882. •j- Gazetta degli Ospitali, Naples, May 14, 1894. DISEASES OE THE LARYNX AND TRACHEA. 285 reported a case in the discharge from which' the sulphur-yellow granulations of actinomymsis were detected. Watson Williams * found the Gaffky typhoid bacillus at the base of ulcers and in the structures of the larynx. Further, croup may be mistaken for tonsillitis, for capillary bronchitis, for hooping-cough, or for the presence of foreign bodies in the larynx or trachea. But the points of distinction are evi- dent. In tonsillitis or in tonsillar abscesses the breathing is not at all, or but very slightly, impaired ; and a glance into the mouth is sufficient to reveal the real nature of the malady. So it is in peritoTisillar abscess, where otherwise the suffocative attacks that are prone to happen might be misleading. In capillary bronchitis, there is dyspnoea, as in croup ; but the dyspnoea is unremitting, and associated with fine rales in the lungs, and not with a ringing cough, a harsh tracheal breathing, a hoarse voice. In hooping- cough, paroxysms of coughing and of obstructed respiration occur ; but then follows the distinctive hoop ; and there is no fever, the voice is not husky, and the child does not suffer between the spells. Foreign bodies in the windpipe give rise to stridulous breathing and to cough, but they do not often mimic croup closely enough to deceive ; and the absence of the peculiar cough and of fever, and the history of the case, prevent error ; so also does attention to the fact that the signs vary aa the foreign body shifts its position. Furthermore, as Gross f in his elaborate work points out, the embarrassed breathing caused by a foreign body is chiefly found in expii'ation. The diagnosis of membranous croup has been considered connectedly because it is convenient and practically useful to so consider it, and because I am still of the belief that there is such a disease as a membranous laryngitis which is not diphtheria. It is, undoubtedly, comparatively rare ; undoubtedly all the older descriptions of membranous croup must be with our modern eyes viewed with suspicion. But I believe it as much an error to deny its existence as it was formerly to hold to the comparative restriction of laryngeal diphtheria. The strong points in the diagnosis of non-diphtheritic membranous croup are : the gradual * Journal of Larygngology and Otology, Oct. 1894. ■[ On Poreign Bodies in tlie Air-Passages. 286 MEDICAL DIAGNOSIS. origin and the slow deepening of the symptoms ; the fact that no membranes appear in other localities ; that the disease has a laryn- geal onset, — though this may happen also in diphtheria, — and the absence of the Klebs-Loffler bacillus in any shreds of membrane in the expectoration. In discussing laryngeal diphtheria the matter is further examined into. Chronic Laryngeal Affections, Of the chronic diseases of the larynx, chronic inflammation of the mucous membrane, and the changes produced in it by inflam- mation, thickening and ulceration, are the most common. Chronic Laryngitis. — ^Alteration of the voice, cough, and an uneasy feeling in the larynx are the main symptoms. The cough is at first dry, but when of any standing is followed by a yellowish opaque expectoration. It either presents nothing peculiar in its tone or else is harsh and barking. The breathing is little, if at all, embarrassed, except when the mucous textures are greatly thick- ened or ulcerated. In that case there is dyspncea, the respiration is apt to be noisy and the voice completely lost, because the vocal cords have also suffered. There is, moreover, considerable pain on pressure ; the sputum is muco-purulent, or else purulent and streaked with blood ; and sometimes, if the cartilages also be in- volved, fragments of them are expectorated, and by the touch we recognize the changed state of the tube. The symptoms of chronic laryngitis are mostly not purely local. Chronic laryngitis is frequently, indeed, found to be connected with a broken constitution, because the inflammation of the larynx, both in its simple and in its ulcerated form, is often combined with tuberculosis, or with syphilis. In every patient, therefore, suffer- ing from chronic laryngitis, we must endeavor to ascertain whether either of these morbid conditions is present. Chronic laryngitis frequently turns out, on thorough examination, to be laryngitis linked to a serious pulmonary difiiculty ; or we detect ulcers in the pharynx associated with those in the larynx and cicatrices, and are enabled to trace clearly the ravages of constitutional syphilis. As seen with the laryngoscope in chronic laryngitis, hypersemia, general or partial, is present, associated in cases of long standing with considerable and uniform swelling of the mucous membrane ; DISEASES OF THE LARYNX AND TRACHEA. 287 the vocal cords are often uneven at their edges, and there may be, chiefly between the arytenoid cartilages, superficial ulcers. Papil- lary growths upon the edges of the vocal bands may follow inflammation or repeated attacks of hypersemia. Chronic laryngitis is Jiable to be mistaken for an aneurism of the aorta, or, more strictly speaking, an aneurism of the aorta is liable to be regarded and treated as a case of chronic laryngitis. The distinction, as will hereafter be shown, is mainly made by attention to the physical signs ; often the paralysis of a vocal cord is of great significance. Cases of functional or nervous aphonia, too, are sometimes con- founded with chronic laryngitis ; and it is by no means always easy to avoid this error. The loss of voice may be either partial or complete. It not unfrequently comes on without any previous warning ; and this fact aids us greatly in diagnosis. So does the absence of cough, of expectoration, of local pain, and of all difii- culty in breathing; for none of these symptoms are commonly observed in aphonia which is solely nervous. One of the causes of the disorder is overstimulation of the vocal nerves, by straining the voice in singing or in speaking. We also meet with it as occasioned by narcotics or by lead poisoning, and perhaps most frequently as a reflex manifestation, due to irritation of the intes- tines by worms, or to a disorder of the uterine system. In these instances of nervous aphonia the voice suddenly disappears and as suddenly reappears, a phenomenon not unusual in the aphonia of hysteria ; and we may have from impaired but not wholly lost power the voice absent only for some hours daily. It is evident that in all cases of nervous aphonia the laryngoscope will assist us greatly, as it will show the tnae condition of the parts, as regards both their structure and their mobility. It also aids us in dis- tinguishing these laryngeal disorders from cases of aphonia due to want of strength in breathing, — to want of power in expiration. Enlarged bronchial and cervical glands, or an aneurism which compresses the laryngeal nerves, also produce hoarseness, and ultimately complete loss of voice. Under such circumstances there is a short cough, attended often with loud tracheal rales ; and we observe attacks of dyspnoea, with a noisy, hissing respira- tion. The practical lesson which all such cases teach, is to re- member that the symptom considered most characteristic of 288 MEDICAL DIAGNOSIS. chronic laryngeal inflammatiou — the altered voice — may occur when no laryngitis exists ; also to examine with the laryngoscope, and to note the effect of palsy of the muscles the result of nerve- pressure. In thoracic aneurism, pressure symptoms, such as the dyspncea and the altered voice, with paralysis of laryngeal mus- cles, may be produced either by pressure upon the recurrent laryngeal nerve, which ou the left side passes around the arch of the aorta, or upon the vagus. Pressure upon the vagus will give rise to abductor paralysis of the corresponding side, with adductor spasm of the laryngeal muscles of the opposite side, the spasmodic movements b?ing intermittent. Pressure upon the one recurrent nerve causes one-sided abductor paralysis, the cord being at first in the middle line, but later it assumes the position due to adductor paralysis. Pressure upon one vagus, inducing double adductor spasm, produces serious dyspnoea and difficult phona- tion ; but pressure on one of the recurrent nerves may occasion intermittent dyspnoea that is usually not very troublesome, and scarcely, if at all, affects phonation. Major's * researches have given us much of this definite knowledge. Now, in the nervous forms of aphonia just mentioned, with the exception of those caused by pressure, the loss of voice is due to deficient power, and the cords move sluggishly or not at all. When the disorder reaches a high degree, we perceive, on looking into the laryngeal mirror, that the vocal cords do not approximate as the patient attempts to say a or o. But, besides these cases, owing to general want of force, we find cases of spasm of the tensors of the vocal cords with most peculiar, partially interrupted voice, and of absolute paralysis of individual muscles, as of one adductor of a cord ; or of one or both posterior crico-arytenoids, or abductors ; or of the crico-thyroids, or tensors. In some of these there is considerable dyspnoea, with noisy breathing ; in all the laryngoscope affords the only means of diagnosis. In paral- ysis of the external tensors of the vocal cords, the crico-thyroid muscles, there is inability to use the higher notes with any free- dom ; the voice is rough or entirely lost, and viewed with the mirror we find in phonation a want of longitudinal tension, as indicated by a wavy outline of the glottis, the convexity of the * Transactions Amer. Laryng. Assoc, New York, 1891, p. 66. DISEASES OP THE LARYNX AND TRACHEA. 289 upper surface of vocal bands on expiration and phonation, and concavity on forcible inspiration. The contraction of the muscles which can be felt externally in the healthy subject during phona- tion is completely absent. This form of disorder most frequently results from overstraining the voice ; it may be caused by cold, and is apt to be bilateral. Geo. W. Major * reports a case caused by exposure to cold. Palsy of the thyro-epiglottic muscles has its usual origin in diphtheria. The epiglottis stands erect, and does not move during attempts at deglutition. In palsy of the relaxors of the vocal cords, the thyro-arytenoid muscles, the deep tones are nearly gone. It is often unilateral, and comes mostly from overexertion of the voice during catarrhal laryngitis. Viewed in the laryngeal mirror, the edges of the cords do not approach in the median line, and the edges seem excavated. In paralysis of the posterior crico-arytenoid muscles, we see in the mirror the glottis merely as a narrow slit, becoming still narrower during inspiration. There is no disturbance of voice, and scarcely any sign of laryngeal catarrh, but there is most marked and noisy laryngeal dyspnoea. This paralysis of the abductors may happen from compression of the recurrent nerves by an organic stricture of the cesophagus.f Bilateral paralysis of the adductors is a common disorder, occurring in connection with locomotor ataxia and affections of the brain and of the medulla. Unilateral paralysis of the adductors is more rare ; it accom- panies malignant disease of the oesophagus, aneurism of aorta, and, exceptionally, metallic poisoning, as lead and arsenic. It some- times follows exposure to cold, or attends rheumatism or phthisis. When met with in connection with paralysis of the same side of palate or tongue, it is centric, at times bulbar. E. Fletcher Ingals has described cases thought to be hysterical in origin. We also encounter sensory neuroses of the larynx, and among these hyper- sesthesia is common. Chronic laryngitis, or rather its chief symptom, loss of voice, is at times fdgned ; and the deception may be kept up for an indefi- nite period. Yet we possess, in the use of ansesthetics, the means of detecting the fraud at any moment. Just before the impostor * Proceed. Amer. Laryng. Assoc., 1892, p. 10 f Case of Dujardin, Annales des Maladies de I'Oreille, 1887. 290 MEDICAL DIAGNOSIS. falls into the deep sleep produced by ether, or as he is recovering from the insensibility it occasions, his will no longer controls his voice, and he speaks in his natural tone, or even screams violently. Now, under the term chronic laryngitis, which formerly for want of more precise knowledge was made to embrace most kinds of chronic diseases of the larynx, many different morbid processes are embraced, the exact nature and seat of which we may discrim- inate by the laryngoscope. Thus, the disorder may be wholly, or almost wholly, coniined to the epiglottis. We may find this structure highly congested and enlarged ; Ave may be able to note that it is pendent, nearly completely covering the glottis ; and it is frequently the seat of ulceration. The attending symptoms in any case are those regarded as characteristic of a greater or less degree of laryngeal inflammation. In instances of ulceration, there is soreness with pain in swallowing, hoarseness and irritative cough, followed at times by blood- streaked expectoration. The ulceration may terminate in total destruction of the epiglottis. A turban-shaped swollen epiglottis is often met with in phthisis associated with pyriform swelling of the arytenoids. Pallor of these structures, indeed of the whole larynx, is one of the early signs of pulmonary tuberculosis, as Cohen has pointed out. When the vocal cords are affected, we recognize in the laryngeal mirror either their reddening in part or entirely, or their indura- tion and thickening, or we observe oedematous swelling in and around them, or their ulceration ; and we ca,n usually detect during breathing and phonation their impaired action. The in- flammatory redness may be only in one cord. Small collections of mucus are often found adhering to different parts of the laryn- geal membrane. Now, all these conditions are generally combined with marked aphonia ; the voice, indeed, may be reduced to the merest whisper. Venous congestion of the larynx is so rare an affection that Mackenzie has met with but four cases of it.* In making our diagnosis we must always be careful to find out if the laryngeal phenomena be not secondary, forming part of a general morbid state, such as dropsy, tuberculosis, syphUis, or changes in the blood. Chronic hypertrophy of the ventricular bands is the * Disease of the Throat and Nose, vol. i , 1880. DISEASES OF THE LARYNX AND TRACHEA. 291 result of inflammatory thickening, and, as Tauber * proves, occurs mostly in those who use the voice much in their professional vocations. Tiirck has given the name of " chorditis tuberosa" to a condition of the vocal bands in singers, having; these charac- ters. Midway in the upper plane of the bands there is a peculiar uneven surface, and, in addition to redness and swelling, some white, opaque spots as large as poppy-seeds.f Paralysis of one vocal cord may exist, with immobility of one side of the larynx, and yet voice may be restored and be abso- lutely normal ; the healthy cord, as in cases narrated by Bosworth, swinging over to the paralyzed side, so as to make up for the loss of power on that side. Voice may even exist, to a restricted ex- tent, not only without vocal cords, but after entire extirpation of the larynx, as in the remarkable case of Hickey, reported by J. Solis Cohen,J in which the larynx was removed for malignant growth, and the trachea permanently fixed in the neck. After swallowing air, the patient was able to talk, and even to sing, by skilfully using his pharyngeal muscles. Alteration of the voice, mumbling speech, as though there were some difficulty in closing the glottis, while the movements of the vocal cords appeared normal as seen with the laryngoscope, with- out true aphasia, is mentioned by John N. Mackenzie as a symp- tom in a case of bulbar disease.! Diseases of the cartilages and of the penchondrium are most frequently encountered in connection with tuberculosis, syphilis, and low forms of fever. The affection often begins in the sub- mucous tissue, and the ulceration spreads until the cartilaginous parts of the larynx are involved. The arytenoid cartilages are generally first attacked ; and portions of these cartilages may be thrown off and expelled. At times pus is formed which gives rise to swellings that can be recognized by the aid of the laryngeal mirror ; sometimes a displacement of the cartilages takes place, before any portion of them is completely separated, and the most distressing and dangerous attacks of suffocation result; or the * Cinoin. Lancet, 1887. t Klinik der Krankheiten des KeUkopfes, "Wien, 1866. X Pharyngeal Voice, Transactions of the Amer. Laryng. Assoc, 1894. g Transactions Amer. Laryng. Assoc, Kew York, 1891, p. 6. 19 292 MEDICAL DIAGNOSIS. perichondritis may lead to the development of bone-substance and a constriction of the tube. In some instances the purulent col- lection presses on a vocal cord, which, with the laryngoscope, may be seen to be immovable. This instrument reveals very generally the ravages the disease has committed ; and we are thus enabled to form an opinion as to how far the destruction has progressed, and which of the soft parts as well as of the cartilages are involved. Leaving out the frequent perichondritis and caries of the cartilages which follow the deposition of tubercle, we find in laryngeal phthisis consider- able swelling and ulceration of the epiglottis, and often semi-solid pyriform swellings of the aryepiglottic folds. The thickening is more regular and uniform than that of syphilis, and the tubercu- lar ulcers not large and solid as in this affection, but small and numerous, and both vocal cords are involved ; while in this as in every other respect syphilis is more apt to be local and unilateral. Tubercle bacilli are found in the discharge from the laryngeal ulcer, and in catarrhal ulceration the ulcers are generally very superficial and on the vocal cords. The symptoms of laryngeal phthisis are difficulty in breathing and in swallowing, local pain and soreness, a greatly-altered or a lost voice, and a distressing, harsh cough, which is followed at times by purulent expectora- tion. Besides, we find the manifestations of disease of the lungs. But it occasionally happens that we encounter cases of tubercu- lous ulcers with abundant bacilli, in which no lung disease exists ; * and it is not uncommon to find the tubercular disease of the larynx preceding that of the lungs. At times we note syphilitic and tubercular ulcers in combination. We may also meet with catarrhal ulcers where there is tubercular disease of the lungs. The diagnosis between pachydermia of the larynx and the inter-arytenoid tumor of phthisis is that in the latter the swelling is distinctly a tumor, with a more or less well-defined margin. The color is usually red or pink ; in pachydermia it is whitish- gray or only slightly pink, and the surface may be smooth or coarsely papillary, while in the former it is smooth or finely granular, with sometimes a furrow or cleft. These features are * Canadian Practitioner, 1887. DISEASES OF THE LARYNX AND TEACHEA. 293 specially relied upon by McBride.* Ulceration occurs in pachy- dermia only exceptionally and as a complication ; it is common in phthisis of the larynx. As the result of disease of the cartilage and of the perichon- drium, especially as the result of the process of cicatrization, we may have stricture of the larynx and trachea ; for this is, in truth, the most common origin of laryngeal stenosis. The inspiration is prolonged and noisy ; the voice is generally, although not of necessity, affected. There is dyspnoea, and with the laryngoscope we can see how greatly the calibre of the tube has been encroached upon. Cicatrization is common after syphilis, but Cohen's case f proves that it may occur spontaneously also in tubercular ulcera- tions. Adhesions may be congenital, a web-like membrane uniting the vocal cords through a part of their extent, as in a case of Morell Mackenzie's. According to Paltauf,|: primary stenosis of the larynx may be caused by scleroma, which may develop early in the larynx. The diagnosis depends upon the detection of the characteristic minute structures. Lepra occurs in the larynx only by extension from the pharynx, and is accom- panied by manifestations upon the surface of the body, which clearly explain its character. Ulcers in the posterior walls of the larynx give rise, as a rule, to distressing cough. Respecting tumors of the larynx and poly- poid growths in its interior, we cannot distinguish them, by their symptoms alone, from chronic laryngitis. Their most trustworthy signs, irrespective of the cough and the altered voice, are a steadily increasing difficulty in breathing, and attacks of suffocation for which nothing in the lungs or heart or great vessels accounts. New growths may occur in the larynx, of the benign form. Papilloma, papillary fibroma, is probably the most common ; myxoma is rare; fibro-myxoma and fibroma unusual. Malig- nant disease in various forms may affect the structures of the larynx. Very frequently the diagnosis can be positively made only with the aid of the microscope. The detection, at the seat of the larynx, of a growing tumor. * Edinturgh Med. .Journal, April, 1893. t Amer. Journ. Med. Sci., Dec. 1888. % Sajous, Annual of Univer. Med. Sci., 1893. 294 MEDICAL DIAGNOSIS. accompanied by a severe cough, by a sanious sputum, by signs of destruction of tissue, as seen with the laryngeal mirror and as found in the expectoration, by perichondritis and exfoliation of the laryngeal cartilages, by hemorrhages, and by emaciation, would, in addition to the symptoms just enumerated, warrant the diagnosis of canoer, whether or not much pain wer6 present. In some instances, too, gangrenous pneumonia occurs. If the tumor be flat, with a broad infiltrated base, rather soft in con- sistence, and color not much changed from normal, and there be a peculiar musty odor to the breath and expectoration, a probable diagnosis of carcinoma may be made. This may be confirmed by the subsequent rapid development of the malignant disease, associated with distress in swallowing, bloody expectoration at times, and quickly appearing cachexia. Polypi in the larynx may sometimes be seen by depressing and dragging forward the tongue until the epiglottis is brought into view; at least they have been thus discovered, and even successfully operated upon. But as regards polypi, or, indeed, any form of morbid growth, we possess in the laryngoscope the most certain, usually the only certain, means of detecting them, and even of aiding us in re- moving them, as is now being constantly done. These laryngeal growths vary much in size and in color ; they are often seated at the anterior free edges of the true cords, or still more generally just above or just below their origin, and are, as a rule, readily discerned. Sometimes they may exist for years, merely pro- ducing changes in the voice and some cough, but no very great distress ; or they may lead to fits of strangulation and to sudden death. It is impossible to be sure of their nature without repeatedly examining portions of them. Papillomas are usually cauliflower-like or in bunches ; they occupy most frequently the vocal cords, while sarcomas are oftenest found at the anterior portion of the larynx. Oysts of the vocal cords are much rarer than other forms of growths ; they sometimes rupture spontaneously, and the hoarse voice quickly clears.* Myxomata of the larynx and the epiglottis, according to Van der Poel,t may be manifestations of pernicious anaemia. They * Heinze, Archives of Laryngology, New York, 1880. f Amer. Larj-ng. Assoc, 1890. DISEASES OF THE LARYNX AND TRACHEA. 295 diflFer from cysts in being a pure, gelatinous growth character- ized by stellate fusiform cells, often anastomosing, embedded in a homogeneous, or finely fibrillated, soft, gelatinous basement substance. Many cases that are classed as cysts would properly come under the head of myxoma if the aid of the microscope had been sought. Before concluding these remarks on diseases of the larynx, it may be thought necessary to point out the differences between them and diseases of the trachea. But affections of the trachea need not be separately considered. Lying between the larynx and the bronchi, the trachea commonly shares in their disorders. Thus, we have seen croup to be a malady in which both larynx and trachea are involved. Slight inflammation of the trachea occurs constantly in slight attacks of laryngitis or of bronchitis. Ulcers in the trachea may exist without ulceration of the larynx ; but then they usually escape detection. Sometimes, however, they reveal themselves by a constant pain at the lower portion of the neck and the upper part of the sternum, joined to all the symptoms of ulceration of the larynx except the impaired voice. 3Iorbid growths, too, occur in the trachea, — cancer, carcinoma, syphilitic growths, — as they do in the larynx, and the tube may be altered in form and in structure. Vegetations also form in the trachea after tracheotomy.* "We can make use of the laryngoscope to assist us in the diagnosis of any of the forms of tracheal disease referred to. Yet the instrument is not always available ; for it is only under favorable circumstances that the entire extent of the trachea can be seen. In Tiarrowing of the trachea the bronchial tubes are also at the same time often narrowed. The stenosis may be caused by ex- ternal compression, as from a goitre, from an aneurism, or from a mediastinal tumor ; or the constriction may be due to some cause, such as new formations, in the walls of the tubes. The chief symptoms are the same in either case ; and they are, long-drawn- out respiratory acts, noisy breathing, especially in paroxysms, dyspnoea, particularly marked in inspiration, epigastric retraction, feebleness or absence of vesicular murmur, with clear pulmonary * See cases collected by Tetel, Des Polypes de la Trachee, Paris, 1879. 296 MEDICAL DIAGNOSIS, resonance, loud wheezing heard' with the stethoscope at or near the place of constriction, and voice slightly, if at all, impaired. This, the normal appearance of the larynx as shown by the laryn- goscope, and the almost imperceptible motion of the windpipe during breathing,* are of great value in distinguishing a tra- cheal from a laryngeal stenosis. A bronchial stenosis is chiefly discriminated by the signs of the constriction being one-sided, and attended with marked thrill of the thoracic wall of the affected side, and with loud sounds issuing from it, loud enough to be heard at a distance. Subglottic oedema may be detected by the laryngoscope on deep inspiration. * Gerhardt; also Eiegel, in Ziemssen's Cyclopsedia. CHAPTER IV. DISEASES OF THE CHEST. An examination of the diseases of the chest must be prefaced by a description of the methods of investigation which have given to their diagnosis such certainty. The same methods may be ap- phed in the study of the maladies of other parts of the body, but they are of special service in the recognition of thoracic disorders, and will be here, therefore, most appropriately considered. The discrimination of disease by the eye, the ear, the touch, in fact by the direct aid of the senses, is called physical diagnosis ; the signs thus ascertained are connected with perceptible altera- tions in the material properties or physical nature of structures, — such as alterations in their form, their density, or their sounds, — and are known as physical signs. Physical signs are, then, the exponents of physical conditions, and of nothing more. But as the same physical conditions may occur in various diseases, so may the same physical signs occur in various diseases. An isolated sign is, therefore, not diagnostic of any particular malady. It reveals usually an anatomical change ; but it does not determine the disorder occasioning this change. The tendency to ascribe to each thoracic affection, and even to each stage of an affection, a pathognomonic sign, has greatly re- tarded the usefulness of physical exploration. By presenting a never-ending list of specific signs, it has frightened many from attempting to become acquainted with the most serviceable of all the means of diagnosis, and many more, by the unnecessary compli- cations introduced, have been disheartened at the very threshold of their studies. The subject may be much simplified by laying less stress on individual signs, and by grouping them together according as their association becomes distinctive of certain well- marked physical states. Morbid anatomy then steps in with its teachings, and tells us in what diseases these states are commonly found. It is in conformity with these views that I shall at- 297 298 MEDICAL DIAGNOSIS. tempt, in the following pages, to delineate the signs of thoracic affections. But physical signs cannot be acquired from books ; they must be learned at the bedside. Their value can be ascertained by reading ; yet to distinguish them with readiness requires constant cultivation of the eye, of the ear, and of the sense of touch. And it is of great importance to have clear ideas regarding the structure of the parts to be investigated, and of their action in health. For the sake of convenience, the surface of the chest has been mapped out into regions. Various arrangements of these have been made by different authors. The simplest division of the chest is into anterior, posterior, and lateral surfaces. The regions into which the anterior surface may, for practical uses, be sub- divided, are an upper region, extending from just above the clav- icle to the fourth rib, and a lower region, from the fourth rib downward. Posteriorly, also, there are an upper and a lower part of the chest to be specially examined. It is hardly necessaiy to say that all these regions are double, — the same on each side of the chest. Many more divisions are usually made ; but they are perplexing to the student, and of doubtful value. The artificial boundaries generally laid down are, indeed, too minute and yet not minute enough ; they are too minute for ordinary purposes, not minute enough when it is desirable to localize a physical sign. Whenever this is requisite, instead of resorting to the names of the regions usually employed, I think it preferable to designate the seat of the sign with reference to some fixed anatomical point. This may be done for the anterior part of the chest by indicating the distance above or below the clavicle, or near what part of the sternum, or at which rib, or spreading over how many intercostal spaces, the sign in question is perceived. At the posterior part of the chest, the spinous ridge of the scapula, its lower angle, and the spinal column, serve as landmarks. For most clinical pur- poses, it is only needed to study the region above the spinous process of the scapula, as separate from the space below. But in some instances it may be necessary to notice the region between the scapulae, inter- scapular, or that extending from the lower angle of the bone to the limits of the chest, infra-scapular. Let us now examine the different methods of physical diagnosis, and particularly in their relation to pulmonary diseases. DISEASES OF THE LUXGS. 299 SECTION I. DISEASES OF THE LUNGS. The Different Methods of Physical Diagnosis, and the Physical Signs of Pulmonary Diseases, INSPECTION. If the chest be examined with the eye, we obtain an idea of its form, size, and movements. In health this inspection shows us that the two sides of the chest are, to a great extent, symmetrical in form, as well as in size and in movement. Both sides rise equally during inspiration and sink equally during expiration. On both sides the motion of inspiration is longer than that of expiration, and the pause between them extremely slight. This respiratory movement is visible over the whole thorax. In males it is most distinct at the lower portions of the chest ; in females it is most discernible at the upper. This difference in the two sexes becomes the more manifest, the more hurried the breathing. In healthy adults the lungs expand with regularity from sixteen to twenty times in a minute. In certain pulmonary affections, especially in pneumonia, the number of respirations often exceeds fifty in a minute. But hurried breathing and changed movements of the thorax occur independently of diseases of the lung ; the heaving of the chest in an hysterical paroxysm proves this. Where the diaphragm does not descend, as in con- sequence of peritonitis or of abdominal dropsy or of tumors, the breathing is much more rapid, and is perceptible at the upper parts of the chest. Again, the thoracic movements may be dis- tinct on one side and hardly noticeable on the other, as in pleurisy or in pneumothorax. Lastly, as happens in some cerebral lesions, the motions of the chest may be very slow and labored, or irreg- ular, or they may have apparently ceased, and the breathing be altogether abdominal. The form of the chest is sometimes strikingly altered by dis- ease. Congenital malformations, imperfect development, and cur- vatures of the spine modify it; so do intra-thoracic affections. 300 MEDICAL DIAGNOSIS. Frequently the chest presents a retracted or an expanded look. Ketractfon denotes diminished size of the lung, and, if one-sided, is usually indicative either of chronic changes in the lung-tissue, as in chronic pneumonia or in the forms of phthisis, or of false membranes which bind down the lung ; or it is found in a very marked manner in empyema with external opening. Expansion of the chest is met with in emphysema, in pneumothorax, and in pleuritic effusion. A local or partial expansion, or bulging, may be encountered in the latter disease, or it may depend on thoracic tumors, on pericardial effusions, or on hypertrophy of the heart. The size of the chest can be only approximatively judged of by the eye. Where accuracy is necessary, measurements must be resorted to. MENSURATION. To measure the circumference of the chest or of the abdomen, or to ascertain the distance from one portion of the surface to the other, a graduated tape is all that is required. To attain the former object, the spinous process of a vertebra is chosen as a fixed point, and the tape is thence passed round the body to the median line, first on one side, then on the other, taking care that it be applied evenly to the skin, and that the level of the measure- ment be the same on both sides. This level, if the examination be recorded, should always be noted, that we may have a imiform standard of comparison. And for the same reason it is best to adopt the plan of making our measurements as nearly as pos- sible on the same line : for example, in determining the circular width of the thorax, we can, as a rule, select a line immediately above the nipple, or draw the tape around the chest toward the sixth costo-sternal joint, and, therefore, on the level of the sixth rib near its attachment to the cartilage. We measure thus the width of the chest ; if we wish to obtain the longitudinal diam- eter, the line from the clavicle to the base of the chest is taken. Where the chest is deformed, Woillez's cyrtometer, a chain with links, may be used in place of the tape. In estimating the size of the chest in disease, it must be borne in mind that even in health its two sides vary widely. The half- circle on the right side is, in right-handed persons, at least half an DISEASES OF THE LUNGS. 301 PiQ. 16. inch larger than the half-circle on the left. But the measure- ments, to be trusted, must be performed while the patient is hold- ing his breath in expiration. In inspiration the girth of the chest is increased fully three inches. In well-developed men it meas- ures at the upper part about thirty-three to thirty-four inches during expiration. If it be desirable to ascertain in how far the respiratory acts modify the dimensions of the chest or of the abdomen, this may be readily effected by the ingenious " chest-measurer" of The etethometer of Qualn. The box is ci'L 1 ,1 tt i ,1 n placed on the Bternum, and the Btriog car- BlDSOn, or by tne Stethometer rfed around the chest, one revoluti.in of the cf r\ • i> r^ 71 J. n /. index, which is moved by a rack attached to 01 t^Uam or 01 Carroll,* all of the string, indicates an inch of motion in Iha . , -J . cheat. which mstruments register accu- rately the movements of breathing ; or the respiratory curves can be traced and studied by the atmograph of Burdon Sanderson, or by the anapnograph, an instrument made use of by Bergeon and Kastus, and similar to the sphygmograph,t or by Eiegel's double stethograph ; or the curves of the respiratory movements may be seen in the tracings of the pneumograph applied to the chest. Ran- some has called attention to the value of recording the exact extent of the respiratory movements by stethometry as a means of prog- nosis in chest disease.]: The ti'ansverse diameter — the breadth — of the chest may be determined by means of a pair of callipers, arranged specially for the purpose ; and the curves or flatness of the surface may be ascertained, should it be necessary, by Alison's stetho-goniometer (Fig. 1 7) ; but it is rarely necessary. In fact, these minute meas- urements, however interesting to the physiologist, have, as yet, not been made available to the physician. Inspection teaches us the same as mensuration. What it teaches with less precision can be learned for purposes of diagnosis with a graduated tape. * New York Medical Journal, 1868. I Gazette Hebdomadaire, Ser. 2, v., 1868. I Medico-Chirurgical Transactions, vol. xlvi., 1881. 302 MEDICAL DIAGNOSIS. Mensuration may be employed not only to judge of the size of the chest and of its movements, but also to ascertain the amount Fig. 17. ^(^^V- 1 \~J)- III! nil iiiiliiii III! nil ^ imlmiimhiiiini iiii The stetUo guniuineter of Scutt Al.son. of air which is received into the lungs. The instrument used for this object is the spirometer, an invention of Dr. John Hut- chinson, and since his time numerous modifications of the instru- ment have been made ; for instance, the ordinary dry and the wet gas-meter have been adopted to the purposes of spirometry, and an instrument small enough to be carried in the pocket has been suggested. The results the spirometer has yielded are of value from a physiological point of view ; from a clinical, there are too many sources of fallacy and too many drawbacks to render them of great importance ; and not the least of these drawbacks is, that it takes much practice to learn how to blow. The spirometer may indicate that a large quantity of air enters the lungs, and thus be- come a rough test of their normal condition. But when less air passes into the organ than the spirometric standard requires, this leads in itself to no conclusions ; certainly not to any concerning the disease which occasions the diminished vital capacity. In esti- mating results arrived at by the spirometer, it must be remembered that sex, weight, age, and height have to be taken into account. To the latter Hutchinson assigns much importance, since he enun- ciates the law that for every inch above five feet, eight cubic inches are to be added to the healthy standard. For the height of five feet, the breathing volume is one hundred and seventy-four cubic inches. But these calculations are not exact ; they only approxi- mate the truth. Moreover, the vital capacity may be increased by practice, with the spirometer or by the use of pneumatic instru- ments designed to breathe in compressed air or to breathe out into rarefied air. DISEASES OF THE LUNGS. 303 To determine both the expiratory and the inspiratory power, the hEemadynamometer may be employed. Hammond* recom- mends the use of the instrument in the examination of recruits. According to his observations, healthy men of five feet eight inches raise the column of mercury about two inches by inspiration, and about three inches by expiration. Waldenburg measures the force in respiration by a special appa- ratus, and has introduced pneumatometry as a means of diagnosis. The power exerted in expiration is greater than in inspiration. In some affections the expiratory pressure is largely diminished, as in emphysema and asthma, while in the forms of phthisis the force of inspiration is much lessened. PALPATION. Palpation, or the application of the hand, confirms the results obtained by inspection and mensuration as to size, form, and movements. It may, in addition, be employed to determine spots of soreness, the density and condition of tumors, the state of the thoracic walls, the frequency of the breathing, and the action of the heart. The hand may further be of service as a means of dis- tinguishing vibrations produced by rhonchi, rhonchal fremitus, or by the voice, vocal fremitus ; or it may detect fluid by the sense of fluctuation it imparts, or a roughened serous membrane by the friction fremitus. When both fluid and air are present in a large hollow space, by shaking the patient a distinct vibration of the parietes is felt, accompanied by a splashing sound, known as the Hippocratic or succussion sound. Palpation is to be practised by applying the palmar surface of one or of several fingers evenly, and without too much pressure, on the part to be examined. PEECUSSION. By percussing or striking bodies we elicit sounds by which we judge of their composition. Percussion was first practised by striking directly with the hand over the organs to be explored ; a * Treatise on Hygiene, Philadelphia, 1863. 304 MEDICAL DIAGNOSIS. The pli-ximeter ; about natnrHl size. It may be conveniently made of hard rubber. method which, although serviceable to ascertain marked differ- ences, or to obtain an idea of the general resonance of a part, is inferior to mediate percussion. The media used to receive the blow are various : a disk or plate of ivory, of wood, or of leatlier • a piece of india-rubber ; or the middle finger of the left hand. The finger answers best for percussion of the chest ; for abdominal percussion a pleximeter is preferable. When the finger is employed, it ought to be applied with its palmar surface firmly Pig. 18. pressed against the chest, and as parallel as possible to the ribs. One or two fingers of the other hand may then be used to tap with, — for the finger is, for ordinary purposes, better than any of the percus- sion hammers invented, — the greatest attention being paid to the circumstance that the percussing finger strikes perpendicularly, whatever pleximeter be used, and not slantingly, as is too generally the case. The whole movement should proceed from the wrist, and only from the wrist, and ought not to be too rapid, or unequal, or of great force. If all of these apparently unimportant points are attended to, the results obtained may be relied upon ; if not, the want of manual dexterity invalidates the conclusions. No other fault is so often committed by the beginner as that of raising the finger used as a pleximeter from the surface, — thus obtaining the sound of the finger, and not that of the organ he wishes to percuss, — unless it be the fault of sti'iking with great force, as if the object were to break into the cavity of the chest. Forcible percussion is of use only when the sound of deep-seated organs is to be brought out. The main sounds elicited by percussion may be designated as dull, clear, and tympanitic. Of course, these, like all other sounds, may differ in strength, in duration, and in pitch. A dull sound denotes absence of air. It is the sound both of fluids and of solids. It is, thus, the sound sent forth from the airless viscera, — from the liver, spleen, and heart. When it DISEASES OF THE LUNGS. 305 takes the place of the pulmonary sound, it bespeaks consolida- tion, from whatever cause induced, or the presence of something which checks the normal vibrations of the lung-texture. Dulness is always associated with an increased sense of resistance to the percussing finger, and over parts emitting it the vibrations of the timing-fork, which Bass has introduced into diagnosis, are weak, while they are loud over normal pulmonary structure. A dear sound is produced by a series of marked and un- hindered vibrations which are emitted from a substance containing air. As thus defined, a clear sound evidently is yielded by per- cussing any air-containing organ. But custom has restricted the emplojTnent of the term clear to denote the peculiar resonance obtained by striking over pulmonary tissue. When, therefore, a clear sound is spoken of, it means a sound having the nature of that of the lungs, or of normal vesicular or pulmonary resonance. A resonance analogous to the vesicular resonance may be obtained, Flint points out, by percussing a loaf of bread. A tympanitic sound, on the other hand, is a non-vesicular sound, having the character of that of the intestine. Wherever heard, it indicates the presence of quantities of air in conditions similar to that contained in the intestine, — namely, enclosed in walls which are yielding, but neither tense nor very thick. When elicited over the chest, it may be only the transmitted sound of a distended stomach or colon. But generally a tympanitic sound over the seat of the lungs is expressive of emphysema, or of pneumo- thorax, or sometimes of a cavity or of oedema of the lungs. Again, as Skoda has taught us, it occurs in moderate pleural effusions above the level of the liquid. Many find difficulty in distinguishing betvveen the clear sound of the pulmonary tissue and the tympanitic sound. The more ringing character of the latter, and its higher pitch, constitute its essential prop- erties. If the cavity communicate with a large column of air in the bronchial tube, the note on percussion varies, as pointed out by Wintrich, accordingly as the patient opens or closes his mouth. It is more markedly tympanitic and higher in pitch when the mouth is wide open. Altering the position from a sitting to a horizon- tal one, when the cavity is partially filled with fluid, Gerhardt has shown changes the tympanitic percussion note, and I have B06 MEDICAL DIAGNOSIS. Pig. 19. obsei-ved it to be markedly altered — ■ indeed, to disappear — on full held inspiration.* As modifications of the tympanitic sound may be viewed the amphoric or metallic sound, and the cracked-^ot or cracked-metal sound. The first of these is a concentrated tympanitic sound of raised pitch, and denotes a large cavity with firm, elastic walls. The second is not unfrequently found associated with it. It requires for its develop- ment a strong, abrupt blow of the percussing finger while the patient keeps his mouth open. The condition that usually occasions the sound is a cavity communicating with a bronchial tube. It is also met with uncombined with an excavation, as in the bronchitis of children, in pleurisy above the seat of effusion, near a peri- cardial exudation, in emphysema, and in certain instances of pneumothorax. Indeed, any disorder in which the chest-walls remain very yielding, and in which a certain amount of air con- tained in the lung or pleura is, by sudden percussion, forced into a bronchial tube, will occasion this cracked-metal sound. In addition to the character of all these sounds, we study their degree, or amount of fulness : such changes as are Fig 19. — A servireablo model of a pTcussioD hammer; not quite natural size. The india-rul-biT ie i-crewed to the rine, which lias ii diameter of fntm five-eiglitlis to three- quarters of an inch. The metallic ring is attached to a steel stem with a very decided sprinp:. The pinnted portion of the india-rubber is used to strike with on tLo pleximeter. * Amer. Journ. of JMed. Sci., July, 1875. DISEASES OF THE LUXGS. 307 expressed by « more or less," " diminished or increased." Thus, a clear sound may be increased, owing to stronger vibrations and a larger quantity of air, yet not lose its distinctive pulmonary character, as happens often, for instance, when the air-cells are dilated ; the sound of the large intestine is fuller, more tympanitic, than that of the small intestine, and so forth. With changes in fulness or volume of sound go hand in hand changes in its pitch. Increased volume is linked to lowered pitch, diminished volume to higher pitch; but so is increased tension. To sum up the chief results of percussion, as above described : Quality, or Chakactek of Sound. Cleak : — Presence of air, — as in the lung-tissue. Dull : — Solidification or compression. Tympanitic : — Certain amount of air enclosed in a structure or cavity the walls of which are not too tense. Metallic : — Large hollow space, with firm but elastic walls. Cracked-metal sound: — Usually a cavity communicating with a bron- chus. Degree, or Intensity. Any of the sounds mentioned may be diminished or increased in intensitv as the conditions which produce them are modified. Pitch. Heightened or lowered as amount of air or as tension is altered. If it be desirable to obtain a more distinct idea of the sound than can be done by the ordinary method of ptactising percus- sion, it may be accomplished by resorting to auscultatory/ percus- sion, — a method which was introduced by Cammann and Glark, and which consists in listening, with a stethoscope applied to the parietes, to the sounds elicited by percussion. It is a means of ' determining with accuracy the boundaries of various oi'gans, as of those of the lungs or heart, or of the liver or spleen, and yields particularly exact results when carried out with the double steth- oscope. The percussion sound will also be found to vary with the re- spiratory movement, and useful information may be obtained by 20 308 MEDICAL DIAGNOSIS. the appreciation of the note elicited by percussion while the breath is held after a ftiU inspiration or in a prolonged expiration, — a method of diagnosis for which I have proposed the name of respiratory percussion.* As a standard for comparison in disease, the results of respira- tory percussion in health must be carefully determined. It will be foujid that in the normal chest, anteriorly, a full held inspira- tion increases the resonance, makes the sound fuller, and raises the pitch ; but, making allowance for the cardiac region, the reso- nance below the apices is relatively less increased on the left than on the right side. Posteriorly, we find in the supra-spinous fossae, and on a line toward the spine, that a full inspiration makes the percussion sound fuller and raises the pitch, especially on the right side. In the inter-scapular and infra-scapular regions the tone on gentle percussion is distinctly pulmonary and the pitch moderately high. On the left side an admixture of tympanitic resonance may be detected, particularly in the infra-scapular region. The pitch is somewhat lower in the left scapular and infra-scapular region than in the right. A full held inspiration elevates the pitch, increases the resonance very much, and makes the difference between the sides less apparent. A held and complete expiration greatly lessens resonance and lowers the pitch on percussion. The quality of the percussion note during an arrested respira- tory movement is but little changed ; perhaps it is somewhat less soft, corresponding to the marked resistance to the percussing finger. In a held inspiration, nevertheless, we obtain the idea of a greater mass of tone ; in a held expiration, the reverse. In- crease in volume of percussion note accompanies, contrary to our u^ual experience, heightened pitch ; and this is more especially noticed in connection with the slight change in quality above mentioned. This anomaly is probably due to the altered tension of the structures, both lung-texture and chest-walls, during held respiratory movement. These are the chief facts connected with a study of respiratory * Amer. Journ. Med. Sci., July, 1875; see also Friedreich, Deutsches Ar- chiv fiir Klin. Med., Bd. xxvi. DISEASES OP THE LUNGS. 309 percussion in health. The application to disease is manifold, as we shall find in the study of emphysema, of phthisis, of pleurisy, and of pneumothorax. Percussion of the Healthy Chest, The sound elicited by striking a healthy chest differs in accord- ance with the part percussed. The anterior portion renders a clearer sound than the posterior, on account of the slighter thick- ness of the thoracic walls. But the pulmonary resonance is not, even anteriorly, alike at all parts. The portion of lung above the clavicle yields a sound which becomes somewhat tympanitic as the trachea is approached. Percussion is difficult in this region, as it is almost impossible to apply the finger or pleximeter properly to the surface ; hence arise errors in diagnosis if too much value be attached to trifling differences between the two sides. Over the clavicle the sound sent forth is clear and pulmonary at the centre of the bone ; at its scapular extremity it is duller ; toward the sternum it becomes of higher pitch, and mixed with the sound of the bone. In the region bounded above by the clavicle, and below by the upper margin of the fourth rib, the resonance is very marked. In fact, the sound of this region may be taken as a type of the pulmonary sound : it is very clear and distinct, and but little resistance is offered to the percussing finger. Yet a slight disparity generally exists between the two sides. On the right side the sound is somewhat less clear, shorter, and of a higher pitch, than on the left. From the fourth rib downward, on the right side, the resonance of the lung, on strong percussion, is found to be slightly deadened ; near the sixth rib the perfectly dull sound indicates that the liver has been reached. On the right side, during full inspiration, the liver is pushed downward for the space of an inch or more ; and the dull sound on percus- sion begins, therefore, lower down, and on a line corresponding to the displacement of the organ. On the left side the heart deadens the sound from the fourth to the sixth rib, and, in a transverse direction, from the sternum to the nipple. This dull sound is lessened in extent during inspira- tion, and in cases of emphysema ; indeed, under any circumstances in which the lung more completely covers the heart. Lower down, owing to the liver reaching over to the left side, and to the pres- 310 MEDICAL DIAGNOSIS. •ence of the spleen and a portion of the stomach, the sound ren- dered on percussion consists of a mixture of the dull sound of the solid viscera and of the clear sound of the lung with the tympa- nitic sound of the stomach. The latter character of sound pre- dominates when the stomach is empty. Over the upper part of the sternum, to the third rib, the percussion sound is slightly tympanitic; at the lower part, the heart and liver cause this tympanitic or tubular character of sound to give way to a dull sound. Position exerts some influence on the results of percussion. On exchanging the recumbent for the^ ^ Tubercle bacilli. is a question whether they may not have accidentally got into the air-passages. Another valuable micro-organism in the sputum is the pneumo- coccus, especially the one described by Fraenkel as characteristic of pneumonia ; it has, however, also been detected in the saliva, in abscesses, in meningitis, and in empyema. Two cocci generally are found, together. It is depicted in discussing pneumonia. Let us here examine only the process by which it is best discerned, which, moreover, is a most valuable one in the diagnosis of many micro-organisms, the process of Gram. Gram's decolorizing method makes use of an aqueous solution of iodine and iodide of potassium : one part of iodine, two parts of iodide of potassium, and two hundred and fifty parts of water. The preparation is previously stained in aniline water solution of gentian violet, made in the usual way by shaking up in a test- tube filled with water one to two cubic centimetres of aniline until an emulsion is formed, which is filtered, and to which enough of a concentrated solution of gentian violet has been added to render the liquid of a dark color. The iodine solution is then washed out of the tissues ; the bacilli or cocci are easily isolated by the stain. The prepared section or cover-glass should be slowly but completely warmed in the aniline solution of the gentian DISEASES OF THE LUNGS. 345 violet, either on the water-bath or over the flame, then laid for from one to two minutes in the aniline water solution of gentian violet, and subsequently placed in absolute alcohol until the color is dis- charged. The bacteria show the stain of gentian violet ; the tissue may be double-stained red with picrocarniine or other dyes. This method of Gram is of the greatest value in distinguishing micro-organisms. For instance, it separates the pneumococcus of Friedlander, which does not stain with it ; and the bacilli of cholera, of typhoid fever, and of glanders do not retain the stain. HsBmoptysis. — Sputa are streaked with blood in bronchitis, intimately admixed with blood in pneumonia ; yet we do not call this haemoptysis. It is only when a certain quantity of pure blood is expectorated that the complaint is regarded as haemoptysis, or hemorrhage from the lungs. Now, a pulmonary hemorrhage may be an idiopathic affection ; but it is not often so. It is mostly symptomatic of a grave disease of the lungs or of the heart. It is at times a discharge that takes the place of a suppressed flow of blood from another part of the body, as in vicarious menstrua- tion. Among diseases of the heart, mitral disease is most gen- erally connected with haemoptysis. Tubercular disease of the lungs is by far the most common pulmonary affection in which hemorrhage happens. But it may also occur in gangrene, in bronchial dilatation, in abscess, in congestion of the larynx, and in the early stages of pneumonia. We also meet with it in pur- pura, in typhoid and typhus fevers, and in arthritic subjects. When called to a person who has been spitting blood, we have first to solve the question. Where does the blood come from ? It may issue from the nose or mouth ; from the trachea ; from the oesophagus or stomach ; it may stream from an aneurism which has burst into the air-passages ; or it may be that the lung is bleeding. When in epistaxis the blood, instead of flowing out of the nos- trils, flows backward, it is coughed up. But on the patient in- clining forward, it will issue from the nose. The color of the blood is not florid ; and it can be seen trickling down the pharynx. Inspection is of equal service when the blood comes from any part of the oral cavity ; especially if it proceed from the gums. Their swollen state, their spongy appearance, and the readiness with which they bleed when pressed, point out at once the source of the hemorrhage. 346 MEDICAL DIAGKOSIS. Loss of blood from the larynx and the trachea, or from the oesophagus, is exceedingly rare ; and when it does occur, it is de- pendent upon some local lesion, such as an ulcer, or the presence of some foreign substance that has been swallowed. By atten- tion to the history, then, we can recognize the cause and the seat of the hemorrhage. The blood itself furnishes no certain mark of distinction. Occasionally the hemorrhage takes place into the interior of the larynx, and only a very small quantity of blood is expectorated. Cases of hemorrhagic laryngitis are usually connected with catarrhal inflammation of the windpipe, with or without ulceration; they are accompanied by severe dyspnoea, and with the laryngeal mirror the blood can be seen trickling down the windpipe. When blood is vomited from the stomach, it is preceded by a feeling of weight and uneasiness in the epiga'^tric region, and sometimes by decided nausea. The ejected matter consists of a dark grumous blood, thus altered by the gastric juice, and is often mixed with broken-down food. Its dark color is invariable, ex- cept where an artery has been laid bare by an ulcer, in which case a sudden discharge of florid blood takes place. There is not commonly more than one act of vomiting ; the blood which re- mains in the stomach passes into the intestines, and goes off with the stools. Hsematemesis is attended with tenderness at the epi- gastrium. It is usually symptomatic of an organic affection of the stomach, liver, intestine, or spleen ; it may, however, depend upon the swallowing of irritating poisons ; or happen in fevers or in scurvy, or as a substitute for suppressed discharges. The blood which gushes out of the mouth when an aneurism opens into the air-passages is red and arterial. It spurts out in jets, and the patient rarely long survives the hemorrhage. Should this not prove quickly fatal, we are seldom at a loss to determine the cause of the bleeding ; for we find the physical signs of the aneurismal tumor in the chest. But when the blood comes from the lungs, it presents charac- ters and is connected with symptoms totally different from anv of those just mentioned. The bleeding is preceded by a sense of weight and of uneasiness in the chest. The patient perceives a saltish taste in the mouth and a tickling sensation in the larynx when suddenly the mouth fills with blood, or after a slight cough DISEASES OF THE LUNGS. 347 he expectorates a quantity of light-red and frothy blood. His anxiety becomes great ; the skin is covered with a cold sweat ; the pulse is quick and bounds under the finger. He spits up more blood, and this continues to come up at varying intervals and in changing quantities all day, or for several days, or even for a much longer period. It is at first pure blood, or mixed with the sputum ; is red and not coagulated, and frothy, except when the hemorrhage is very profuse. But after one or two bleedings, the matter which is coughed up contains dark clots, being the blood which has been retained somewhere in the air- passages since the previous attack. The blood is never, at the onset of the hemorrhage, dark and grumous ; yet in rare cases it has more of a venous than of an arterial hue. The amount which is brought up at one bleeding ranges from one to two drachms to as many pints ; but the quantity that comes out of the mouth is by no means an index of the quantity extravasated. The blood may be effused into the pulmonary structure, and but little be expelled. After the description above given, it is unnecessary to point out the marks of discrimination between blood ejected from the lungs and blood from other parts. The symptoms are different; the blood itself is different. And listening to the chest detects bub- bling sounds in the air-tubes ; still, to find these is not requisite for the diagnosis of pulmonary hemorrhage, and indeed, while the bleeding is going on, the patient's welfare forbids an extended thoracic examination. But as soon as circumstances permit, that examination becomes of immense value by showing us with what morbid state the hemorrhage is connected, and whether the bleed- ing is symptomatic of a disease of the heart or the lungs, or does not depend upon either. It is mostly owing to an affection of the heart or the lungs, and is exceedingly prone to be repeated. Yet the lungs may bleed frequently without there being an organic lesion within the chest to account for the hemorrhage. I had, some years ago, a patient under my care who had been spit- ting blood daily for five years. Although enfeebled by the loss of blood, his general health remained good. His lungs and heart appeared to be sound. Another patient had pulmonary hemor- rhages at varying intervals for eighteen months. He finally died of exhaustion ; but he never presented any physical signs of tho- 348 MEDICAL DIAGNOSIS. racic disease. An examination of the body was, unfortunately, not permitted. But in the case of a gentleman that I had watched for years, the repeated hemorrhages were found at the autopsy to be unconnected with disease of the lungs. He died of an acute disease complicated with pleurisy. In these instances the hemorrhages recurred often. But we meet with robust persons in whom the loss of blood follows active exercise or exertion and is not apt to be protracted or to be repeated. In such cases, of which I have seen a number in soldiers sent to hospitals after the fatigue of a long march or the excitement of a battle, simple congestion of the lungs is probably the cause of the disorder. Except under the circumstances mentioned, haemoptysis is a grave symptom. It is not dangerous as regards its immediate termination, but dangerous because it is, for the most part, the indication of a serious malady. Few die as the direct conse- quence of the hemorrhage, but many die of the disorder of which the hemorrhage is the consequence. Diseases in which Clearness on Percussion is met with and constitutes a Valuable Sign. Some of these ailments are acute, others chronic ; and nearly all have as their prominent symptom a cough, and are affections, or follow affections, of the bronchial tubes. Acute Bronchitis. — This is an acute catarrhal inflammation of the bronchial mucous membrane, which occurs idiopathically, or happens as a secondary complaint in the course of fevers, of rheumatism, and of cardiac disorders. Let us examine the manifestations of the idiopathic malady. Bronchitis varies considerably according to the size of the tubes involved. When the smaller tubes are affected, a disease called capillary bronchitis, or suffocative catarrh, is established, the prog- nosis of which is very grave, and the diagnosis of which presents points for special consideration. The symptoms of acute bronchitis of the large and middle-sized tubes are, a sensation of tickling in the throat, soreness or pain behind the sternum and along the lower ribs, a slight oppression in breathing, and a paroxysmal cough. Let us add to these pain in the limbs, coryza, and a fever of moderate intensity, rarely DISEASES OF THE LUNGS. 349 reaching 103°, and we have the main phenomena met with during the onset and at the height of an attack of ordinary acute bron- chitis. The fits of coughing in the earlier stages are followed by a clear, frothy expectoration, which, as the cough becomes looser and less fatiguing, changes from an almost transparent fluid to a yellowish or greenish sputum. This may be uniform or streaked with blood ; it may be small in amount, or in considerable quan- tity; and it consists chiefly of pus-cells and of large, round, alveolar cells with some blood-corpuscles. The fever soon leaves ; but long after it has ceased, the patient still has a cough and expectoration, both of which only gradually disappear. The physical signs may be inferred from the lesions. As there is no condensation of pulmonary tissue, there is no dulness on percussion, the thickening and injection of the bronchial mucous membrane not being sufficient to modify materially the normal resonance. But these conditions must alter the respiratory mur- mur. They bring out more of the bronchial element of sound, hence more expiration with the coarser inspiration, — in other words, a harsh respiration ; or the swelling obstructs the entrance of air into the air-vesicles, and enfeebles the vesicular murmur. Again, new sounds, the rales, are produced ; first dry, then moist. This succession of the rales is, however, not absolute, and depends, to a great degree, on the density of the fluid in the bronchial tubes. Dry rales, mixed with moist, may be perceived even in the later stages of acute bronchitis, and long after the febrile signs have ceased. In fact, the tenacity alone of the exudation determines the nature of the rales, and even somewhat their exact character ; for every dry rale is not precisely like every other dry rale, nor every moist rale equally moist. With reference to size, the sono- rous rales and the large bubbling sounds prevail when the disorder attacks the larger tubes. Sometimes, when the bronchial inflam- mation is severe and extensive, we find a sound which seems to be neither a dry nor a bubbling rale, but rather a compound of both, — a dry sound, yet not continuous, giving the idea of being caused by the breaking up of fluid. Or, there may be a mixture of the sounds of respiration with the rales, occasioning a peculiar kind of breathing, — one in which we can recognize neither a distinctly vesicular nor a distinctly bronchial element, nor a well-defined rale. All these states are dependent upon the amount, and, above 350 MEDICAL DIAGNOSIS. all, upon the condition, of the exudation in the bronchial tubes. But they indicate nothing beyond the fact that there is an exu- dation present which is very large in quantity and tenacious in character. When the sounds are of the indeterminate nature just alluded to, the vibrations produced in the tubes are apt to be transmitted to the parietes of the chest, occasioning with each respiration a marked fremitus. The diagnosis, then, of acute bronchitis is determined by the cough, the fever, the expectoration, and the signs of clearness on percussion, diffused rales, or harsh respiration. From all, those diseases of the lung which result in the consolidation of the pul- monary tissue, such as pneumonia and tuberculosis, we distinguish bronchitis by the absence of dulness on percussion. Some cases of acute tuberculosis, on account of the sudden invasion of the malady and the general diffusion of the physical signs, are liable to be mistaken for acute bronchitis ; but the different progress of the disorder usually clears up all doubt. Error in diagnosis is more likely to arise from the habit, when the signs of bronchitis have been made out, of not looking further ; forgetting, in the attention to the disease within the thorax, the various morbid states which bronchitis may accompany, and particularly its fre- quent association with the eruptive fevers, such as measles and smallpox, with typhoid fever, and with malaria. Capillary Bronchitis. — This is a disease of the aged and of young children. It begins with an acute inflammation of the larger bronchi; or the disorder may from the onset affect the smaller tubes. In either case, signs of obstructed circulation soon manifest themselves ; there is lividity of the lips and cheeks, with hurried breathing, a rapid pulse, an anxious countenance, great restlessness, moderate fever temperature, and a cough, followed by viscid expectoration. As the malady advances, the color of the skin and the mucous membranes shows more and more the want of properly-aerated blood ; the sputa cease with the failing strength ; and in old persons delirium and coma, in young chil- dren convulsions, mark the closing struggle. The physical signs are those of ordinary bronchitis, but modi- fied by the seat of the malady. High-pitched whistling sounds, accompanied or superseded by very fine moist rales, denote the smaller size of the tubes involved. The resonance on percussion DISEASES OF THE LUNGS. 351 is clear, or very slightly different from that of health. When materially duller, it indicates that the pulmonary tissue itself shares in the inflammation, or that it has been exhausted of its air and has collapsed. The parts of the lung which the physical signs prove to bear the brunt of the disease are the lower lobes. In the upper there may be large rales and some fine ones ; but it is low down and at the posterior portion of the chest that the fine sounds are most abundant. Yet when the inflammation is extensive, and the accumulation of secretions and morbid products great, quantities of small rales are heard at every part of the chest. From this description of capillary bronchitis it will be ap- parent that it differs from ordinary acute bronchitis in the greater tendency to prostration and to suffocation, in the signs of im- perfect aeration of the blood, and in the fineness of the rales. Like the more usual kind of acute bronchial inflammation, capillary bronchitis is liable to be mistaken for acute lobar pnevr- monia and for phthisis. And in the majority of cases the same rules serve for its discrimination ; the absence of percussion dul- ness and the diffusion of the morbid sounds are here again of the utmost value! The rapidity of the attack and the signs of suffocation might mislead into the supposition of the existence of oedema of the glottis, of laryngitis, or of croup; errors in diagnosis which the detection of fine chest rales will prevent. Capillary bronchitis which really merits the name is a very rare disease, though I believe it to exist. What is called capillary bronchitis is for the most part catarrhal pneumonia or broncho- pneumonia, one of the most common, as it is one of the most fatal, of the diseases of childhood. Like capillary bronchitis, the disease affects both lungs. It is commonly observed in con- nection with measles, hooping-cough, influenza, or diphtheria ; it is especially seen in children previously in impaired health or scrofulous or rachitic. It is apt to be attended by cerebral symp- toms, — indeed, it may set in with these, — by rapid breathing and paroxysms of dysiDnoea, and by high and irregular fever, ranging between 102° and 105°. As the inflammation is limited to the lobules, it yields but imperfect signs of consolidation. The bronchial breathing is rarely very marked ; crepitant rale is not usually perceived, or can scarcely be distinguished from the small 352 MEDICAL DIAGNOSIS. bubbling sounds of fine bronchitis ; and, from the usual associa- tion with inflammation of the fine bronchial tubes, it is in indi- vidual cases often extremely difficult to say whether portions of the lung-tissue are consolidated. Theoretically, broncho-pneu- monia may be distinguished from capillary bronchitis by the dul- ness on percussion ; practically, this aids but little. Dulness on percussion is in children difficult to elicit ; and, again, a dulness may be temporarily produced in capillary bronchitis by collapse of the pulmonary tissue. Broncho-pneumonia may or may not be preceded by bronchitis of the fine tubes. We may suspect that the inflammation has infiltrated the lobules, if the breathing be very rapid, the fever severe, or the temperature, which is rarely above 102° in the pre- ceding bronchitis of the finer tubes, rise suddenly by several degrees ; if the cough lessen as the pneumonia develops ; if laryn- geal symptoms arise ; and if, in addition to rales, not very diffused, spots of dulness, which do not change their seat, and do not dis- appear under respiratory percussion, be discerned, and plastic pleurisy appear as a complication. On the other hand, when there are early most marked signs of deficient aeration of blood ; when the child seems to suffocate from want of power to expec- torate ; when a multitude of fine dry and moist sounds are heard at every part of the chest, and little or no corresponding impair- ment of resonance on percussion is detected, — we know that the capillary bronchi are extensively filled with pus and morbid secretions, and that true suffocative catarrh is threatening life. Capillary bronchitis is a rapid disease ; catarrhal pneumonia runs a much slower course, lasting perhaps weeks, and showing a tem- perature record that is marked by great alternations between morning and evening. Chronic Bronchitis. — The symptoms and signs of chronic bronchitis are not very different from those of the ordinary form of acute bronchitis. The duration of the complaint and the absence of fever, except during marked subacute or acute exacer- bations, are the chief distinguishing elements. Yet the cough, although on the whole chronic, is far from being constant. It may disappear almost altogether, and then reappear with more than its previous severity ; and this state of things may go on for years, undue exposure and change of season aggravating the disorder. DISEASES OF THE LUNGS. 353 The sputa vary, even more than in acute bronchitis, in tenacity and quantity. There may be merely a small quantity of yellowish matter expectorated in the morning, or an almost continued flow from the bronchial tubes, — bronchorrhcea. The physical signs differ accordingly. A harsh or feeble respiration, and few or many, either dry or moist, rales, are present, in conformity with the state of the bronchial mucous membrane and of its secretions. The sound on percussion is clear, and this, with the diffusion of the signs discerned on auscultation, is of great importance. Ex- cessive secretions somewhat impair the pulmonary resonance, but only temporarily ; for with the shifting secretions shifts the very slight dulness. One of the most important points in the diagnosis of chronic bronchitis is to attend to the manner in which it arises. It may follow a seizure of acute bronchitis, or be the result of recurring attacks of subacute character ; it may appear as a primary aifec- tion, or it may follow the exanthemata ; or, again, it may com- plicate some previously existing disorder, as Bright's disease, rheumatism, lithsemia, gout, psoriasis, or eczema, and be directly traceable to the constitutional taints of these maladies ; and its symptoms will vary and be influenced by those of the general malady to which it is subordinate. In the ordinary idiopathic malady the general health, as a rule, suifers but little. In some instances, however, emaciation takes place, and the disease simulates phthisis. This is pnrticularly the case in the bronchial affections among knife-grinders and coal-miners, also in those of granite-masons, of sandpaper-makers, of flax-dressers, and of potters. The resemblance becomes still greater when superadded bronchial dilatation and fibroid indura- tion of the lung produce physical signs like those of pulmonary consumption. A chronic catarrhal inflammation of the mucous membrane of the nose may be mistaken for chronic bronchitis, with which, indeed, it may coexist. But when occurring uncombined, there are no rales in the chest or altered breathing-sounds indica- tive of disorder there, though there may be a cough, from the throat being also affected. The secretion, too, from the nose is very coidIous and of muco-purulent character, the upper part of the nose looks somewhat flattened, and the sense of 354 MEDICAL DIAGNOSIS. smell is impaired, — not one of which signs is met with in chronic bronchitis. It seems almost unnecessary to speak of the differential diag- nosis between chronic bronchitis and rose cold and hay asthma. The coexistence of marked signs of irritation of the eyes, the nose, and the throat ; the appearance of the distressing affections at a particular period of the year ; the fixed time in M'hich they run their course ; their occurrence in those of neurotic constitu- tion and having an irritable nasal mucous membrane ; the almost instant relief on leaving the regions where the attack has been brought on and on reaching favorable localities; the de- pression of the nervous system ; and, on the other hand, the less decided signs of bronchial affection, — clearly distinguish the maladies. We meet occasionally with a form of bronchitis in which the expectorated matter is solid. This plastic bronchitis pre- sents all the usual i-igns and symptoms of bronchial inflamma- tion. It may be chronic, or it may be acute. It is most fre- quently chronic, with occasional acute or subacute exacerba- tions. The disease extends in this way over weeks, months, or even years, and is apt to end in complete recovery. But in its acute form it is a complaint of great danger and accom- panied by much dyspnoea, and has led to death by suffocation.* Males, as we find by looking at the cases which Peacock f has collected, are more often attacked than females. The same carefully-collated observations show that the disorder affects more commonly the upper than the lower part of the lungs. As regards the physical signs. Fuller,^ who has met with a number of well-marked examples of the complaint, states that there is weakness or entire absence of breathing over the affected portions of the lungs, and that, from attending collapse, com- plete and rapidly-developed dalness on percussion may ensue. But the only absolutely diagnostic phenomenon is the peculiar membranous material expectorated. In form this may be either in thin shreds, or moulded into an accurate cast of a bronchial tube * Andral, Clinique Medioale. t Transactions of the Pathological Society of London, vol. v. J Diseases of the Chest. DISEASES OF THE LUNGS. 355 Fig. 31. Cast from a case of plastic bronchitis. and its ramifications. The expectoration of the firm bodies is sometimes attended with copious haemoptysis. The casts consist of layers of fibrin in which leu- cocytes and alveolar epithelium are embedded. Leyden's crystals and Curschmann's spirals may also be detected. The disease is most apt to occur in the spring months, and the chronic cases are not infrequently associated with tuberculosis. The little round solid pellets which consumptive patients or even some persons in good health cough up from time to time are the result of a plastic bronchitis on a very limited scale. A kin- dred disease to plastic bronchitis has been described as "bron- chiolitis exudativa." The sputum is grayish and very tena- cious, and full of spirals which come from the bronchioles. Gradually-increasing dyspnoea and attacks of asthma are promi- nent symptoms.* Another variety of chronic bronchitis is putrid bronchitis. This may happen in connection with bronchial dilatation or with chronic pneumonia, or without these conditions ; occasionally it appears after a suppurative pleurisy which has broken into the lung. There is fever with irregular temperature ; at times chills occur. The distressing cough is followed by a copious, half- liquid sputum, extremely offensive, and containing little yellowish plugs, the so-called Dittrich's plugs. The peculiar odor is thought to be due to a micro-organism, especially to a short, slightly-curved bacillus described by Lumnitzer.f Cases of putrid bronchitis may be mistaken for gangrene of the lung ; but the odor is different, and they lack the physical signs of lung destruction and elastic fibres in the sputum. We must, how- ever, bear in mind that putrid bronchitis may terminate fatally * Curschmann, Deutsch. Arch, fur Klin. Med., Nov. 1882. t Wien. Mediz. Presse, May, 1888. 356 MEDICAL DIAGNOSIS. by induced pneumonia or pulmonary gangrene. Sometimes it produces death by metastatic abscess of the brain. Emphysema. — ^A distention of the air-cells is a frequent sequel of chronic bronchitis. It may happen in only one lung ; but the air-vesicles of both are usually distended. The effect of this is to obliterate some of the capillaries, and to interfere with a flow of blood through the lungs. From this proceed, to a great extent, the feeling of constriction and the dyspnoea, the anxious look, the bluish lip, of emphysematous patients, and the tendency the disease has to produce dilatation or dilated hypertrophy of the right side of the heart. Emphysema is essentially a chronic malady ; but in its course subacute attacks of bronchitis occur which much augment the • difficulty of respiration. The embarrassment in breathing is, indeed, the most prominent of the symptoms. It is not so much the difficulty of getting air into the lung, as it is of getting it out, which annoys the patient. He breathes as if he had no object but that of forcing the air out of the pulmonary tissue. And this task is often aggravated by spasmodic narrowing of the bronchial tubes : hence it is very common to meet with the loud wheezing of asthma in those whose air-cells are permanently dilated. In long-standing cases of the disease the patient looks cachectic, is cyanosed, the shoulders are rounded, the chest is barrel-shaped, and dropsy of the feet is noticed. There may be also a chronic cough, which may be dry and occur in paroxysms of marked intensity. The physical signs of emphysema are easily deducible from the pathological conditions. The distention of the lung-tissue explains the great prominence and fulness of the chest, and the displacement of the liver or heart. The ringing clearness on percussion — at times almost tympanitic in its character and the increased resistance to the finger have the same cause. Nor is it difficult to understand how the loss of elasticity in the dilated air-cells will give rise to an unchanged note on respiratory percus- sion, to prolonged expiration, and to a feeble inspiratory murmur. If bronchitis coexist, the signs on auscultation are necessarily somewhat altered. The respiration is harsh, or intermixed with dry and moist rales. The former especially assume great promi- nence, and are heard as sonorous, or still oftener as sibilant, rales DISEASES OF THE LUNGS. 357 during the prolonged and labored act of expiration. Occasionally a crackling sound is heard in emphysema.* When the emphy- sema is partial, all these signs are limited ; when it is more general, they are diffused. If the upper lobe of the right lung or the lower lobe of the left, which, according to Louis,t are the parts most frequently Pig. 32. Appearance of the chest in a patient suffering from a high degree of emphj-sema. The h*-art is 'dieplaced. The other physical signs are extreme percussion clearness ; a feeble, hardly audible inspiration ; a very prolonged expiration. affected, be emphysematous, the visible local bulging might mis- lead into the idea of the prominence being due to an aneurismal tumor, or to the presence of fluid in the pleural cavity. Any doubt will, however, be dispelled by a careful examination of the chest. The dulness over an aneurismal tumor, its pulsation, and its sounds, are different from the exaggerated clearness on percus- sion and the changed respiratory murmur of an emphysematous * Gerhardt, Berlin. Klin. Wochensclir. , Marcli 12, 1888. ■j- Mem. de la Soo. Med. d'Observation, tome i. 23 358 MEDICAL DIAGNOSIS. lung. Pleuritie elusions produce a bulging at the lower part of the thorax. But, although there may be a very clear, or rather a tympanitic, sound above the fluid, the absolute dulness over it shows that the prominence of the chest is not caused by distended air-vesicles. When the emphysema is extended and general, there is little or no action of the diaphragm, and the complaint gives rise to displacement of the liver or heart ; and this circum- stance, taken in connection with the dilatation of the chest and the dyspnoea, brings the malady into a category of affections which will be examined hereafter. When considering this group, we shall return to emphysema, and point out its distinguishing marks from the disease for which it is most likely to be mistaken, — pneumothorax. We shall only here add that the affection of the heart, the torpid displaced liver, and the presence of albumen in the urine, in emphysematous patients, may call away attention from the primary pulmonary cause. An effusion of air may take place into the areolar tissue uniting the lobules. There are no physical signs peculiar to this inter- lobular emphysema; they are exactly the same as those furnished by dilatation of the air-cells, except that a dry friction-sound and a large, dry crackling, both of which occur occasionally in vesic- ular emphysema, are much more common. Nor are there any general circumstances specially indicative of the disease, save its suddenness, and the external emphysema which follows. The latter is detected under the jaw, or at the base of the neck, and yields a peculiar crepitation. Yet the extravasation of air into the areolar tissue of the neck is not a constant attendant on the extravasation of air in the lung. Besides, the possibility of a crepitating swelling in the neck being due to a rupture of the bronchial tube or of the larynx must be borne in mind. The rupture of the air-cells which gives rise to interlobular ■emphysema is brought about by any severe effort, by violent coughing, by laughing, or by the throes of parturition. It has also been known to happen in the course of pneumonia or of pul- monary hemorrhage and to have caused sudden death. Its most frequent association, however, is with hooping-cough. A compensatory emphysema is met with when distention of the air-cells takes place in the unaffected lung or in an unaffected lobe. It generally occurs at the anterior margins, and is grad- DISEASES OF THE LUNGS. 359 ually developed by the high tension in the air-vesicles of those portions of the lungs which have to do more duty. It is thus chiefly met with in cases of extensive pleural effusion, in pneumo- thorax, and sometimes in pneumonia. The physical signs are those of ordinary emphysema. In all the disorders which have just been treated of, the reso- nance on percussion has been dwelt upon as a most valuable sign. Before proceeding to consider the diseases in which dulness is encountered, a few words may here find their place on a morbid condition in which clearness rapidly gives way to dulness, and dulness changes quickly back into clearness. As, moreover, the complaint to which I allude — collapse of the lung — bears a close connection with bronchitis and emphysema, and has been made to play an important part in the explanation of some of their symp- toms and complications, its consideration is at this time fitting. In noticing that dulness on percussion sometimes appears in the course of capillary bronchitis, it was remarked that this does not of necessity show that the inflammation has extended to the lobules ; it may be owing to the air in the lung being exhausted and to the pulmonary tissue having collapsed in consequence of accumulations in the bronchial tubes. These accumulations occa- sion collapse by shutting up the tube through which the air reaches the air- vesicles. No air can enter; the residual air is gradually exhausted, and the disordered portion of lung is reduced to a state as if it had never breathed. But, although in the ma- jority of instances this condition of things is brought about by catarrhal secretions in the bronchial tubes which cannot be expec- torated, it would be a mistake to suppose that these are always present. Any want of power to fill the cells of the lung with air may lead to their collapsing. In some of the typhoid forms of acute and chronic diseases, in the pulmonary congestions of the aged and enfeebled, and in those occurring just prior to death, large portions of the lung-tissue may collapse simply from in- ability to breathe with sufficient force. We also meet with col- lapse of the lung in hooping-cough. When we inquire whether the diagnostic signs of collapse of the lungs are so clearly defined that we can always make out the state of the pulmonary tissue, we have to admit that our 360 MEDICAL DIAGNOSIS. knowledge of the pathological phenomena as yet exceeds our power to recognize them in the living. The physical signs are not satisfactory; the symptoms vary with the conditions pro- ducing the disease. There is dulness as in the other forms of condensation, as in pneumonia, as in pleurisy. Neither voice nor respiration is characteristic. The most usual physical sign is dul- ness on percussion, with an absence of all respiration, or with a blowing sound, which is faint and not so distinct as in pneumo- nia. The dulness is not great, may be changed during respira- tory percussion, and in cases dependent upon inspissated mucus may disappear suddenly when the obstructing cause is removed. Yet collapse of the lung is at times a state of long duration. Great stress is laid by some on the signs of emphysema which surround the dulness of the condensed tissue. Should a pneu- monic process affect the collapsed portion, the dulness is sta- tionary, and we are apt to find the high but variable tempera- ture of broncho-pneumonia. After collapse the breathing becomes very difficult. The patient makes intense efforts at inspiration ; owing to the non-expansion of the lung during these efforts, the ribs move inward and recede, instead of moving outward as in ordinary breathing. This sign, the suddenly-increased dyspnoea, and the appearance of dulness unaccompanied by marked bronchial breathing, ai-e, in a case of bronchitis, the most trustworthy indications that collapse of the lung-tissue has taken place. Yet where the collapsed lobules are small and scattered through the lung, these signs are not all pres- ent, and the diagnosis is uncertain. The dulness is M^anting ; and the peculiai'ity in inspiration may not be observed. When collapse affects a large portion of lung, it much resem- bles lobar pneumonia and pleunsy, from both of which, however, it may often be distinguished by the phenomena indicated, and, still more positively, by the history and the absence of that group of symptoms and physical signs which characterizes inflammation of the lung or the pleura. How nearly it resembles broncho- pneumonia has already been stated. The diminution in volume of portions of the chest, the shifting character of the physical signs, and the speedy re-entrance of air into parts that had shown signs of condensation, are the most trustworthy points in diacr- nosis. DISEASES OF THE LUNGS. 361 Diseases in whicli Dulness on Percussion occurs. The diseases of the lungs in which dulness on percussion is met with are all those in 'which compression or consolidation of the pulmonary tissue takes place. Especially do we find dulness, and the physical signs which accompany it, in the phthises, in pneumonia, and in pleurisy. Phthisis. — Phthisis presents itself in a chronic and in an acute form. The chronic variety is by far the most frequent. It is essentially " the consumption," which is such a scourge to the human race. In by far the greatest number of instances this consumption is linked to tubercular disease. And although we can recognize a non-tubercular form, I shall, unless it be otherwise specified, use the term phthisis as meaning tubercular disease. Beginning usually with a short and insidious cough, with a feel- ing of lassitude, and a decline in general health ; attended at times from its onset with a pain in the affected lung and a somewhat quickened circulation ; or giving the first indications of its exist- ence by the occurrence of a hemorrhage ; or developing itself after severe bodily or mental fatigue ; or traceable to some neglected cold, — the disease becomes fiiUy established, with symptoms which hardly need a detailed description. The harassing cough by day and by night ; the impaired appetite and disturbed digestion ; the loss of blood from the lungs ; the steadily-augmenting debility ; the short breathing ; the exhausting night-sweats ; the hectic fever ; the deceptive blush which this imparts to the cheek ; the increased lustre of the eye ; the singular hopefulness ; the tem- porary improvements ; the relapses ; and the greater vividness of the imagination, so strongly contrasting with the waning frame, — are phenomena with which sad experience has made not only every physician, but many a fireside, familiar. The most constant of all these symptoms are the hemorrhage, the cough, and the emaciation. The cough is at first dry, and followed by a frothy expectoration. As the disease advances, the sputa thicken. They become greenish in color, streaked with yellow, and " nummular," consisting of large greenish masses of a rounded form, or sometimes rounded yet with jagged edges, which masses do not sink in the cup containing them, but float imperfectly in a thin serum. This expectoration is, however, by 362 MEDICAIi DIAGNOSIS. no means pathognomonic of the malady ; it is occasionally en- countered in chronic bronchitis. In the last stages of consump- tion the sputa are often homogeneous, and have a dirty-grayish, decidedly purulent aspect. Examined -microscopically, they show alveolar epithelium, pus-cells, exudation corpuscles, and elastic tissue, the most distinctive of which is the elastic tissue of the alveolar walls. Yet the only absolute sign in the sputum is the bacillus tuberculosis. Its presence bespeaks tubercular disease, its absence is an almost conclusive argument against the exist- ence of this affection. The numbers found in the sputum bear a direct relation to the extent and gravity of the complaint ; in arrested tubercle they become very few or disappear. In lung destruction from syphilis or from chronic pneumonia, in the non- bacillary form of fibroid phthisis, in cavities from bronchial dilatation, in gangrene of the lung, the bacillus is not observed. But failure to find the bacilli in the expectoration is not as valu- able evidence as finding them ; for Koch himself could not detect them in a certain number of cases of consumption. It is also a question whether a few of the bacilli may not be found in the sputum from accidental lodgement in the air-passages. In rare instances, the cough remains slight throughout the malady ; but generally it is a very distressing feature of the com- plaint, and is particularly worrying at night. Sometimes its violent paroxysms bring on vomiting. But vomiting and other gastric symptoms occur irrespective of paroxyms of coughing. In truth, anorexia, nausea and vomiting are often very prominent and early symptoms, and may exist where no obvious lesion of the gastric mucous membrane is found ; dilatation of the stomach attending the dyspeptic symptoms is not uncommon. Early anffimia, with increase of the blood-plates, is another frequent symptom.' Among the less constant symptoms of pulmonary consumption are a troublesome and rebellious diarrhoea connected with catar- rhal inflammation or with fistula in ano, chronic laryngitis and chronic pharyngitis, and the red line around the border of the gum. In some persons this gingival line is a mere streak ; in others it is more than a line in breadth ; in none is it a certain indication. A sign which has a much more definite connection with tubercular disease of the lungs is the appearance of the DISEASES OF THE LUNGS. 363 nails. The end of the finger is somewhat clubbed ; the nail is curved, prominent in the centre, depressed at the sides, its surface slightly cracked, its appearance bluish. This peculiar condition of the nails is sometimes met with even in the earlier stages of the disease. A similar nail is, however, seen in chronic pleurisy and in diseases of the heart. The laryngeal symptoms are apt to be a very distressing complication, and mostly end, no matter how they begin, in tubercular laryngitis. This, and the laryn- goscopic appearance of the ulcers which attend it, have been described when treating of laryngeal diseases. A significant symptom of phthisis is the heightened temperature as ascertained by the thermometer. Indeed, the temperature may be greatly elevated for several weeks before we find physical signs indicative of the deposition of tubercle, or of an undoubted in- crease in the already existing deposition. Furthermore, the rise in the body heat closely corresponds to the activity of the depo- sition of tubercle. If the temperature be decidedly and perma- nently elevated throughout the day, there is active deposition. When the animal heat is normal, the deposition in the lungs has ceased, and the tubercular process is arrested or retrograding. It may also be normal or even subnormal in very chronic cases. But these statements, as I know from repeatedly examining into the matter, do not aid us much in discriminating lingering lung complications in febrile states, or affections intercurrent in tubercular phthisis, from a spread of the disease, or certain forms of persistent non-tubercular consolidations. The morning tem- perature in tubercular phthisis is often higher than the evening temperature, though we frequently see the reverse. Very gen- erally the maximum temperature is reached in the afternoon; sweats occur in the evening, and there is a drop of two or three degrees towards morning. The temperature chart may simulate that of a remittent or an intermittent fever, and the frequent occurrence of chills and the sweats makes the resemblance still closer. In the last days of the disease the temperature may fall greatly. The thermometer has been made use of in another manner in the diagnosis of tubercular consumption. Peter * calls attention . * Olinique Medioale, tome ii., 1879. 364 MEDICAL DIAGNOSIS, to the advantage of local thermometry. A surface thermometer is applied firmly in front of the chest in the second intercostal space, and if the temperature is higher there than on the other side, or than normal, it is because there are tubercles underneath. In beginning tuberculosis the increased local heat is in proportion to the extent of the lesions. In health the temperature of the chest-walls is about 36° Cent. (96.8° Fahr.) ; it may rise in tubercle to 37° Cent., or more, and in consumption with cheesy degeneration still higher, surpassing the general fever heat of the body. The symptoms which precede a fatal termination are various. Patients may go on failing for years ; or an intercurrent attack of acute tuberculosis, of pneumonia, of tubercular meningitis, or of an affection of the intestines, may at any time result in death. But at no stage of the disease do we derive as exact knowledge from a study of its symptoms as we do from a study of its phys- ical signs. Before explaining these, it is necessary to recall briefly some facts connected with the general laws governing tubercle, and the tendency of tubercular matter to soften and destroy the textures among which it is infiltrated. It may undergo, at any period in its course, a retrogressive development, by shrivelling up, or by passing into a calcareous state. "When situated in the lungs, it seeks the apices by preference ; it is rarely limited to one lung, although one lung is usually the most diseased, and often at the beginning of the malady is alone affected. It is not merely a local complaint, but stands in connection with a pecu- liar, tainted state of the constitution, whether this be produced by infection from the products of the bacilli or not ; hence the symptoms of phthisis are not solely the expressions of the con- dition of the lungs. These pathological facts are all of the greatest importance. They tell us where to seek for the earliest indications of a deposit. They explain to us its signs. They teach us to look further than the lungs, and prepare us for finding lesions in other organs. In accordance with the laws affecting tubercular depositions, we have three stages of phthisis, which run, however, by almost im- perceptible degrees into one another. They are : 1. Incipient stage, or beginning deposition; 2. More complete deposition, occasioning consolidation ; DISEASES OF THE LUNGS. 365 3. Stage of softening and of the formation of cavities. 1. A few scattered tubercles do not change the normal percus- sion resonance ; nor do they appreciably alter the natural breath Fig. 33. Slight percussion dulnesa. Feeble or harsh respira- tion Prolonged expiration.. Exaggerated respiration,., Beginning infiltration ; masses of tubercle have accumulated, but the intervening lung-tissue is still healthy. sounds. But as soon as the deposit is sufficient to impair the elasticity of the lung-tissue or to increase its density, a relative loss of clearness on percussion on one side, and modifications of the vesicular murmur, such as feeble or jerking inspiration, or a prolonged expiration, may be ascertained. The dulness is readily detected by percussing the patient with his mouth open and during a fixed expiration, or the difference between the two sides becomes very manifest _ during held inspiration; in other words, respiratory percussion will aid us. To find the dulness at the upper part of the chest posteriorly, the position recommended by Corson,* of crossing the arms and clasping the shoulders, is very advantageous. In a certain number of cases, with the slight dulness on percussion and the changed breathing is associated a * New York Journal of Medicine, March, 1859. 366 MEDICAL DIAGNOSIS. . blowing sound in the subclavian or in the pulmonary artery. A murmur is, indeed, at times present in the pulmonary artery long before any other physical indication of tubercle is discernible. All these physical signs may be accompanied by rales of various kinds. What makes them significant is, that they occur at the upper portion of the lung, whether anteriorly or posteriorly. If, therefore, any modification of the vesicular murmur, or any adventitious sound limited to the apex, exist ; if there be a slight dulness on percussion above or under the clavicle, or in the supra- spinous fossa ; if this coincide with flattening of the anterior sur- face of the chest, especially on one side, with defective expansion of the thorax and shortness of breath, with a cough, and falling off in general health, — the diagnosis of beginning tubercular disease is almost positive. But these signs possess now less value to us than formerly, for the detection of bacilli would be of greater import than any or all of them. 2. As the infiltration advances, the signs become more decidedly those of consolidation. Greater dulness on percussion at the upper portion of one or of both lungs, scarcely influenced by respiratory percussion ; more resistance to the percussing finger ; stronger vocal resonance ; a sinking in of the side most affected, and often soreness to the touch over the diseased part ; a very harsh mur- mur ; or, when the infiltration surrounds the bronchial tubes, a distinct blowing respiration, — ^are all present in varying degree, and all denote consolidation. And chronic consolidation at the apex has, in the large majority of instances, but one interpreta- tion ; phthisis. In the second stage, as well as in the first, we often meet with superadded signs of bronchitis which occasionally mask the respiratory sounds, and with friction-sounds from local pleurisies, or with fine crackling. 3. The diseased organ now passes into a state of softening, or rather some portions of the lung begin to soften, while others remain indurated, and in yet others fresh infiltration takes place. Moist crackling or persistent moist rales indicate that softening has begun. The broken-down material may be expectorated, and the malady for a time be stayed ; but such is not often the case. The area of the softened mass widens; cavities form; and in addition to the moist rales, to the physical phenomena of the second stage, and to the increasing debility, night-sweats, and DISEASES OF THE LUNGS. 367 hectic, the signs indicative of a cavity are noticed. What these are, may be learned from the following engraving. Prominent among them are the cavernous voice, especially in whispering, Pig. 34. Cavernous respiration. Gurgling. Cavernous voice. Cavities of various sizes. and the hollow breathing. But the hollow, cavernous respira- tion may be caught only in expiration, or it may be temporarily superseded by very large bubbling sounds, — gurgling. Again, over small or over deep-seated cavities none of these sounds may be perceived ; and, in truth, even when they exist, their limita- tion to a particular locality is an element in the diagnosis of a cavity almost as important as their presence. The results of percussion over an excavation are not always the same. They depend much on the thickness and the state of the walls. of the cavity. If dense, percussion yields a dull sound ; if thin, a tympanitic, or its varieties, a cracked-pot or a metallic sound. If only a certain amount of indurated tissue intervene between the cavity and the surface of the chest, a singular sound, a mixture of dull and tympanitic, is produced. If healthy lung-tissue form the walls of the excavation, the sound is clear, or nearly so. More- over, in all cases the pitch and, to some extent, the character of the 368 MEDICAL DIAGNOSIS. sound are changed by percussing over the cavity while the mouth is kept open. When it is shut, the sound elicited is of lower pitch. On inspiratory percussion, the previously tympanitic or mixed sound becomes dull. Another sign by which we may judge of the existence of a cavity at the upper part of the lung is the extraordinary clearness with which the heart-sounds are heard at that point, or a waving impulse in the second intercostal space. Such, then', are the physical signs which indicate the varied structural conditions of the lung in the three stages of phthisis. With these signs are associated, as symptoms, cough, purulent sputum full of elastic tissue, increasing quickness of breathing, chest pains, progressive debility, hectic fever, digestive disorders, and emaciation, — symptoms the occurrence and severity of which mark also, though not very accurately, the periods of the malady. Since our knowledge of the value of the bacillus of tubercle, all points of diagnosis with reference to a pretubercular stage are of little importance. For, unless we found the bacillus in instances supposed to be pretubercular on account of defects of tempera- ture, lessened muscular power, vomiting, imperfect assimilation, emaciation, sore throat, slight, dry cough, and of limited physical signs, we should have no proof that the disease had or was likely to have anything to do with consumption. An interesting contribution to our knowledge has been made by Fowler,* which will help us in the clearer appreciation of the malady. It consists in watching the extension of the lesions in their " line of march," which is found to take place in a regular manner. The primary lesion is not often in the extreme apex of the lung, but has its site from an inch to an inch and a half below the summit of the lung, and rather nearer to the posterior and external borders. Lesions in this position tend to spread back- wards, and thus is explained why we may have the physical signs of deposit marked in the supra-spinous fossa while they are still uncertain in front. Another site of primary affection is at a spot corresponding on the chest-wall with the first and second inter- spaces below the outer third of the clavicle. The lower portion of the lung is usually involved before the apex of the opposite lung. * The Localization of tlie Lesions of Phthisis, London, 1888. DISEASES OF THE LUNGS. 369 Let us now look at the disorders with which phthisis, in its various stages, is likely to be confounded, premising that in doubtful cases the diagnosis is always to be established by the presence of the tubercle bacillus. They are, to speak of thoracic affections only : Chronic Beonchitis; Chronic Pneumonic Consolidation; Chronic Pleurisy; Pulmonary Cancer ; Syphilitic Disease of the Lungs ; Bronchial Dilatation ; Pulmonary Abscess ; Pulmonary Gangrene. Actinomycosis. Chronic Bronchitis. — The first stage of consumption is particu- larly prone to be mistaken for chronic bronchitis. Distinct dulness on percussion at the apex is of much aid in discrimination, espe- cially if it be on the left side, and if alterations of the vesicular murmur correspond to it. When the dulness is not discernible, we have to depend, in our efforts at a separation of the two diseases, on the history of the case, especially as to family, likelihood of exposure to infection, the occurrence of blood-spit- ting, the limitation of the physical signs to the apex, and the proofs of increased activity of the surrounding lung. Cough and expectoration are common to both affections. But they are associated, in chronic bronchitis, with physical signs more or less diffused through both lungs, and unaccompanied by much consti- tutional disturbance ; while from the onset of phthisis the falling off in general health is out of proportion to the local lesions. Where the deposition is at all extensive, an erroneous diagnosis of bronchitis is with ordinary care impossible, unless, as is always highly improbable, phthisis should be complicated with emphy- sema, or the tubercles be quiescent and so diffused as not to im- pair the resonance on percussion. Under the latter circumstances especially, the occasional tympanitic character of the sound over the seat of the tubercular deposition is liable to be misconstrued into increased clearness on percussion, and into, a disproval of the existence of phthisis. When tubercle and emphysema coexist, the percussion note may really be pulmonary and like that of 370 MEDICAL DIAGNOSIS. healthy lung. We should then have to judge of the one disease following the other mainly by the respiratory sound, which be- comes much feebler; generally, too, the dyspnoea is increased. The thermometer, as Ringer suggests, by showing a higher tem- perature than in pure emphysema, may assist us. But the most certain sign would be the bacilli in the sputum. A difficult diagnosis may be at times the distinction between chronic bronchitis and the phthisis of old people. This, indeed, often happens in a latent form, and is very slow in its develop- ment; the temperature may be normal or subnormal. Besides the microscopic examination of the sputum, auscultation alone is of much value, since the chest remains resonant on percussion, owing to the dwindling of the muscles of the thorax, the ossifica- tion of the ribs, and the rarefaction of the lungs. In the stage in which the signs of consolidation become well defined, phthisis may be mistaken for any of those conditions which occasion the physical signs indicative of greater density of the lung-tissue, and which are accompanied by cough and by loss of flesh. Such are particularly pneumonic consolidation, pleuritic effusion, and cancerous deposits. Chronie Pneumonic Consolidation. — Chronic pneumonic con- solidation, or chronic pneumonia, gives rise to many manifesta- tions which simulate consumption. These are cough, emaciation, and the local signs of chronic condensation, — increased voice and fremitus, sinking in of the chest-wall, feeble inspiration and pro- longed expiration, or a fully-devel6ped bronchial respiration. But in pneumonic consolidation the history usually points to an antecedent acute affection ; the health is not so much impaired ; there has been no hemorrhage, although, owmg to intervening acute bronchitis, the sputa at times may have been streaked with blood ; and the dulness on percussion and the other physical signs of consolidation are, for the most part, perceived over the lower lobe of one lung. In many of these cases interstitial fibroid changes ultimately take place in the lung, and we thus have a chronic interstitial pneumonia, and this allies the cases closely to fibroid phthisis. Yet it is clinically convenient to keep them apart, as the consolidation may slowly disappear, and the retrac- tion of the chest and other features of fibroid phthisis as ordi- narily seen are not present. DISEASES OP THE LUNGS. 371 This position of the physical signs is of great importance. Yet there are two sources of fallacy which may arise. On the one hand, tubercles may, by way of exception, be seated in the lower lobe ; on the other, chronic pneumonic induration may affect the apex. When an infiltration of tubercle takes place in the lower lobe, its distinction from chronic pneumonic condensation is very difficult. Our surest guides are attention to the pathological law which teaches that consumption is not met with in an advanced state in one lung alone, and the examination of the sputum for bacilli ; and by noting the want of those serious symptoms which go hand in hand with the physical signs of tubercular phthisis we may determine the real nature of the case when an inflammation of the upper lobe has resulted in its persistent induration. I adduce a few instances, by way of illustration : A gentleman was under my care for years, in whom, after pulmonary inflammation, signs of condensation remained in the upper part of the right lung. He did not suifer at all, except from attacks of acute bronchitis, to which he was very liable. During these he lost flesh ; but when they passed off he rapidly regained it He had a chronic cough, but it was very slight. After the lapse of a number of years I lost sight of him. In another case, with a similar history, I found dulness on per- cussion, prolonged expiration, and a friction-sound limited to the apex of the right lung. There had been a continuous cough, but very little constitutional disturbance, and no hemorrhage. The abnormal signs lasted for a year, and then almost disappeared under a succession of blisters, and the cough ceased. In both cases the signs were confined to the summit of one lung. I had some time since under observation a patient affected much in the same manner, a man seventy-five years of age, in whom the dulness at the right apex had for years remained sta- tionary. I might cite many more examples ; but these are suffi- cient to justify the conclusions that can be drawn from the facts mentioned. But to return to the points of difference between chronic indu- ration of the lung and tubercular phthisis. They may be thus summed up : when the signs of consolidation, whether existing at the upper part of the lung or not, are out of proportion to the general symptoms, there is reason to believe that they are not the 372 MEDICAL DIAGNOSIS. result of tubercular infiltration. The non-occurrence of hemor- rhage would tend to strengthen such an inference. Very impor- tant information is drawn from watching whether the physical signs undergo changes indicative of a deposit in the hitherto healthy portions of the pulmonary texture. To the presence or absence of the bacillus tuberculosis in the sputilm great weight must be attached. But the presence is of far more value in diagnosis than the absence. A great and complicating difficulty in the differential diagnosis remains to be mentioned. It grows out of the circumstance that tubercular disease may be developed in a lung which is in a state of chronic induration. Whatever the explanation, the fact cannot be disputed that we find persons who are without a trace of pul- monary disorder, seized with an inflammation of the lung, which is followed by persistent consolidation, and in the course of time by undoubted tubercular phthisis. Indeed, many of the reported cases of tubercle affecting primarily the lower lobe of the lung are, in reality, cases of tubercle following chronic pneumonic consolidation. The history is usually as follows. A person in all respects healthy is attacked with an acute pulmonary affection. He recovers from it, but with a trifling cough, with a persistent dulness on percussion, and with a feeble respiration, heard over one of his lungs. He continues ailing, yet is not positively ill, when, without any apparent cause, after a time varying from a few months to years, the pulse becomes frequent, his cough in- creases, the expectoration augments greatly in quantity and be- comes decidedly purulent, the temperature rises, and he emaciates rapidly. Profuse night^sweats occur ; and the physical signs, which have been stationary for a long time, now begin to change. The dulness extends ; and, instead of the enfeebled respiration, a harsher, blowing respiration is perceived over the affected part, and moist crackling and the signs of a cavity follow. If doubt still exists as to the nature of the malady, the advance of the disease will clear it up. True to the laws of tubercle, a deposit takes place in the lung previously sound, and not at the lower portion, but at its apex. Hemorrhage may or may not occur. In the patient from whose case the above description is drawn, it did not happen ; and in others, too, it was wanting. Its presence is, therefore, strongly DISEASES OF THE LUNGS. 373 in favor of the fact that tuberculosis has occurred ; its absence does not positively prove the contrary. At all stages a minute examination of the sputum will tell us when the bacillar infection takes place. It is supposed by many that the tubercle bacilli have existed in the lung prior to the inflammatory disease, or may, indeed, have caused it. But this is not often borne out by the clinical history. It is more likely that the bacilli have formed, as a rule, in the damaged organ. Cases of the kind with the cheesy changes in the lung and the disintegrating products of the inflammation form the variety of phthisis that was not long since asserted to be a special disease, pneumonic phthisis, but which we no longer doubt to be only a clinically somewhat different variety of tuber- cular aifection. These remarks will apply almost equally whether the origi- nal seizure was an ordinary croupous pneumonia or a catarrhal pneumonia. In both we have the signs of consolidation re- maining ; in both the same questions of diagnosis may arise, as to whether the lung is undergoing cheesy degeneration, and as to the occurrence of tubercle. Yet there are some points which the chronic consolidation attending a chronic catarrhal pneumonia exhibits, that I shall here refer to. In the first place, the history of a preceding acute catarrhal attack is clear, or there have been a series of attacks, after one of which the lung was left solid, and since which the patient has remained delicate, prone to take cold, and is easily put out of breath. Now, he may come under our observation iii the midst of one of these broncho-pneumonic seizures, and we may watch him for five or six months with the signs of consolidation over portion of one lung, whether at base or apex, or with affected points, often symmetrical, in both ; fur- ther, there are night-sweats, fever with decided evening exacerba- tion, diarrhoea. Gradually these urgent symptoms yield ; he gets about, but a spot or spots .of consolidation in one or both lungs do not pass away for many months ; or the chronic catarrhal pneumonia may remain as such, or pass into pneumonic phthisis, which means really tubercle.* When this happens, great vari- ation between morning and evening temperature, simulating a * See a paper of mine, Pbila. Med. Times, June 19, 1880. 24 374 MEDICAL DIAGNOSIS. malarial fever, increasing cough and dyspnoea, marked sweats, decided emaciation, announce the event ; while the physical signs show extending dulness, crackling and fine moist rales, over the aifected spots or in parts not previously diseased, and ultimately cavities. At all stages repeated examinations of the sputum for tubercle bacilli are of decisive value. Chronic Pleurisy. — A persistent cough attended with emaciation and with dulness on percussion is common to chronic pleurisy and to phthisis, and is a cause of many errors. But the seat of the dulness at the lower part of the thorax ; its much more absolute character ; the almost entire cessation of all breath-sound ; the diminished or absent vibration of the chest- walls when the patient speaks ; the dilatation of the affected side, — are in striking con- trast with signs most manifest at the apex, with the distinctly- prolonged expiration, with the rales and the evidences of begin- ning softening. Nor are the symptoms of a pleuritic effusion as grave as those produced by phthisis. Even where the fluid filling the chest is pus, we do not find hectic fever so intense, emaciation so great, or night-sweats so constant and exhausting; and the patient coughs less, and never spits up blood. In those cases of chronic pleurisy in which the side, instead of being dilated, is retracted, the diagnosis is more difficult. Attention to the seat of dulness being at the lower part of the chest, to the diminished respiration, voice, and fremitus, and to the shrinking affecting only one side of the thorax, will, however, serve as the foundation for a correct conclusion. Tubercle may complicate pleuritic effusions. We suspect this by the occurrence of hemorrhage, and by the marked emaciation and hectic. We can only be sure of it by finding signs of deposit on the non-affected side, — which deposit, in accordance with the custom of tubercular disease, will take place first at the apex,— and by bacilli in the sputum. Tubercular pleurisy may be a one-sided as well as a primary disease. It is no.t always accompanied by •effusion. There may be only great and irregular thickening of the pleural membrane attended with variable fever, with coarse friction, with much pain, and with or without bacilli in the scanty expectoration. Chronic double pleurisy is apt to be associated with a tubercular affection of the lungs, but it may be rheumatic, or may occur without obvious cause. DISEASES OF THE LUNGS. 375 Pulmonary Cancer. — Cancer of the lung has many symptoms which it shares with tubercle. Cough, night-sweats, hemorrhage, gradual wasting, belong to both diseases, as do the signs of pulmo- nary consolidation. But cancerous formations are usually limited to one limg. Only one side of the chest is, therefore, flattened or distended. Over the cancerous lung the percussion dulness is great. There is either loud, blowing respiration, or, if the mass have compressed or obliterated a bronchus, enfeebled or absent breathing and absent tactile fremitus. We find no rales; but all the signs of consolidation are more perfect than in tubercle. Owing to a cancerous deposit in the mediastinum, the dulness at times extends beyond the median line. Paroxysmal dyspnoea, enlargement of the clavicular lymph-glands, and prominence of the large veins on the chest and arms are common. Fever is very generally absent. Cancer in the lung may soften ; yet the signs of softening are rarely as manifest as they are in tubercle. The sputa are puru- lent, or like currant-jelly or prune-juice. Further, a cancerous tint of the skin may be present ; and cancerous tumors in other parts of the body become almost absolute evidence in favor of a deposit in the lung being cancerous, since, with rare exceptions, cancer and tubercle do not coexist. The character of the pain must be also taken into account. In tubercle, it is transitory and shifting; in cancer, it is much more constant, and much more severe. Syphilitic Disease of the Lungs. — Syphilis may occasion a specific form of bronchitis, preceding the syphilitic eruption ; or produce gummata, which may soften and be eliminated, and which, ac- cording to Eicord, form in the lungs toward their periphery and base ; or give rise to chronic interstitial pneumonia of the base. When syphilis manifests itself in the pulmonary structures, it pro- duces most of the phenomena of phthisis. The chief differences are, that the nodules affect generally only one lung, most fre- quently the right, and principally the base or the lower part of the upper lobe ; that they remain circumscribed, not spreading to the surrounding textures ; and that they occasion, as a rule, neither haemoptysis, nor fever, nor night-sweats, nor decided emaciation, nor marked cough or rales, but dyspnoea out of proportion to the local disease. The most common physical signs are dulness on 376 MEDICAL DIAGNOSIS. percussion, deficient fremitus, altered vesicular breath-sounds, and obvious sinking in of the supra- and infra-clavicular regions ; in some instances signs of destruction of the lung are found. Still, the syphilitic affection can be distinguished with certainty only by the history of the case, and by the thickening of the periosteum of the head of one or both clavicles. Milroy,* in his investigations on soldiers, also lays stress on the thickening of the perichondrium of one or more of the upper cartilages, with frequently a tumefac- tion of the soft parts between them and the skin. To these tests may be added that recognized by Broderick,t substernal tender- ness, as a means of diagnosis of acquired syphilitic taint. In all cases, we must be careful that the thickening at the upper part of the chest-walls and the altered resonance thus occasioned be not looked upon as signs of a tubercular consolidation. And as regards the tenderness, pain on pressure, as has been correctly asserted, is met with at the lower part of the sternum in a large number of phthisical cases. Syphilis of the lung may also be associated with syphilitic lesions in other organs, especially in the larynx, and we may find considerable cough, with emaciation, diarrhoea^ and albuminuria. But even then there are no night-sweats and fever attending the emaciation, the great debility, and the marked dyspnoea. The diagnosis of syphilis has been made by microscopical examination of the sputum, finding nucleated granular cells, shrivelled nuclei, spindle-cells, and remnants of a finely-striated stroma.J To the absence of tubercle bacilli in doubtful cases great weight must be attached. Fibrous pleurisy and pleuritic effusions are compara- tively frequent ; even small cavities occur in the lung.§ The preceding diseases are most likely to be confounded with the stages of consumption prior to softening and the formation of cavities. Next let us review those affections which, like phthisis, occasion the signs of excavation, and which, therefore, may be mistaken for its third stage : they are, chiefly, bronchial dilata- tion, abscess, and gangrene of the lung. * British Army Medical Keport, quoted in Annals of Military and Naval Surgery, vol. i., 1863. f Madras Medical Journal, July, 1865. J Sokolowsky, Deutsche Medicinische Woehenschrift, Sept. 12, 1883 ; Cube, also Guntz, quoted in Schmidt's Jahrb., No. 6, 1882. § Satterthwaite, Boston Med. and Surg. Journ., June, 1891. DISEASES OF THE LUNGS. 377 Bronchial Dilatation. — A dilatation of the bronchial tubes takes place in two forms : either the tubes are uniformly dilated and like the fingers of a glove, or else they form cavities by un- dergoing a saccular enlargement. The former variety furnishes the symptoms and physical signs of a case of chronic bronchitis attended with copious expectoration. The percussion clearness may be slightly lessened, owing to the condensation of the sur- rounding pulmonary tissue ; the respiration may be more strictly bronchial ; but otherwise both symptoms and signs are those of chronic bronchial inflammation. In the globular form of dilata- tion we meet with all the sounds of tubercular excavations : the hollow, blowing respiration ; the hollow, well-transmitted voice ; gurgling ; even metallic tinkling. In the acuter cases, Wilson Fox * has observed the metallic quality of the rales to be very distinctive. Yet all these phenomena are in strange contrast with the almost unimpaired health, and with the non-occurrence of hemorrhage, of night-sweats, and of emaciation. Pain, Lebert has shown, is among the early manifestations of the disease. Thus, when we find the signs of a cavity, and when the gen- eral symptoms do not indicate profound constitutional disturb- ance, we may suspect a bronchial dilatation. This suspicion becomes a certainty, if the cavity be at the middle or the lower portion of the lung, and if the resonance on percussion be but little impaired. For in bronchial dilatation the dulness over the seat of the disease is very slight ; certainly not nearly so great as that yielded by the dense walls of a tubercular excavation. It is also true that the dulness on percussion is not increased by re- spiratory percussion, and, for the most part, follows, and does not precede, the auscultatory signs of a cavity. We find further evidence in the stationary character of the physical signs : for months they do not change ; whereas in phthisis they continually alter with the advancing malady. The expectoration of bron- chial dilatation, too, is more abundant than that of consumption, purulent, acid, and in very chronic cases fetid, suggesting, indeed, at times, the existence of gangrene. Nor does it look like the sputum of phthisis, for the bulk of it is much more fluid, and in the watery secretion float small masses of pus and detritus far * Treatise on Diseases of the Lungs and Pleura, London, 1891. 378 MEDICAL DIAGNOSIS. less compact than the nummular sputum of phthisis. It may contain elastic fibres, but not tubercle bacilli. As regards the cough of dilated bronchi, it is much more persistent, being con- stant by day and by night, and only at times relieved by expec- toration, which then varies in copiousness according to the size of the sac* Skodaf describes, as a peculiar physical sign present in saccu- lated bronchial dilatation, a large and coarse crackling, called by him the large bubbling, dry crepitant rale. In a case which came under my observation, the diagnosis was made by this ausculta- tory sign. The patient, a boy aged twelve years, had swallowed a bone, which lodged in a bronchial tube and gave rise to bron- chitis and bronchial Avidening. He died subsequently of acute meningitis, and the bone was found firmly embedded on one side of the globularly-dilated bronchial tube. Pulmonary Abscesses. — Abscesses of the lung may form in the course of acute pneumonia, but are not then likely to be mistaken for chronic phthisis. Different is it with abscesses which are de- veloped three or four months after an attack of pneumonia, and where the lung-texture has remained partially consolidated. I have seen not a few examples of chronic induration of the lung terminating in this way. A man who was shot thi-ough the lung was seized, soon after the injury, with inflammation of that organ. Percussion dulness and blowing respiration continued at the lower part of the left lung. One day, after exertion, he suddenly ex- pectorated a considerable amount of pus. The signs of a cavity were detected at once ; but they subsequently disappeared, and perfect recovery took place. In another case of pneumonia, the disease in like manner lapsed into a chronic state. Five months after the acute attack, the evidences of an excavation became mani- fest at the edge of the right scapula, and existed there for two months ; then, so far as physical signs could prove, the cavity closed. Instead of the hollow, blowing respiration and gurgling, only a somewhat roughened vesicular murmur was perceived. Such is, however, not always the termination. The abscess may grow larger and larger, until the entire lung is destroyed ; * Skoda, Allgem. "Wien. Med. Zeitung, 1864, No. 26. f Percussion and Auscultation. DISEASES OP THE LUNGS. 379 amphoric percussion note, amphoric respiration, amphoric voice, and, at times, metallic rales, being the physical signs observed. Lung abscesses differ from bronohial dilatation in not being permanent and fixed. They have this in common with tubercular excavations — they change. They increase like these ; but, further, they do what tubercular cavities do not — they decrease. Their physical signs are in every respect like those of all cavities, and vary with the size of the excavation. Sometimes metallic respira- tion and voice may be heard over it ; or perforation of the pleura produces the signs of pneumothorax with effusion. In fortunate instances the pus is expectorated, or the abscess opens externally, and a cure is thus established. But very large abscesses are apt to wear out the patient. Hectic fever, and occasional hemorrhage, attend them ; yet neither is as constant a symptom as it is in con- smnption. The sputa are usually copious, purulent, full of elastic tissue, and fetid, differing in this respect from the expectoration of phthisis, which is only temporarily fetid, if the secretions de- compose in the cavities. Again, abscess of the lung may be dis- tinguished from tubercular disease by being ordinarily situated at the base of the organ ; by its following — although there are exceptions to this rule, chiefly in septic conditirms — pneumonic consolidation ; by the occurrence of copious expectoration being often, not constantly, sudden ; but especially by its limitation to one lung. The other lung remains perfectly healthy. It may enlarge, and its murmur be more distinct ; but the sounds denote its texture to be normal. Abscess of the lung is not infrequent in suppurative diseases of the nose, or larynx, or oesophagus. It is still more common from embolic infection. The small amount of constitutional disturbance which pul- monary abscesses sometimes entail is remarkable. In several patients, in whom I have noticed abscess of the lung consequent upon chronic pulmonary consolidation, the physical signs of a large cavity were in strange contrast with the regular pulse, the almost undisturbed breathing, the slight cough, and the healthy complexion. Let us tabulate the differences between a tubercular excavation and a pulmonary abscess : 380 MEDICAL DIAGNOSIS. Pulmonary Abscess. Catitt from Phthisis. Signs of cavity usually at the lower Signs in the upper lobe. lobe. Copious and purulent sputa, contain- Sputa less copious, and at first num- ing elastic fibres, but free from mular, containing tubercle bacilli, tubercle bacilli. as well as elastic fibres. Comparatively small amount of con- Graver symptoms, and a different stitutional disturbance. history. One lung affected. Usually both lungs affected. What has been called " dissecting pneumonia," a suppurative inflammation starting mostly in the peri-lobular and peri-bronchial tissues and dissecting the lobules, and subsequently destroying the parenchyma, leaving nothing but the bronchial ramifications and vessels, has symptoms that are in the main those of abscess, of which, indeed, it forms a variety. The absence of fetid breath and of fetid sputum distinguishes it from gangrene.* Pulmonary Gangrene. — Another disease which yields the signs of an excavation, and which, like phthisis, is attended with wasting of the body, here claims attention. Gangrene of the lung occurs either as diffused or as circumscribed gangrene, after pneumonia, after wounds of the lung, from blows on the chest, from poisoned blood, or from emboli in the pulmonary tissue. The physical signs are those of a cavity, seated usually in the lower portion of the lung. The symptoms are : great and increasing prostration, dyspnoea, a very pale face, a quick pulse, hemorrhage, emaciation, and a cough, followed by profuse purulent sputa of a greenish or brown color. But nearly all these symptoms happen also in phthisis. What is characteristic of gangrene is the extreme fetor of the expectoration and of the breath. The sickening odor is not perceived during each act of breathing, but mainly after coughing, and, as it were, in jets. It is the symptom by which, especially if taken in connection with the signs of breaking up of the pul- monary tissue and the sputum, gangrene is with certainty recog- nized. Some authors lay stress on the fact that a cavity is found in only one lung, and at its lower part. This is unquestionably of aid in discriminating between phthisis and gangrene ; but it does not distinguish between a gangrenous excavation and a simple * See an elaborate paper by Hutinel and Proust, Arch. Gen. de Med., Nov. 1882. DISEASES OP THE LUNGS. 381 abscess of the lung. The only positive proof of gangrene of the lung is, as just stated, that the signs of breaking down of the pulmonary tissue are accompanied by a disgusting and more or less persistent fetor of the expectoration and of the breath ; some- times a sickening, faintly sweetish smell, sometimes faecal, oftener that of putrescence. I say persistent, because local gangrene, on a small scale, occurring around tubercular cavities or in bronchitis, may give rise to temporary extreme fetor of the breath. But it is only temporary, and therefore not liable to lead to fallacious in- ferences. The expectoration may be fetid in cases of bronchial dilatation or of abscess of the lung, but is never brownish, as is not uncommon in gangrene ; and neither it nor the breath has that peculiar gangrenous odor which makes the patient as unbearable to himself as to his attendants. In rare instances pleurisy with fetid effusion may occasion a faecal smell of the expectoration and breath, which is gradually lost.* The fetid sputum of fetid bronchitis is not associated with any signs of breaking down of the lung. Yet in considering the diagnosis regarding bronehial dilatation we must not overlook the fact that, as Dittrich and Traube f have shown, this bears a marked relation to gangrene. Decomposition takes place in the secretions retained in the bronchial dilatation, and ulceration of the coats may ensue, leading to a gangrenous process in the surrounding tissue. Now, as just mentioned, the sputum even in bronchial dilatation may become fetid. As, moreover, it, like gangrenous sputum, may present a dirty green- ish-yellow color, and separate on standing into three distinct strata, of which the uppermost is frothy though dense, the second serous, and the third dense, containing pul-e pus and detritus ; as, further, we meet in both affections with little solid masses of particularly offensive odor full of fat and fine needle-shaped crystals of mar- garic acid, — we may have to depend, for a differential diagnosis, on finding with the microscope pigment grains and masses of elastic tissue. Bacteria and vibriones bespeak a similar pulmonary origin, and they and the substance in which they are embedded yield a purple or blue reaction with iodine.J Pulmonary Actinomy oasis. — This rare disease resembles tuber- * As in the case reported by William Moore (Dubl. Quart. Journ., May, 1865). t Gesammelte Abhandlungen. J Leyden, Klinische Vortrage, No. 26, 1871. 382 MEDICAL DIAGNOSIS. cnlar disease of the lung in presenting cough, fever, wasting, and a muco-purulent expectoration. The attending fever is of irreg- ular type, sometimes like that of typhoid fever, more generally like hectic fever. The physical signs are mostly those of tuber- cular deposit. The absolutely distinctive feature is finding the ray fungus in the sputum. Besides the lungs, other parts of the body may be involved, such as the jaw, the alimentary canal, and the subcutaneous tissues. The diseases just considered exhibit, thus, points in which they are similar, and points in which they are dissimilar, to pulmo- nary consumption. Other affections might be added which are sometimes mistaken for this malady, such as intermittent fever, ansemia, dyspepsia, chronic diarrhoea, chronic laryngitis, chronic pharyngitis, and thoracic pains. But each of these, although it may accompany tubercular consumption and even mask some of its symptoms, lacks, when it is present as an idiopathic affection, those local evidences of deposition and softening, lacks that pro- found and persistent constitutional disturbance, which form as striking a part of phthisis as the disease in the limgs. An ex- amination for bacilli is always of the greatest value. lu the remarks on the diagnosis of pulmonary consumption, the complaint has been assumed to be progressive; in rare instances it retrogrades. Now, before dismissing the subject of phthisis, the signs by which such retrogression can be discovered may be mentioned. They are not very fixed. In those cases in which many tubercles undergo a cretaceous transformation, calcareous particles are coughed up ; the signs of softening cease ; fibroid changes take place in the affected lung ; the apex flattens ; and a feeble murmur, with prolonged expiration or a harsh respiration, with slight dulness on percussion, is all that remains to indicate that tubercular disease has existed. It is hardly necessary to say that the cough stops, and that flesh and strength return. These phenomena may be noted even when large cavities have existed. But, unfortunately, it is not very often that we have opportunities to make such observations. We meet occasionally with instances in which the physical signs of an infiltration into the lung-tissue depart with tolerable rapidity. They occur in those who have a decidedly scrofulous aspect, en- largement of the glands of the neck, or a scrofulous inflammation DISEASES OF THE LUXGS. 383 of the eyes. In accordance with the acknowledged' identity of scrofula and tubercle, we are forced to admit that the disease in the lungs is tubercular. Yet the connection with the enlarged lymphatics ; the circumstance that the diminution in size of the glands is often followed by increased pulmonary deposits ; that these depositions are very beneficially influenced by treatment; that they disappear sometimes altogether, or only reappear months afterward, — all make it a question whether there be not a scrofu- lous disease of the lung independent of a tubercular, one pursuing more the course of an external scrofulous disease, one, moreover, which presents a much more favorable prognosis than ordi- nary consumption. Among scrofulous children cases like those mentioned are not uncommon. The disorder certainly differs from the common forms of pulmonary tuberculosis, and it is not bronchial phthisis. It does not present the paroxysmal cough, the signs of pressure on the trachea or the large bronchi, and the dull sound on percussion between the scapulae, which are the com- mon accompaniments of enlarged and tuberculous bronchial glands. Indeed, the bronchial glands are not of necessity involved. Some years since, I had an opportunity of inspecting the lungs in one of these instances of supposed pulmonary scrofula. I was treating a little girl for this affection, when she received a severe injury which resulted in her death. She had, when first seen, an eruption on the scalp, sore eyes, and enlarged cervical glands. She was also much troubled by a cough ; and marked dulness on per- cussion was discerned at the upper portion of the left lung. Here, as in fact throughout the whole of the left lung and the upper part of the right, the respiration was harsh. But for two weeks before her death the symptoms and signs had strikingly improved under cod-liver oil and iodide of iron. She was" rapidly losing her cough and gaining strength. The dulness on percussion was diminishing, the respiration becoming less and less rough. At the autopsy the greater part of the left lung and a portion of the right were found to contain yellowish, cheesy deposits, which exhibited under the microscope a large quantity of granules and some shrivelled cells, without distinct nuclei. The examination was made before the days of the knowledge of the tubercle bacillus. It would be out of place to pursue here this intricate subject. I shall only add that there are no phenomena which serve as 384 ' MEDICAL DIAGNOSIS. a foundation for an absolute diagnosis of a scrofulous, in dis- tinction from a tuberculous, infiltration. But the rapid fluctua- tion in the physical signs, their occurrence in those who present a strongly scrofulous aspect, and the course of the disease, may furnish a clue by which to separate clinically, as far as they can be separated, cases of the disorder. Perhaps the absence of htemoptysis from among the symptoms may be a matter of im- portance from a diagnostic point of view. Certainly hemorrhage did not happen in any of the cases of pulmonary scrofula which have come under my observation. As regards bacilli in the sputum, I do not know of any observations, but most likely the bacillus of tubercle is present. Tlie Acute Affections of the Lungs accompanied by Dulness on Percussion. In continuing the consideration of the diseases in which dulness on percussion is a marked sign, let us glance at a group of acute affections, in the distinction of which dulness and the physical sounds which correspond to it hold an important part. The acute diseases of the lungs are bronchitis, pneumonia, pleurisy, and acute phthisis. They have some signs and many symptoms in common. They all present fever; they are all associated with more or less dyspncea and thoracic pain ; they all occasion a cough. If, therefore, a physician meet with an acute disease of the chest, and find the heart healthy, he at once asks himself. Is the malady acute bronchitis ? is it acute phthisis ? is it acute pneumonia ? is it acute pleurisy ? Now, the symptoms and signs of acute bronchitis have already been discussed. It has been pointed out that the want of intensity of the fever, and. particularly the umimpaired resonance on percus- sion, separate bronchial inflammation from all affections which oc- casion consolidation or compression of the lung- tissue. We may then proceed to examine the other acute pulmonary affections. Acute Phthisis. — When phthisis runs its course rapidly, it is known as acute phthisis, acute tuberculosis, or galloping con- sumption. This formidable complaint is met with at the close of other diseases, especially of fevers; but exposure, toil, and anxiety are also among its exciting causes. Acute phthisis shows, more even than chronic pulmonary con- sumption, that the disease is not simply one of the lungs. The DISEASES OF THE LUNGS. . 385 lesions found by the knife of the pathological anatomist are indeed for the most part insufficient to account for the early exhaustion and the emaciation. The disorder often begins with a severe chill : fever follows; at first like any fever with anorexia, quickened pulse, and elevated temperature, but soon accompanied by ex- hausting night-sweats and rapid emaciation, which, in connection with the intense restlessness and prostration, the high temperature, and the supervention of delirium, may cause the febrile dis- turbance closely to resemble typhoid fever. The symptoms that point to the thoracic malady are the accelerated breathing, the cough, the copious expectoration, the pain in the chest, and the spitting up of florid blood. The physical signs are not always the same. If the tubercles be scattered through the lungs, no signs are perceived but those of diffused acute bronchitis ; indeed, the sputum is the same in composition, and tubercle-bacilli are not found,* or are infrequent. More commonly the signs are like those of chronic pulmonary phthisis, and associated with the fever and prostration we find the percussion dulness of a deposit or the evidences of the destruc- tion of the pulmonary tissue, furnished by coarse, moist rales, and cavernous breathing. Tubercle bacilli are then usual. When the malady assumes the form resembling chronic pul- monary consumption, the diagnosis from bronchitis is not per- plexing ; but when its phenomena are similar to those of acute bronchitis, the recognition of the tubercular affection is often impossible. This remark applies particularly to the distinction of the miliary form, acute miliary tuberculosis, from bronchitis of the finer tubes ; since the slight constitutional symptoms and the coarseness of the rales of ordinary bronchial inflammation are too unlike the phenomena of acute consumption to occasion difficulty in their discrimination. But from bronchitis of the finer tubes the diagnosis can be effected only by taking into account that repeated chills, rapid emaciation, and profuse sweats are wanting in the bronchial affection ; that the temperature is not so high, nor so irregular ; that the skin is more livid ; that the rales are more abundant and more perceptible at the lower part of the chest ; and that, perhaps, the breathing is not so hurried or so difficult. * Jaksch, Klinische Diagnostik, 1887. 386 MEDICAL DIAGNOSIS. Moreover, with the intense dyspnoea there are generally frequent and violent fits of coughing, and marked chest pains, in the acute tubercular malady. Yet none of these signs are convincing proofs. The presence of dulness on percussion, or the sinking in at the upper part of the chest, the occurrence of hemorrhage, the finding of the tubercle bacillus, if present, the eruption of miliary tubercles in other organs, and the longer duration of the case are alone conclusive evidence in favor of the acute tubercular disease. Hemorrhage is, however, by no means so constant in the acute as in the chronic form of the affection. Much the same symptoms will enable us to distinguish between acute tuberculosis of the miliary form and broncho-pneumonia, except that we can draw no inference from the dulness on per- cussion, further than that its early occurrence, with the bronchial symptoms, points to the pneumonic malady, its later occurrence, after the grave symptoms, to the tubercular. When the dulness on percussion is well defined, acute phthisis might be mistaken for ordinary pneumonia. But the signs of deposit and of softening in both lungs, and the seat of the lesions at the apices, show differences from a disease which in the large majority of instances is one-sided and at the lower part of the lung, which exhibits a characteristic sputum, and in which breaking up of the pulmonary tissue is so rare. Yet there are cases of acute phthisis that display symptoms and signs very puzzling, and strongly simulating those of pneumonia. A person in perfectly good health is seized, after exposure, with cough and fever. They are accompanied by dyspncEa, and soon we find signs of consolidation of the lower lobe, or of the entire lung. The dulness on percussion does not disappear under treat- ment; and a hollow, blowing respiration and gurgling, usually first perceptible at the angle of the scapula, gradually appear, and indicate the formation of a cavity. Emaciation, which began from the onset, progresses more rapidly, and goes hand in hand with extreme prostration and profuse perspirations. The sputa are copious and purulent, but at no time mixed with blood. The other lung is carefully examined ; all its sounds are normal. The case remains in this condition for several weeks, the patient tem- porarily improving under stimulants, yet, on the whole, growing weaker and tormented with fever of very irregular type. A slight DISEASES OP THE LUNGS. 387 roughening of the inspiratory murmur, or dry rales at the apex of the unaffected lung, attract attention, and dulness on percussion and the signs of deposition become there more and more manifest. A post-mortem examination exhibits nearly the whole of one lung converted into a uniform yellowish or grayish mass of tubercle, and containing one or several large excavations ; not a vestige of healthy lung-structure is to be seen. Scattered tubercles are found in the other lung, and mainly at its apex. The case just described is one of a group which every physician has met with. The beginning of the case as one of pneumonia or broncho-pneumonia, the persistent consolidation, the occurrence of rales and of subsequent dulness on percussion at the upper part of the previously unaffected side, the continuance of the dis- ease, and the prostration and sweats which accompany it, permit us to foretell its nature and the probable fatal termination. Such cases were not long since classed as aevie pneumonio phthisis, and looked upon as inflammatory, with resulting caseous infil- tration of the pulmonary tissues and disintegration of the cheesy infiltration. With our present knowledge of the bacillar origin of consumption, they are explained by supposing that the tubercle bacilli have fastened readily on the altered lung, or, more generally, that these have occasioned the attending inflammatory process. Acute phthisis may simulate other affections besides those of the chest. It has at times the delirium and prostration, the dry tongue, and the bronchial rales of typhoid fever. The diarrhoea and the abdominal symptoms are, however, wanting. Yet simul- taneous deposition of tubercles in the intestine may cause these ; and in this case the only mark of difference from typhoid fever is the absence of an eruption ; uuless, even under these circum- stances, we are aided by the fact pointed out by Fox, that, unlike the persistent high temperature of typhoid fever with its regular diminution when the disease declines, the thermometric record in acute phthisis shows great and sudden variations, bearing no rela- tion to the number of respirations or to the beats of the pulse. The temperature may vary many times in the course of the disease to the extent of six or seven degrees. Acute phthisis lacks the eye phenomena, the gastric disturbance, the rigid muscles, the convul- sions, of meningitis ; else the active delirium it occasionally produces might be attributed to inflammation of the membranes of the brain. 388 MEDICAL DIAGNOSIS. Acute phthisis sometimes progresses with extreme rapidity. I have seen a case terminate in thirteen days. It is almost invari- ably fatal. Yet it has its periods of deceptive improvement : the disease may proceed speedily toward softening, and then remain for a time stationary. In some instances the termination in death is the result of complications, as of tubercular meningitis, or of erysipelas of the throat and the bronchial tubes. Acute Pneumonia. — Inflammation of the lung, or '>' croupous pneumonia," is the type of the acute pulmonary affections. The hot, dry skin, the flushed face, the quickened pulse, the extremely rapid breathing, the thoracic pain, the cough, and the peculiar ex- pectoration, point out at once the acute nature of the attack and the organ which is disturbed. Beginning commonly with a chill, or with flushes of heat, the disease progresses with the symptoms indicated. A few of these require a detailed description. The expectoration is characteristic. It consists at first of a glairy mucus ; soon it becomes more viscid, and acquires the ap- pearance dependent upon the admixture of blood with the mucus and exudation-matter, to which the term rusty-colored has been given. This rusty sputum is pathognomonic of pneumonia ; yet cases run their course without it. The expectoration is sometimes like prune-juice, or it is purulent. Both augur badly : both in- dicate that destruction of the lung-tissue has begun. The shortness, or increased frequency, of breathing is another marked symptom. The patient draws from forty to eighty breaths a minute ; but the pulse, although rapid, does not quicken in proportion. Pneumonia, therefore, forms an exception to the rule that with greater frequency of breathing the pulse rises. This perverted pulse respiration-ratio may be made an impor- tant element in the diagnosis. The febrile symptoms are ordi- narily severe ; still, they are not associated with decided cerebral disturbance. Headache is common ; delirium is rare, and, when it occurs, is indicative of great danger. In drunkards it may take the form of delirium tremens. The flush on the cheek is so decided that by this and the hurried breathing alone the disease may often be recognized. The flush on the cheek is not accidental. It is sometimes very dark, and, according to Bouillaud, is most obvious when the inflammation affects the apex of the lung. Herpes is also a common symptom. DISEASES OP THE LUNGS. 389 The temperature rises abruptly, and on the first or second day attains 103° to 105° F. In children and in robust adults it is specially high. It shows little change, except an evening exacerbation and a marked morning remission of from 1.5° to 2.5° for five to nine days. Between these days, sometimes on the fifth, generally on the seventh day, it falls abruptly, and a Fig. 35. T ::: 7 : " 7 T : " i ..( ~ 't • E :!TT "T ~ ~ -p ~'Z ^ ' r „ f :Zi M - BOWELS NUMBER OF MOVEMENTS i 1 - ~ - = = - - - - URINE, DAILY AMOUNT h 1 J_ _ _ L _ . _ __ __ _ _ 107° 106° 105° - - — - - t ^ ^ £ ~~ -' - - - - - — - - - J^ »■ < i \ ^- • • > 1 104° 103° 102° 101° 100° ^: m f ?■ ' e I ' \\ \ i * Az » v^"^ I-; ' "* " >r - - " - \ L i 99° . _ -J ^ [-■-^ - -h - - n,. . f -f 1 - -- 98° 97° - - - 4- - - - - - s - — ^ ^ *■ - DAY OF DISEASE 1 2 3 4 5 6 7 8 10 11 1 s 13 14 15 16 PULSE IR 96 96 qfi z 98 19 B4 R4 92 92 04 08 lOB 100 96 90 96 92 92 92 90 B2 se 86 92 8 as 8 8 86 e 8(1 84 B4 ao 78 86 80 78 8B S 90 84 8 90 90 84 86 76 74 72 72 72 72 RESPIRATION 2H i: 3! 32 Z8 23 34 aa 30 36 30 9^ 32 30 38 30 30 26 24 22 26 24 18 2 20 2 22 20 22 20 20 20 SO IB 20 S 20 20 20 20 20 0.0 72 20 ;i " DATE, APRIL 5 8 ' 8 9 10 11 12 13 14 5 16 17|18 19 20 Temperature chart in pDeumonia. The observation was begun on the firwt day of the disease. The criuiB commenced toward the end of the fifth day, and coiitiiiut'd througli the sixth to the seventh, with a secondary rise on the sixth. The cliart is typical, except that tlie fever tempera- ture throughout was about a degree lower than is usual. There was a slight right-sided pleurisy, but no attending bronchitis. true crisis occurs. The temperature may sink to the norm, or even below it, and then another, though not marked, rise take place. At times there happens on the fifth day a partial but de- cided drop, soon again followed by ascending temperature. This pseudo-crisis is apt to occur in cases that become prolonged. It is, too, in this class of cases with slow resolution that a gradual termination of the fever is often observed. Sometimes the course of the fever is marked by sudden elevations and striking remis- sions. This is more common in double than in single pneumonia, and seems to correspond with fresh invasions of lung-tissue. 25 390 MEDICAL, DIAGifOSIS. The urine is high-colored, and that of fever. Nitrate of silver does not precipitate its chlorides. They commonly disappear during consolidation of the lung, and their reappearance shadows forth returning health. The vanishing of the chlorides from the urine happens also in other acute affections ; but in pneumonia it is most absolute. In studying the clinical history of pneumonia we must not forget how often it exists in combination with other maladies. We find it in association with meningitis, and we must therefore always examine any cerebral symptoms with care ; we note it in connection with endocarditis, which may coexist with meningitis ; while its as.sociation with pleurisy is so common that this can be hardly looked upon as a complication. Among the rarer symp- toms are jaundice, parotitis, croupous colitis, and transitory aphasia, appearing on the second or third day of the attack. The physical signs which denote that the lung-tissue has be- come the seat of acute inflammation vary with the effects of the inflammation. In the first stage, or that of engorgement and beginning exudation in the air-cells, into which, however, the air is still capable of entering, there is only a slight impairment of the normal resonance on percussion. The vesicular murmur is at first somewhat altered ; it may be feebler or harsher. But soon are heard with each act of inspiration, and limited to the inspira- tion, numerous rapidly-evolved, very fine, crackling sounds, the " crepitant" or vesicular rales. As the exudation becomes firmer, and the tissue of the lung solidifies by occlusion of the air-cells, the stage of red hepatization is before us. Now all the signs of complete consolidation are dis- cerned. We find decided dulness on percussion, unchanged by full inspiration ; blowing respiration in its purity, high-pitched and tubular-sounding; bronchophony; and increased vocal fre- mitus. Rales from the accompanying bronchitis are heard with extreme distinctness through the solidified tissue, Skoda's con- sonating rales ; so are the sounds of the heart. A crepitant rale is still here and there perceptible, or the ear catches a pleural friction-sound. When the exudation is reabsorbed or expectorated, the signs of consolidation become less and less perfect. A vesiculo-bronchial succeeds to the bronchial breathing. The dulness on percussion DISEASES OF THE LUNGS. 391 lessens; crepitant rales — not, however, so fine as at the onset of the aifection, and mixed with larger moist rales — return; the cough increases ; the expectoration becomes more copious, loses its tenacity and rusty color; the dyspnoea diminishes, — all ■phenomena indicative of the breaking up of the exudation, and of the return of air into the vesicles. If, instead, the exudation be converted extensively into pus, and the lungs soften, the phys- ical signs are the same as in the second stage. The rarity of excavations of sufficient size explains why gurgling and the signs of a cavity .are not perceived. We suspect the mischief that is going on within the chest from the protracted dyspnoea, the in- creasing rapidity of pulse, the purulent or brownish sputa, the pinched features, the dry tongue, and the mental wandering. Recovery may take place even then. This third stage is indeed Fig. 36. Percussion diilness... Bronchial breathing. Bronchial voice Increased fremitns... Diagram illnstrativ y^\': cct pulmonary consolidation, such as happens in the second stage of pneumonia. not so much an abrupt, suddenly-established process, as it is the extension and greater diffusion of a state that may be found in portions of the lung which to the eye have all the appearance of red hepatization. In every instance of red hepatization the micro- scope shows that in parts the lung-tissue is infiltrated with granules and is undergoing softening, and it is probable that this breaking 392 MEDICAL DIAGNOSIS. down occurs, even though on a small scale, in all cases of pneu- monia which recover. It is often impossible to determine that the third stage has arrived; and death may take place long before the lung presents the condition which pathologists term gray hepatization. With reference to the diagnosis of this third stage, we may suspect, from the symptoms, that the pulmonary tissue is seriously damaged. But we can never know it, unless we find the physical signs of extensive softening ; and in the large majority of cases this cannot be done. The morbid piienomena, physical signs and symptoms of the malady correspond, tlien, usually in this manner : I. Stage of engorgement and beginning ex- udation. II. Stage of solidifica- tion of lung-tissue (red hepatization). Pneumonia. Crepitant rale ; slight percussion dulness. Percussion dulness; bronchial respiration ; bronchophony ; often a pleural friction- sound. Cough ; beginning dysp- noea and rapidly-de- veloped fever heat. Eusty-oolored sputum ; dyspnoea; cough ; high fever, temperature gen- erally above 103°, with raarlied evening ex- acerbations and morn- ing remissions. III. Stage of softening (gray hepatization). The same physical signs as in the second stage ; unless large abscesses have formed. Chills ; prostration, etc. ; purulent or brown- ish sputum; generally high temperature, 104° to 106°, or upwards. Here is a disease which presents such striking symptoms and signs in nearly all its phases, in which the sputa are so peculiar, the hurried breathing so evident, the physical signs so distinct, that error is, with ordinary care, difficult. It becomes still more so, if a few of the pathological peculiarities of pneumonia be borne in mind : the fact that it is rarely double ; that it comparatively seldom affects the upper lobe of the lung, and that it is often ac- companied by the signs of pleurisy or of bronchitis. In some instances sudden disturbance of the circulation takes place with the rapid development of cyanosis. These symptoms bespeak a heart-clot. Let us now contrast pneumonia with the various diseases of the DJSEASES OF THE LUNGS. 393 lungs with which it may be confounded. In its first stage, on ac- count of similar signs, the acute inflammatory disorder is sometimes mistaken for oedema of the lung, or for the pulmonary engorgement in some fevers, or for other kinds of congestion of the lungs ; and still more frequently these morbid states are mistaken for it. Pulmonary (Edema. — This consists in the transudation of serum into the air-vesicles. It may be acute, the result of sudden con- gestion, such as that following injuries of the brain or irritation of the par vagum ; or it may arise at the termination of acute affections of the lungs. It is more usually, however, chronic, and is seen as a dropsy of the air-cells, associated with dropsies elsewhere, and in connection with organic disease of the liver, heart, or kidneys. The characteristic manifestations of oedema — be it acute or chronic — are embarrassed breathing, expectoration of frothy serum, and crepitating and fine bubbling sounds dif- fused over both lungs, and dependent upon the fluid in the air- cells and small bronchial tubes. It presents, thus, many points of similarity to the first stage of acute pneumonia. The dysp- noea, the crepitation in the lung, may well mislead ; but we can- not err, if the frothy sputum, the general distribution of the rales, their somewhat coarser character, the bluish lip, the noisy breathing, and the absence of fever be taken into account. In acute oedema these phenomena are but the precursors of death. In chronic oedema the rales are persistent, and so is the difficulty of respiration. The patient has usually to be propped up with pillows, otherwise he cannot breathe. Pidmonary Engorgement in Fevers. — In fever of low type a crepitant rale, which might be supposed to be a proof of beginning inflammation of the lung, is often heard at the back part of the chest. The sound is the consequence of pulmonary congestion, with probably slight eff'usion into the finest bronchial tubes and air-vesicles. It is perceived over both lungs ; and this, taken in connection with the history of the case, with the absence of de- cided shortness of breath, and with the rale not being followed by dulness on percussion and blowing respiration, shows that it is not dependent on inflammation of the pulmonary tissue. It is necessary to be aware that these fine rales may occur in fevers without being due to a true pneumonia ; as otherwise the patient is apt to be treated for a disease of the lung which has no existence. 394 MEDICAL DIAGNOSIS. Pulmonary Congestion. — Besides the lung congestion just re- ferred to as occurring in fevers, we have other causes producing a marked congestion, or "hypostatic pneumonia." We find it in enfeebled hearts and in mitral and tricuspid disease, in those whose blood is impoverished and who are for any length of time bedridden, in instances of acute rheumatism, and due. to the pressure of tumors. In the dependent portions of the lungs the manifestations of congestion show themselves first ; they are, besides the signs of impeded circulation and of deficient aeration of blood, slight expectoration, scarcely any fever, varying short- ness of breath, somewhat impaired resonance on percussion at the lower part of the chest, — generally more over the right than over the left lung, — feebleness of respiratory murmur, and a few fine and coarse moist rales. The sputum contains numerous epithe- lial cells, and blood pigment in all stages of change. The congestion in all the instances mentioned is passive, and either hypostatic or mechanical. An active congestion of the lungs is a rare condition, though it may come on after strenuous exertion, during mountain climbing, or subsequent to extreme heat or cold. The physical signs are the same as those of passive congestion ; the sputum is apt to contain more blood. There is little, if any, fever ; and the history of the case, the stationary character of the physical signs, and their double-sidedness, dis- tinguish the congestive disorder from pneumonia. In its second stage, owing to the cough and dyspnoea, and in part, also, to some similarity in the physical signs, acute pneu- monia may be confounded with pulmonary apoplexy, acute pleu- risy, acute phthisis, and acute bronchitis. Pulmonary Apoplexy. — An effusion of blood into the texture of the lung is generally, althoijgh by no means invariably, accom- panied by external hemorrhage and by great difficulty of breathing. Over the effused blood there is dulness on percussion, and the ear hears an enfeebled or bronchial respiration. Around the seat of the mishap it encounters moist rales. Now, here are signs bear- ing some resemblance to those of pneumonia. But we miss from among them the decided fever. We note, on the other hand, not blood intimately mixed with the expectoration, but pure blood, florid or sooty-looking, almost devoid of air, in not large amount, at times surrounded with muco-purulent matter, and ordinarily DISEASES OF THE LUNGS. 395 voided fof a number of days. On close scrutiny a grave disease of the heart is generally detected to explain why an extravasation of blood into the pulmonary structure has taken place. Then we most frequently find the branch of the pulmonary artery lead- ing to the infarcted part plugged by an embolus, which has been formed in the right cavities of the heart or been washed in through the general venous system, and most commonly affects the right lung. Again, we have more pain than in pneumonia, and the dyspnoea is different. In pneumonia it augments up to the height of the malady. In pulmonary apoplexy it is greatest, and it is very great, when the blood is extravasated ; after that it declines. Yet the two affections often coexist. The closure of the vessel produces a pneumonia from embolism, or the blood acts as a for- eign body, and around it is lighted up an inflammation of the lung-structure, which is apt to have its seat in the posterior part of the lower lobe of the right lung ; further, the inflammation may be the starting-point of caseous degeneration ; or sloughing or gangrene may result. Pneumonia from embolism may be also caused by a pysemic condition, and the clots may have their origin in bedsores, in ulcers, and in various forms of suppuration. The plugs are satu- rated with ichor, and metastatic abscesses supervene. The symp- toms are the same, and we can make a diagnosis only by the his- tory ; there are the same circumscribed spots of consolidation, and the same kind of pain, which is also often found to be associated with a localized pleurisy, sometimes followed by effusion. Pulmonary apoplexy is met with in connection with other than thoracic affections. Observations by Brown-Sequard and by Olli- vier have proved its association with central nervous lesions, and have demonstrated its occurrence on the same side as the brain lesion ; * which is not the case with reference to the ordinary acute pulmonary diseases, for these Rosenbach f has shown to be much more frequent on the paralyzed side of the body, and therefore, generally, on the side opposite to the cerebral mischief Pul- monary apoplexy, or " hemorrhagic infarct," is also met with in malignant fevers. Of the other diseases mentioned which resemble pneumonia, the * Arch. Gen. de Med., Aug. 1873. f Centralblatt, No. 16, 1879. ,396 MEDICAL DIAGNOSIS. distinguishing points need not be here fully described. Acute pleurisy will be farther on more particularly studied. With regard to offute phthisis, it is only .necessary to repeat that cases are en- countered, apparently of pneumonia, in which, after the symp- toms of acute inflammation of the lung pass off, those of phthisis come into the foreground. With reference to acute bronchitis, I shall merely recall that the dyspnoea is not so great, and that no percussion dulness is yielded by an inflamed bronchial membrane. Percussion is thus of signal value in the diagnosis of pneumo- nia. In fact, when bronchitis complicates pneumonia, and loud, dry rales take the place of the blowing respiration, it is our only trustworthy guide. A single tap on the chest which elicits an absolutely dull sound tells the difference between pure bronchitis and the inflammation of the bronchial mucous membrane which accompanies inflammation of the parenchymatous structure of the lung. The form of pneumonia most liable to be mistaken for bron- chitis is the pneumonia of childhood or of old age, broncho-pneu- monia or catarrhal pneumonia. This affection has already been described in examining capillary bronchitis. But, as the disease may also occur in adults, and has special features, a few words more will not be out of place. Broncho-Pneumonia. — It mostly supervenes upon acute bron- chitis, except in instances in which it arises from inhaling irri- tating gases. The bronchial attack is usually severe, but it may be so slight as to be readily overlooked. The spread of the disease to the lung-texture is attended with rapid rise of temperature. When the disorder attacks adults, it is apt to seize upon those debilitated by previous disease ; it much more commonly affects the upper lobes than does ordinary sthenic pneumonia, and is generally bilateral. As the broncho-pneumonia merely solidifies lobules, the signs of marked consolidation are wanting, or are perceptible over only a small space. Crepitation is not common, but small moist rales are ; bronchial breathing and increased fremitus show only over limited points ; and the sputum is not rusty and viscid, but catarrhal. Cough and expectoration, some- times absent in croupous pneumonia, are always present in broncho-pneumonia. Catarrhal pneumonia or broncho-pneumonia is often noticed as a DISEASES OF THE LUNGS. 397 && TREATMENT P"1-SE QR liT 1 ED o I i o 31 c :a z m 1 1 ii r 1 I s J |i |[ "T""'I^"T"""I'""irT I ,111 o o o o olo °l°ft' . -L rv . '. ^J W ^ w S S S"*S ? 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J X r -L _ f x^ ^3 - ~ ~ i = ? _ p;;;:±;:;;;;;;;||;:;;;;;;|g|;::- E^:E~±:^^-;;;;;:;:;;;;:;;± 26 A ~ Kit' 'hJmTmi nrr - -n 7 ?■ 27 T ' ' h 1 , h-|- ■■■]■ ■■ ] I 1 u 1 I M I M i 1 [ M 1 11 1 1 1 1 1 M 1 1 1 1 1 I , 1 M 1 n 1 1 M 1 1 00 „ to W tu ' '" ' "I '^...'un.^iuiiMii^ T 3C ffi-""^ 398 MEDICAL DIAGNOSIS. complication of the infectious fevers, especially measles and diph- theria. It is the form of pneumonia developed when particles of food pass into the larynx and bronchial tubes, — aspiration or deglutition pneumonia. Catarrhal pneumonia pursues a much slower course than croupous pneumonia, and generally yields only gradually. The consolidation may continue stationary for weeks, showing a fever with marked daily remissions and exacerbations, like a hectic fever, and then slowly disappear. As interstitial inflammation of the bronchi and alveolar walls is distinctive of the disease, and as the perivesicular structures are markedly in- volved, persistent local consolidation from interstitial pneumonia or fibroid phthisis often follows. On the other hand, caseous degeneration and breaking down of the lung-texture may follow, or extended tubercular infiltration become manifest. Whether the bacillus finds in the consolidated lung a ready lodging, or the broncho-pneumonia is originally excited by the bacillus, phthisis, in truth, is in adults a not uncommon termination ; in children, too, this may happen, or rachitis may develop, or an ill-defined but persistent cachexia, with a great tendency to catch cold. There is a form of broncho-pneumonia, described as tubercu- lous inspiration broncho-pneumonia, that follows hemorrhage from tubercular cavities. It is usually preceded by active physi- cal effort, and its first manifestation is a hemorrhage.* Pneumonia often shows itself in an epidemic form, and is now generally looked upon as an infectious disease, a lung fever. The evidence of a micro-organism as its cause is very strong. The diplococcus pneumoniae, as it is usually called, was found independently by Pasteur and by Sternberg, and has been fully studied by Fraenkel, after whom it has been named. It is present in the buccal secretion of a certain number of healthy persons. Its association with catarrhal pneumonia is not so close as with croupous pneumonia. Indeed, it is thought that the bacillus of tubercle at times excites this, making a specific broncho-pneumonia from the start; the staphylococcus and the streptococcus pyogenes may also induce it, as Northrup's obser- vations clearly prove. * Baumler, Deutseh. Med. Woehensehr., No. 1, 1893. DISEASES OF THE LUNGS. 399 The cocci are best stained in dilute alcoholic solutions of the aniline dyes, and are readily seen in preparations colored by Grain's method. In this respect they differ from the pneumo- bacillus of Friedlaender, which is also found in a certain pro- portion of pneumonic lungs, but does not retain the stain after Pig. 38. The diplococcus pneumoniae of Fraenkel ; the cocci are staineti darlL hlue, the capsules are unstained. (After Jaltsch.) going through the process. The Fraenkel coccus is elongated or round, enveloped iu a capsule, and often found in pairs. The micro-organism of pneumonia has been found in the blood ; in the meningitis that at times attends pneumonia, and generally appears at the height of the malady ; also in the accom- panying pleurisy, and in the lung complication of ulcerative endocarditis. This disease has, indeed, a close association with pneumonia, whether coming on with it or developed in its course. Osier has brought this fact out very prominently in his Gul- stonian Lectures. There are some varieties of pneumonia that present clinical features of a peculiar kind. Apex pneumonia is one. It is more usual in children than in adults, and the frequency with which cerebral symptoms arise and draw away attention from the chest is a matter of common observation. The cases, as a rule, are severe, and the temperature is high. Double pneumonia differs in nothing from ordinary pneumonia except iu the severity of the 400 MEDICAL DIAGNOSIS. symptoms. The cases, unless speedily fatal, are generally of longer duration, and the temperature is less characteristic, for the reason that it rarely happens that both lungs are affected at the same time. Double pneumonia is rare; what is called double Pneumococcue (diplococcus) of Friedlaender, without the capsule, from a pure culture upon gelatin from the sputum in a case of croupous pneumonia at the Pennsylvania Hospital. Drawn by Dr. Joseph Leidy, Jr. pneumonia is generally inflammation of one lung and heavy congestion of the other. Latent pneumonia is not often seen except in the aged. There is but little fever, and it is only by the physical signs that the disease can be recognized. Mi- gratory pneumonia, a condition in which different parts of the lung are successively involved, is not a frequent disease. The temperature shows a tendency to sudden falls, with rapid rises whenever a fresh part of the lung is involved. Some of the older clinicians, especially Wunderlich and Trousseau, regarded the disease as having a close connection with erysipelas. It is always very important to find out whether pneumonia is primary or intercurrent in some other malady, such as in rheu- matism, Bright's disease, diabetes, the exanthemata, the typh fevers, or in septic states. At times it is distinctly noticed to DISEASES OF THE LUKGS. 401 follow contusions of the chest. As has been already said, it may be epidemic. By the symptoms and physical signs we cannot distinguish the sporadic and simple cases from those of the in- fectious malady. Further bacteriological research may solve the matter. There are two other forms of pneumonia which have not been elsewhere considered, and which, as they present somewhat pecu- liar symptoms, require to be noticed. They are typhoid pneu- monia and bilious pneumonia. Typhoid Pneumonia. — Inflammation of the lung may be from its onset attended with extreme prostration. This form of the disease has been made a matter of warm controversy, both as to the symptoms which characterize it and as to the relation it bears to other varieties of the malady. Now, any one who reads the dissimilar descriptions given of it will become convinced that under the term typhoid pneumonia very dissimilar disorders have been ranged together. On the one hand, it has been applied ex- clusively to the inflammation of the lung which may complicate typhus or typhoid fever ; on the other hand, it has been made to include an idiopathic fever in which the affection of the respira- tory organs is occasionally wanting. To neither of these maladies ought to belong the name typhoid pneumonia, since in both the inflammation of the lung is but an incidental accompaniment. Then under the name of pneumo-typhus a disease has been of late years described, especially by German clinicians, in which typhoid fever begins with a well-defined pneumonia, that for the time being throws the enteric symptoms into the shade. Typhoid pneumonia is pneumonia with symptoms of a typhoid type, and marked by rapid failure of the vital powers. The in- flammation of the lung arising in the course of typhus or typhoid fever will of course be apt to present this character; but the malady is also noticed as a consequence of phlebitis ; as super- vening in cases of erysipelas, of Bright's disease, and of delir- ium tremens ; or as the sole apparent affection. It happens not unfrequently in epidemics, and is very often observed among negroes. Its ravages on the plantations of South Carolina and Georgia are sometimes frightful. It is, also, very fatal in jails, and among troops in the field, serving under unfavorable hygienic conditions. 402 MEDICAL DIAGNOSIS. The physical signs are those of the sthenic form of the disease, except, perhaps, that the crepitant rale is less frequent. Most of the same symptoms, too, show themselves : cough, short breathing, and pain in the chest. All of these may be very marked, or so trifling as hardly to direct attention to the lungs. There is, how- ever, one symptom characteristic and constant, and but one, and that is the great tendency to sinking. As regards the expectora- tion, it may be rusty-colored ; yet occasionally, even in the early stages of the complaint, it consists of pure blood. The pulse is always quick, but weak. Dark sordes often collect on the teeth and gums, as they do in typhoid fever. Pain is absent in some cases, and extremely acute and of a radiating character in others. , Concerning delirium, we know that it is much more common than it is in the sthenic variety of pulmonary inflammation, except this affect the apex in children. Some authors mention an eruption. , It is, however, questionable whether the cases which came under their notice were not typhus or typhoid fever, in the course of which pneumonia appeared. The flush on the face in the low type of the malady under consideration is usually of a dusky hue, but not invariably : a pink-colored blush, extending sometimes all over the body, seems to have specially attracted the attention of observers. The disease is always dangerous, and, as Stokes * points out, resolution is extremely slow. Chronic hepatization, with or without a low hectic fever, or a lurking congestion, may continue for weeks. The symptoms of typhoid pneumonia are at times strangely mixed up with those produced by other conditions. In many districts in which the complaint is prevalent, it bears the distinct impress of malaria. Again, articular symptoms seem to predomi- nate in some regions of country, and in some epidemics. Gibbes f speaks of an acute pain in the back part of the eye, in the ears, or in the side of the neck, attended with stiffness of the muscles ; and of a swelling of the tonsils, and of the submaxillary and sub- lingual glands, which he states to be of evil augury. Dickson, J drawing his description of the disease from cases observed in and around Charleston, portrays several forms, the most common of which exhibits a respiration hurried and irregular ; heavy sigh- * Diseases of the Chest. t Amer. Journ. Med. Sci., 1842. J Elements of Medicine. DISEASES OF THE LUNGS. 403 ing ; a feeling of weight at the prsecordial region, with nausea and vomiting ; and a tongue clean, but red. Delirium is present- from the beginning, and does not subside until recovery takes place. The duration of such attacks averages from six to ten days. Bilious Pneumonia. — Jaundice and other indications of he- patic and gastric derangement are not usual in ordinary sthenic pneumonia. They may be occasionally caused by the inflam- mation spreading to the liver, or may be of blood origin. But in the pneumonia so general in the spring and the autumn in the miasmatic regions of some of the Southern and Western States of this country, hepatic symptoms are common, and mark a special type of the disease, known as malarial pneu- monia or bilious pneumonia, or by the familiar name of " bilious pleurisy." This form of inflammation of the lung is simply pneumonia, sthenic or asthenic, on whose features the stamp of malaria is im- printed. The chill with which it begins is usually protracted, and is followed by pain in the side, by fever, by hurried breathing, by cough, and by tenacious, rusty-colored expectoration. The pain in the side, which depends upon accompanying pleurisy, is sharp and severe, and renders the respiration irregular. The sputum is at times rusty-colored, while at others a frothy and bloody serum or pure blood is expectorated. The fever shows the type of the disease. It is much more paroxysmal than in the other varieties of the malady. This peculiarity, and the obvious symptoms of hepatic and gastric disorder, are indeed the only absolutely dis- tinguishing traits of bilious pneumonia. The febrile exacerba- tions are stated by Manson, of North Carolina, to be preceded, during the morning hours, by an insensible chill, — a coolness of the ends of the nose, fingers, and toes, which, in grave cases, ex- tends over the entire extremities. The physical signs are those of ordinary acute pneumonia. Bronchial breathing and bronchophony are said to be more often absent, or to appear and disappear rapidly. It is certain, if this be true, that in these instances the malady could not have been inflammation, but was more probably a collapse of the pulmonary tissue. Any one, indeed, who compares the various statements made with reference to the disease, must have been struck with 404 MEDICAL DIAGNOSIS. the fact that cases of congestive fever in which the lungs have become simply engorged, or perhaps collapsed, and cases of in- flammation of the lung arising in the course of remittent fevers, are included in the description of bilious pneumonia. Acute Pleurisy. — Acute pleurisy has been so often inci- dentally mentioned, that a description of its main points will here suffice. It comes on from cold or exposure, or from injuries to the chest ; but a great many cases are secondary to some general or infectious malady. The first effect of the inflammation is to Fig. 40. Friction sound. Hougliening of the pleura fntm inflammation ; a small amount of fluid has begun to collect. redden the pleural membrane ; an exudation of a soft, grayish, easily-detached lymph then takes place. This constitutes the first or dry stage of the disease ; and if the "two inflamed surfaces unite, the disorder does not pass beyond this stage. Often, how- ever, along with the exudation of lymph occurs an eStision of serum, which produces a special train of phenomena, and gives rise to the second stage, or that of liquid effusion. DISEASES OF THE LUNGS. 405 The physical signs of the dry stage are impaired movement of the chest, a feebler respiration, and a friction sound of vary- ing extent and intensity. The iirst two signs are caused by the patient instinctively refraining from expanding the lung, because of the pain it occasions. The mechanism of the friction sound, its nature, its superficial character and want of uniformity, have been pointed out in a previous part of this chapter. In the stage of effusion the physical signs differ according to the amount Fio. 41. Examination of the poeterlor portion of the rhest while a large effusion Is occupying the left pleural cavity. of fluid the pleural cavity contains. A moderate quantity of liquid only constricts the lung-texture, and leaves the bronchial tubes intact; a large accumulation compresses everything; it drives all air out of the lung, pushes it into a small space against the vertebral column, and displaces the liver or heart. Wherever the fluid accumulates there is dulness on percussion. When the patient is in the erect posture, the flat sound on striking the chest 406 MEDICAL DIAGNOSIS. and the sense of resistance to the finger are marked at the lower part of the thorax, since the fluid naturally settles there. The line of dulness is, however, not the same in front as it is behind. It is generally much higher behind, and alters, of course, with the changing quantity of effusion, and somewhat with the position of the patient. When he lies upon his face, the fluid gravitates, if not circumscribed by adhesions, toward the anterior chest-walls, and the percussion dulness posteriorly becomes far less percep- tible. The peculiar curve of the percussion line often found has been specially described by Calvin Ellis, and is named by Gar- land the letter S curve.* Where the effusion is extensive, the intercostal spaces are widened and their depressions effaced. The side appears to the eye distended, fluctuation may be perceived, and, owing to the absolute compression of the lung, no sound is heard oyer the chest when the patient breathes, or speaks, or coughs. In more mod- erate collections of fluid, the cessation of sound is not so absolute. There is an ill-defined, deep-seated respiration, and the voice reaches the ear with tolerable distinctness, and occasionally with a peculiar bleating resonance attending it. But, as large collec- tions of fluid are more common than small ones, the former set of phenomena are, at the height of the disease, more frequent than the latter. Above the liquid there is mostly increased resonance on per- cussion, or a tympanitic sound, Skoda's sound. Various expla- nations have been given of this. It has been attributed to the complete compression of the lung ; it has been thought to be due to its slight condensation. Whatever be the true explanation, the fact of its occurrence is undeniable. This tympanitic sound is more manifest at the upper part of the chest in front ; it may, indeed, be found in front when it does not exist behind. In some cases the sound has an amphoric, in others a cracked-metal char- acter. When the ear is applied above the line of percussion dul- ness, it recognizes occasionally a friction sound ; and near the spinal column posteriorly, where the compressed lung lies, it perceives almost invariably distinct bronchial respiration and bronchophony. * Pneumono-Dynamios, 1878, and New York Medical Journal, Nov. 1879. DISEASES OF THE LUNGS. 407 When the fluid begins to be absorbed, the voice becomes more audible over the seat of the effusion, the vocal vibrations may be felt by the fingers, and the respiration is again heard. But for a long time it continues enfeebled, and its character is indetermi- nate ; it is neither vesicular nor purely bronchial. As more and more of the fluid disappears, the voice becomes more and more dis- tinct ; a friction sound finally shows that the roughened surfaces have come in contact ; and the dulness on percussion is replaced by a far clearer sound. False membranes now unite the two pleurae ; the intercostal spaces resume their normal shape ; and the chest is either restored to its natural size, or is left perma- nently somewhat contracted. The bronchial breathing near the vertebral column persists for a long time, since the compressed lung unfolds but slowly. These physical signs have been discussed first because they are the most important elements in the diagnosis of pleurisy. The symptoms, indeed, often hardly attract attention ; and if we trusted to them, we should be groping in the dark. Pleurisy mostly begins with a chill, followed by fever and by a dry, irritating cough. The most distinctive, though not a constant, symptom of the first stage is the sharp, acute pain, the " stitch in the side." It is commonly felt under the nipple or in the axilla, and is somewhat increased on pressure. Its seat by no means always corresponds to the seat of the friction sound. As the effusion takes place, the pain disappears, dyspnoea becomes evident, and the patient ordinarily lies on the affected side. The febrile symp- toms and dry cough continue ; yet neither is marked, and both disappear long before the fluid is entirely absorbed. Pleurisy may be idiopathic, coming on generally after exposure to cold and damp ; or it may be an attendant upon other diseases of the lungs, such as pneumonia or tuberculosis, or may accom- pany measles, scarlatina, typhoid and typhus fevers. It may also be caused by wounds of the thoracic walls, by rheumatism, gout, Bright's disease, diphtheria, pyaemia, cirrhosis of the liver, and other morbid states. The malady with which acute pleurisy is most likely to be confounded is aeate pneumonia. Both are affections occasion- ing dyspnoea ; both are, in the majority of cases, one-sided ; both present, in their most advanced stages, dulness on percus- 408 MEDICAL DIAGNOSIS. sion. But the dulness in the latter disease is far less absolute than in the former; nor do we, save in very rare instances, meet with a tympanitic or an amphoric percussion sound in pneumonia, while in pleurisy, as we have just seen, it is far from unusual above the level of the fluid. In the few cases in which an am- phoric or a tympanitic sound is perceived in pneumonia, the peculiar tone is most obvious over the consolidated tissue. The other physical signs of the two diseases show still less similitude. The absence of respiration, of vocal resonance, and of thrill is in striking contrast with the loud blowing respiration, the strong chest-voice, and the increased vocal thrill of pneu- monia. There are, however, exceptional cases of pleuritic effusion, in which bronchial breathing is heard all over one side of the. chest. Especially does this happen if pneumonic consolidation accompany the effusion ; but even in simple compression of the lung, and where the collection of liquid is not extensive, bronchial respiration may be perceived. The diificulty of distinguishing from pneumonia such cases of pleurisy, in which probably the lung-tissue is compressed around the bronchial tubes but these are not encroached upon, is great. As aids in diagnosis, we seek for dilatation of the chest ; we note the peculiarities of the breath- ing, which, although blowing, is mostly fainter than, and is un- like, the high-pitched, brazen respiration of pneumonia ; we find that the percussior dulness over the upper part and where the bronchial respiration is most distinct is not very great, and, espe- cially, that it disappears on respiratory percussion ; we observe that the voice is less strong and ringing, and has, perhaps, a bleat- ing tone ; and we take into account the appearance of the sputum and the character of the fever. On the other hand, pneumonia may present itself in a form distinguishable from pleurisy in the stage of effusion with the greatest difficulty ; it is when the bron- chial tubes as well as the lung structure are filled with a fibrinous exudation. In this massive pneumonia we do not find either tubular breathing or fremitus attending the flat percussion note, and it is only by noting the absence of displacement of the heart or the liver, the violent coughing spells, and observing the frag- ments of moulds of the bronchi in the expectoration that a con- clusion can be arrived at. But generally the diagnosis between pleurisy and pneumonia is easy. It may be thus summed up : mSEASES O^ THE LUNGS. 409 Plettrisy. Sharp pain ; friction sound ; dry cough ; impaired chest-motion. In stage of effusion, obliteration of the intercostal spaces ; enlargement of the side ; displacement of several viscera. In the large majority of cases, dul- ness, with enfeebled or absent res- piration, voice, and fremitus. Decubitus is often on the affected side. Sputa frothy ; rarely any rales in the chest. Fever slight. Tfemperature record irregular, and not characteristic; rarely 103°. Pneumonia. Dull pain ; crepitant rale ; cough, fol- lowed by expectoration. In stage of hepatization, none of tliese signs are manifest. Dulness, with marked bronchial res- piration ; distinct thoracic voice ; increased vocal fremitus. Decubitus not peculiar ; sometimes on the sound side. Sputa rusty-colored ; rales from a«- companying bronchial inflamma- tion common. Fever severe. Temperature record much more characteristic. Temper- ature rises rapidly soon after onset, then is continuous, with marked evening exacerbations and morning remissions. Often reaches 105°, es- pecially in pneumonia of upper lobe. Toward end of disease generally rapid defervescence. In the first stage of pleurisy the pain might cause the disease to be confounded with pleurodynia or intercostal neura-lgia. In all three pain is the prominent symptom. Let us see how it differs in each : Pleurodynia. — Pleurodynia is described as a form of muscular rheumatism. But frequently it is myalgia, or pleui'isy which does not pass beyond the dry stage. Of this nature are most of the fugitive chest-pains from which phthisical patients suffer. Yet there are cases in which no signs whatever of pleurisy exist, but which are attended with as much pain as pleurisy. The pain of pleurodynia is, indeed, often excessively severe ; the patient refrains from deep breathing, since every motion of his chest in- creases his suffering. The pain is augmented by movements of the arm and by pressure, and is generally associated with tender- ness. Pleurodynia shares with pleurisy the feeble respiration and the want of action of the affected side. It differs from it 26 410 MEDICAL DIAGNOSIS. by the absence of friction sound and of fever ; by the shifting pain, often double-sided ; and by the greater tenderness of the chest- walls. Intercostal Neuralgia. — In ansemic women and in consumptives acute thoracic pain is not uncommonly the result of an intercostal neuralgia. The same want of expansion of the chest and the same enfeebled breathing as in pleurodynia are here noted, also the same absence of fever and of pleural friction. The distinguishing marks of intercostal neuralgia are : its intermittent character ; its frequent association with uterine disturbance, especially with leucorrhrea, and the limitation of the tenderness to special points in the course of the affected nerve. Valleix has drawn attention to three pain- ful spots which are tender to the touch : one at the exit of the nerve from the spinal column, the second in the axillary region, and the third near the sternum or in the epigastric region. It is on the left side that we are most apt to find intercostal neuralgia, and between the sixth and ninth ribs that the painful places are usually detected. Pain occurs also in diseases affecting the lung-texture. There is pain of a dull nature in pneumonia, of a more severe character in cancer. But the pain is so dissimilar, and the coexisting symptoms are so unlike, that the error of confounding these maladies with pleurisy, on account of the pain, is not likely to be committed. Diseases presenting Dilatation of tlie Chest, Displacement of the Liver or Heart, and Dyspncea. A group of diseases may here be studied, all of which occasion more or less dilatation and prominence of the chest, and all of which are attended with decided shortness of breath. In bron- chitis and pneumonia a slight increase in the diameters of the chest may take place ; but it is not a sign of any diagnostic im- portance. In the recognition of emphysema, pneumothorax, and pleuritic effusions, the dilatation of the thorax forms one of the main elements ; moreover, it is often combined with marked dyspnoea and with displacement of the liver or heart. These affections, then, may be examined in the same connection, and compared with one another, and incidentally with several less common diseases which present similar manifestations. DISEASES OF THE LUNGS. 411 The history and signs of emphysema were given when treating of the diseases accompanied by clearness on percussion. It was then mentioned that in many instances the prominence of the chest is circumscribed. Such cases cannot be mistaken : the bulging is too limited. But when the emphysema is more gen- eral, and an entire side of the chest or the whole chest becomes dilated, or when the inflated lung displaces the liver or heart, the affection comes into the group under consideration. A patient seeks advice for shortness of breath. His chest is inspected, and looks enlarged. The physical signs prove that the disease is not one of the heart, or an aneurism. What, then, is it ? Is it an effusion into the pleura ? is it an intra-thoracic tumor ? is it pneu- mothorax? is it emphysema? A tap on the chest goes far to- ward showing whether it is the former. If the sound rendered be resonant, it is not liquid in the chest that is producing the dis- turbance, nor, except under rare circumstances, an intra-thoracic tumor : the disorder is either pneumothorax or emphysema. Pneumothorax. — Of all thoracic maladies, pneumothorax is the one the similarity of which to extensive dilatation of the air- cells is the greatest. In both, the large quantity of air occasions increased clearness on percussion ; in both, there is considerable and persistent difficulty of breathing ; in both, the distention of the chest and the displacement of organs may be obvious. In pneumothorax, however, the symptoms and signs are associated with different conditions. Pneumothorax is an accumulation of air in the pleural cavity, but it is something more : the entrance of air is soon followed by the effusion of liquid. Air is let into the cavity of the chest by the pleura being perforated by wounds, or through the diaphragm by malignant disease of the stomach or the colon, or, as is most common, by its partial destruction consequent upon disease of the lung. It is in this way pneumothorax originates in the course of tubercular softening, of gangrene, of pneumonia, or from the bursting of a distended air-vesicle or of a dilated bronchial tube.* In the large majority of instances it occurs in tubercular patients. When air jDasses from the lung into the pleura, it usually hap- pens during a paroxysm of coughing. The pain which ensues * Case recorded by Taylor, Prov. Med. Journ., vol. i., 1842. 412 MEDICAL DIAGNOSIS. is most intense ; and the frig&tful, suddenly-developed dyspnoea, the anxious expression of the fece, soon show how seriously respi- ration is interfered with. If death do not take place, symptoms of pleurisy with effusion manifest themselves ; and, as in pleurisy, the patient lies ordinarily, but not invariably, on the affected side. The distinctive marks of pneumothorax are furnished by its physical signs. The ingress of air into the pleural cavity widens the chest, effaces the depression of the intercostal spaces, and occasions an extremely clear, or, more correctly speaking, a tym- FiG. 42. Physical eigne in pneumothorax on the right side. The heart is observed to be dis- placed toward the left, as actually happened in the case from which the outline was taken. The percussion resonance on the right side w^as tympanitic, extending some- what over the left margin of the sternum ; the fremitus was annulled ; the voice metallic. panitic, sound on percussion. The air prevents the lung from expanding: hence there is au enfeebled or absent respiration, except near the spinal column, where the compressed organ lies, and where the breathing is bronchial. The hand, if laid on any DISEASES OF THE LU^JGS, 413 other portion of the chest, feels, when the patient speaks, no thrill, and no vocal vibration is detected by the ear. When the perfo- ration has not closed, and the air rushes into the artificial cavity produced by the separation of the two surfaces of the pleura, the respiration is amphoric, or it, the voice, and the rales are all accompanied by a distinct metallic ring ; respiratory percussion, too, changes the sound elicited, rendering it duller. Drops of fluid falling into the cavity, or the bursting of bubbles on the surface of the liquid in the pleura, are echoed to the ear with a metallic sound, and are often heard as a silvery tinkle. A metallic echoing sound is also obtained if the ear is placed on tbe back over the affected side of the chest while a coin is tapped on another in front. The presence of the fluid in the pleural cavity gives rise to a dull sound on percussion at the lower part of the chest, which changes readily with the position of the patient, and to a splash, perceptible to the ear and to the finger, when the thorax is suddenly shaken. This continues until the effusion increases, and until the opening in the membrane closes, the air disappears, and the case resolves itself into one of chronic pleurisy, — the most favorable termination of pneumothorax. Now let us compare the physical signs with those produced by emphysema. The sound on percussion in both is very clear, or is tympanitic ; more so, however, in pneumothorax, which, in addi- tion, exhibits dulness at the lower part of the chest. The respira- tion in both is feeble. But it is feebler in pneumothorax, and not accompanied by a long, laborious expiration ; besides, it is often amphoric, and attended with metallic voice and tinkling, — phe- nomena which dilated air-cells cannot occasion. Moreover, there can be no splashing sound in emphysema, and this always exists in pneumothorax, except in those rare instances in which there is no fiuid in the pleural cavity ; on the other hand, the displace- ment of the heart is generally much greater in pneumothorax, and the dilatation of the chest more apt to be one-sided. Yet too much stress has been laid on the latter point as a means of distinction ; for emphysema may be one-sided, and, on the other hand, pneumothorax, as I know from meeting with a number of instances, may occur on both sides. In some cases we are aided in the discrimination by noticing that bulging is perceptible over 414 MEDICAL DIAGNOSIS. the displaced heart, and that a metallic echo follows the caroiac sounds. The physical signs of the two diseases are thus very different ; so, too, are many of the symptoms. Difficulty of breathing exists in both. But in emphysema it takes more the form of attacks of asthma; besides, it does not set in suddenly and with intensity, and remain intense. In pneumothorax the patient remembers to have been seized with a pain in his chest, since which period he has been continuously very short of breath. Yet there are exceptions to this : there are cases in which the symptoms occasioned by perforation of the pleura are from the onset so slight as not to attract the least attention. Such cases cannot be recognized, save by their physical signs. Among these, dilatation of the chest, with the widened intercostal spaces, the displacement of the liver or heart, and the exaggerated and altered resonance on percussion are most valuable in preventing the dis- ease from being confounded with some affections which in other respects give rise to many of the same phenomena. In large cavi- ties, for instance, the respiration and voice may be metallic ; me- tallic tinkling, nay, even succussion, may occur. But the prominent chest, the extremely clear, tympanitic, or metallic sound on percus- sion, bordered by the line of absolute dulness due to the effusion, are not met with. The history also is different, and the dyspnoea is not so great. The same dissimilarities will prevent us from mistaking for pneumothorax a pneumonia in which the percussion sound over the consolidated lung is tympanitic. And a study of the physical signs, too, will at once enable us to discern whether the difficulty in breathing, though it be suddenly developed, and apparently under circumstances which make the swallowing of a foreign body seem likely, be due to this cause, or to perforation of the pleura and pneumothorax.* There is, however, a morbid condition which exhibits nearly all the signs and many of the symptoms of pneumothorax, and which, were it more frequent, would be the source of constant errors of diagnosis, — diaphragmatic hernia. Of this rare affection we know but little. Yet, thanks to Bow- ditch,t what we do know of it teaches us that a protrusion of the * As in a case of the disease communicated to me by Dr. Walter F. Atlee. f Bufl'alo Med. Journ., June and July, 1853. DISEASES OF THE LUKGS. 415 abdominal organs through the diaphragm will generally dilate one side of the chest, compress the lung, and displace the heart. It will do more : it results in dyspnoea ; and, as the stomach or in- testines are, for the most part, the viscera which find their way into the chest, metallic tinkling and a tympanitic sound on per- cussion are detected. These are also signs of pneumothorax. There is, indeed, no mode of separating the two diseases, except by attention to the history of the case, by noting that the dyspnoea of the former suddenly appears and as suddenly disappears, that it has often existed from birth, and that the metallic tinkling happens when the patient is not breathing, and is mixed up with the rumbling sound arising in the stomach or intestine. It has been made a question whether we can distinguish ordi- nary cases of pneumothorax from these very rare ones which are supposed to occur without 'perforation. Now, even admitting that such really happen as a sequence, for instance, of decomposition in pleuritic effusions, there are no signs by which we can recognize them with certainty. It has been claimed for them that there is no antecedent history of a chronic pulmonary affection, particu- larly of phthisis, that there is not that suddenly-occurring severe pain and extreme dyspnoea, that the sputum and breath are never offensive, that metallic tinkling is absent, or rare and inconstant, and that the amphoric breathing is not so well de- veloped or so clearly defined. If in a case of perforation, how- ever, the opening have closed, the physical signs, it is granted, are the same.* Chronic Pleurisy. — Chronic pleurisy is the third of the group of more usual affections which are characterized by dilata- tion of the chest, by displacement of the intra-thoracic viscera, and by shortness of breath. It is true that acute pleurisy in the stage of effusion would, strictly speaking, find here a place ; but the acute symptoms bring it into another class, with which it has been more conveniently described. Chronic pleurisy is established if the fluid, after an acute attack, be not absorbed, or if an accumulation of liquid take place grad- ually, in consequence of subacute inflammation of the pleura. It is also found, especially in its purulent form, in a number of * Boisseau, Arch. Gen. de Med., vol. ii., 1867. 416 MEDICAL DIAGNOSIS. infectious diseases, particularly scarlet fever and typhoid fever. This form is also seen to follow pleuro-pneumonia and perforation of the pleura by softening tubercle. Chronic pleurisy has no constant symptoms, and is often remarkably latent : the patient frequently does not remember to have had acute pleurisy. He is not commonly troubled with much cough, nor is the want of breath so great as might be expected ; he is not capable of talk- ing for any length of time, or in a loud voice, but he does not really suffer from dyspnoea. His general health may remain good, and no emaciation occur. In some persons, on the other hand, the loss of flesh, the quickened pulse, the sweats, the par- oxysms of hectic fever, are so marked as to produce a close resemblance to the last stages of tubercular consumption. While the differing symptoms rather hide the pleurisy from detection, the physical signs render it easy of recognition. These signs have been studied in describing the effusion in acute pleurisy. It is only necessary to recall that the most significant are absent respiration and voice, a flat sound on percussion, with a vesiculo- bronchial or a bronchial respiration above the seat of the liquid. The intercostal spaces are obviously widened ; their depressions are effaced. They are, indeed, sometimes convex, and the finger pressed on them detects a distinct fluctuation. During the act of breathing, the diseased side is almost motionless, presenting a strong contrast to the obvious play of the healthy side. The lung which is not disturbed increases in size. Its murmur is more in- tense, sometimes harsher; and the percussion sound over it is exceedingly clear. In some cases it becomes emphysematous. The heart or liver is displaced. A lateral curvature of the spinal column is apt to take place, and the shoulder remains fixed and stiff during the respiratory acts. To distinguish whether the fluid is collected in one cavity or in several, in other words, whether unilocular or multilocular, is generally impossible. Jaccoud * has, however, called attention to some points which aid in arriving at a conclusion. If we have a zone in the dulness where vocal vibra- tions are preserved, as at the posterior part of the chest from along the vertebral column toward the sternum, and beyond this zone no vibrations are perceived, we may infer that the effusion is * Bulletin de P Academic de Medecine, 1879. DISEASES OF THE LUNGS. 417 divided by a band of pleural adhesion ; if the voice and fremitus be preserved, although weakened, over the whole extent of the dulness, except in a zone of a few finger-breadths at the lower part of the chest behind, while no tympanitic sound is elicited under the clavicle, we are to conclude that the pleurisy is multi- locular. When adhesions to the diaphragm exist, the normal movements during respiration at the epigastrium and hypochon- drium are reversed, and at each inspiration a marked depression of the inferior intercostal spaces is perceptible. Efiusions into the pleural sac may last for a long time, and lead to death by progressive exhaustion ; or the patient may re- cover by the fluid being absorbed, or by its finding a vent through the bronchial tubes or the thoracic walls. But the chest is rarely restored to its former state. The lung was too much compressed, or is still bound down by too firm adhesions, to resume its full share in the function of respiration. The walls of the chest sink in around it, and the side is flattened, sounds duller on percus- sion, and presents a feebler breathing than the other lung, which remains somewhat enlarged. The heart generally returns to its normal position, but the shoulder on the affected side is apt to show a permanent depression. Notwithstanding the decided character of the physical signs, chronic pleurisy is frequently overlooked. The only explana- tion of this is, that too little attention is paid to the physical signs. Were the chest more often carefully explored, we should cease to hear of patients whose pleural cavity is filled with pus being pronounced incurable consumptives, because they are emaci- ating and have hectic fever and clubbed nails ; or being treated for disease of the heart, on account of the displacement of that organ, and of dyspnoea and oedema ; or being dosed with mercury, for an imaginary disorder of the liver; or being subjected to long courses of quinine and arsenic, to -check a rebellious ague which the chilly sensations and paroxysms of fever at times simulate. These physical signs are the same whether the fluid be serum or pus. The character of the fluid produces, indeed, no distinc- tive changes either in the signs or in the symptoms. We suspect empyema if the emaciation be great and accompanied by a quick pulse, high temperature, and hectic fever ; but I have known pus 418 MEDICAL DIAGNOSIS. in the chest with a temperature scarcely above the norm, and, on the other hand, the accumulation not to be purulent with a tem- perature of 103°. Baccelli has proposed a new and simple test to determine the character of the fluid, which, on the whole, I believe to be of use. It consists in ascertaining accurately how the voice penetrates, especially the whispered voice. If easily and thoroughly transmitted, the liquid is serous and homogeneous ; if with difficulty, it is fibrinous or purulent ; if not at all, it is most apt to be the latter. In cases of much doubt I have long been in the habit of using a hypodermic syringe and removing with it enough of the fluid for microscopical examination. The microscopic and bacteriological examination of the exuda- tion will give us valuable information. In rare instances the fluid consists of fat-globules and of masses of cholesterine.* In cases of hemorrhagic pleurisy the hsemoglobinometer will inform us accurately as to the amount of blood in the exudation.f We find it, indeed, full of blood and altered blood constituents in hemorrhagic pleurisy, a form which pleurisy may assume in low fevers, but which is more frequently found in cancerous, and sometimes in tubercular pleurisy. In the latter disease, contrary to expectation, tubercle bacilli, as we know from the observations of Ehrlich, are frequently absent. There is a group of cases in which, either in a serous or a purulent exudate, we detect the diplococcus pneumoniae ; here there may or may not have been a preceding pneumonia. Cases in which the diplococcus pneumo- nise is met with are generally of favorable prognosis. In septic pleurisy the streptococcus is found, and especially, as Koplik has shown, the streptococcus pyogenes ; staphylococci are also met with. These are much more serious cases, both as to duration and as to recovery. When we come to inquire into the thoracic diseases with which chronic pleurisy is likely to be confounded, we shall find that, although many have some signs in common, few, if any, present the same association of signs. Leaving out the malady which is most commonly mistaken for it, — pulmonary consumption, — since the points of difference have already been discussed, the affections * Debove, Sac. Med. des Hopitaux de Paris, tome xviii., 1881. t Henry, Medical News, April 14, 1888. DISEASES OF THE LUNGS. 419 with which chronic pleurisy, while the pleura is full of liquid and the chest enlarged, is liable to be confounded, are : Emphysema and Pneumothorax; Intea-thoeacic Tumoe; Enlaegement op the Livee ; Enlargement of the Spleen ; Abscess in the Thoracic Walls ; Pericardial Effusion ; Hydrothoeax. Emphysema and Pneumothorax. — These, although such dif- ferent diseases, are grouped together because they give rise, like chronic pleurisy, to a dilated chest, and to displacement of the liver or heart. But the other signs above pointed out, which indicate the presence of air, are so striking, that an error in diagnosis can only be the result of carelessness. Intror-thoracic Tumor. — A tumor within the chest may occasion the same distention of its walls, the same displacement of organs, the same dulness on percussion, and the same absent respiration, as an effusion of liquid into the pleura ; yet the signs are not exactly alike. There is no fluctuation in the bulging intercostal spaces ; the vocal fremitus is not so constantly abolished ; and the level of the dulness is not changed by altering the patient's position. Nor is the flat sound so uniform or so strictly limited as that produced by fluid : amid the dulness may be detected here and there a spot yielding on percussion a clear sound. A tumor in the chest, more- over, presses on the nerves, or bronchial tubes, or great vessels, and thus gives rise to severe pain, and to dyspnoea and signs of in- terrupted circulation far more evident than are caused by a pleu- ritic effusion. It not infrequently grows into the mediastinum, and then leads to prominence of the sternum, and to dilatation of both sides of the chest. These phenomena are found, whatever be the nature of the morbid growth. As most of the thoracic tumors are cancerous, we are often assisted in our diagnosis by discover- ing a cancer in other parts of the body, as well as enlarged cervical glands, and by noting the severe pain in the chest, the harassing cough, and the expectoration of blood or of a peculiar jelly-like substance. Yet these evidences, while they aid us in establishing the fact of a new growth in the thoracic cavity, do not by any means determine its situation. We cannot go a step 420 MEDICAL DIAGNOSIS. further, and say with certainty whether the abnormal formation is situated exclusively in the lung, or in the i^leura, or whether it aifects both. When the tumor occupies the mediastinal spaces, and is not cancerous, it is most likely a sarcoma. Lymphadeno- mata come next in frequency.* In children, however, sarcoma is a more frequent neoplasm than carcinoma, f In those cases in which an effusion into the pleura complicates an intrathoracic tumor, attention to the history and to the signs of pressure alone apprises us of its presence. Yet both signs and symptoms may be so closely like those of chronic pleurisy as to render a differential diagnosis impossible. Nay, friction sounds, a stitch in the side, and fever may be produced by a cancer of the pleura, and be apparently so rapidly developed as to cause the disease to be regarded as an acute or a subacute inflammation of that membrane. Cancer of the pleura, like tubercle of this struc- ture, has, therefore, no pathognomonic signs. The most certain sign of cancer of the pleura is probably the one mentioned by Trousseau, — namely, that the fluid which is evacuated by paracen- tesis consists of a bloody serum ; yet, though of great significance when present, its absence is not so valuable a test ; since Moutard Martin found hemorrhagic effusion in only twelve per cent, of the cases he analyzed. Ehrlich J has published seven cases, in three of which he detected special cellular elements in the fluid, and was thus enabled to come to a correct conclusion. In some instances tliere is no fluid in a greatly-thickened cancerous pleura. § It is at times equally impossible to distinguish a circumscribed pleurisy from a tumor in the chest. In those rare cases in which adhesions bound the liquid effusion and encyst it, we observe all the marks of a tumor, — a restricted bulging and percussion dul- ness, and absent respiration and tactile fremitus, though this may be retained over the lines of the adhesions. Several cysts may form as the I'esult of successive attacks of pleurisy, and may exist in any portion of the chest. The fluid may be collected in the mediastinum, or between the lobes of the lung, or anywhere between the surfaces of the pleural membrane. The purulent * Hobart A. Hare, Affections of the Mediastinum, 1889. f Edwards, Archives of Pediatrics, July, 1889. J Charite Annalen, 1882. g Purjesz, Deutacbes Archiv f. Klin. Med., Aug. 1883, DISEASES OF THE LUNGS. 421 contents of the sac sometimes find their way into the bronchial tubes, and are expectorated, or give rise to a distinct fluctuation in the intercostal spaces, and then discharge through the thoracic parietes. In such cases the diagnosis is not difficult. But where these phenomena are not present, the dissimilar history of the case and the absence of symptoms of pressure are the only means of distinction from a tumor in the chest. Fortunately, encysted pleurisy is a rare disease ; were it frequent, it would be a fruitful source of error. The same remark applies to hydatid cysts, which may occasion all the signs of a circumscribed pleurisy.* An examination of the fluid obtained by an exploratory puncture, in which echinococci are found, is the only positive test. Enlargement of the Liver. — An enlarged liver usually descends into the abdominal cavity ; yet it may be forced upward as far as the fourth rib, and, by encroaching upon the lung, may give rise to many of the physical signs of a pleuritic effusion. The surest diagnostic test is, that during full inspiration and expiration the line of dulness descends and ascends ; while the flat sound of a pleuritic effusion is not affected by the play of the lungs. This test will be applicable except where the liver is firmly adherent to the walls of the abdomen. As circumstances to assist in dis- criminating between the enlargement of the abdominal organ and the presence of liquid in the chest, may be mentioned that the heart, if at all displaced, is pushed upward, and not toward the side ; and that the dulness of an enlarged liver extends higher up anteriorly than posteriorly, which is the reverse of what takes place in a pleuritic effusion. Moreover, the respiration at the lower portion of the lung posteriorly, although enfeebled, is still audible. Enlargement of the Spleen.^^An enlarged spleen is attended with prominence and with dulness on percussion at the lower part of the chest on the left side, and might, therefore, mislead into the idea of a pleuritic effusion. Error in diagnosis is pre- vented by attention to the fact that the dulness extends also * See the observations of Vigla, Arch. Gen. de Med., Sept. and Nov. 1855 Lebert's Klinik der Brustkrankheiten, Bd. ii. ; P. Kidd, Transact. Pathol Soc, London, 1884-85, xxxvi ; 0. Hochsinger, Wien. Med. Blatt., 1887( x. ; J D. Thomas, Australasian Medical Gazette, 1887-88, vii. ; L. Bard andE. Cha banneSjEeV. deM6d., Paris, 1888, viii.; Natter, La Semailie Med,, Aug. 1892, 422 MEDICAL DIAGNOSIS. downward and toward the median line. Again, the heart is not laterally displaced, but tilted upward; the respiration is feeble, but not absent; and the vocal vibrations are mostly unimpaired. Abscess in the Thoracic Walls. — This, too, leads to local tume- faction and fluctuation ; but we can ascertain whether a fluctuating tumor in the intercostal spaces communicates with the pleural cav- ity or not — whether, in other words, it is or is not the result of an effusion which is pointing externally — by watching how pressure and the acts of respiration affect . it. For, unless the diaphragm has become immovable from the extent of the effusion, a bulging which is in connection with the pleura is diminished during a full inspiration, and becomes more prominent when the diaphragm ascends in expiration. The swelling, moreover, can be made to disappear to some extent by pressure. It is not so with an ab- scess seated in the walls of the chest. It is not reducible, and does not recede during inspiration. Pericardial Effusion. — An effusion into the pericardium ought not to be mistaken for an effusion into the pleura. The first in- duces prominence and increased dulness on percussion over the region of the heart ; the second, dulness and prominence over the back part as well as over the front of the lung. A few cases are, however, recorded in which an enormously-distended pericardial sac produced a flat sound posteriorly, and gave rise to signs of compression of the lung. But in these attention to the feeble impulse of the heai't and its muffled sounds permitted it to be told that fluid had accumulated in the pericardium, and not in the pleura. Hydrothorax. — A dropsy having its seat in the pleural cavity is called hydrothorax, or water on the chest. The term is, in truth, sufficiently significant, the fluid which is poured out being very thin and watery. The physical signs of hydr'othorax are the same as those of an effusion due to inflammation ; but, as the dropsy results from an organic disease of the liver, heart, or kid- neys, the serum collects in both pleural sacs. Now, an effusion caused by an inflammation of the pleura is nearly always one- sided. Even where both pleurae are filled with fluid, — a rare condition, except in tubercular pleurisy, — one is affected before the other. This does not happen in hydrothorax. Thus the double-sided effiision, and its usual association with dropsies in DISEASES OF THE LUNGS. 423 other parts of the body, are matters of much significance. Be- sides, in forming a diagnosis of hydrothorax we may lay stress on the absence of friction sounds ; on the smaller quantity of fluid ; on the history of the malady ; and especially on the pres- ence of a structural lesion of the liver, kidneys, or heart. These, then, are the diseases with which chronic pleurisy, when it produces dilatation of the chest, may be confounded. Indeed, in view of the frequency of the operation of aspiration or of para- centesis, it is important to know what affections besides chronic pleurisy may lead to prominence of the chest and to compression of the lung ; and tapping the chest has in itself certain diagnostic bearings which may be here alluded to. One of these is an albu- minous expectoration that follows, which may be looked upon as a passing albuminuria due to circulatory disturbances. It is not an unfavorable event ; on the contrary, in cases in which it hap- pens, retraction of the thoracic parietes is less likely to occur.* Diseases in wldcli Ketraction of tlie Chest occurs. Chronic Pleurisy. — We may here continue the description of chronic pleurisy in the stage of absorption, since it is under these circumstances that the most marked retraction of the walls of the chest takes place. This shrinking of the thoracic parietes is not a sudden, but a gradual act, and instances are therefore con- stantly met with in which the upper part of the chest is flattened and the lower, owing to its still containing fluid, bulges. The contraction of one side of the thorax attains its highest degree M'hen the effusion in the pleura is discharged through the chest- walls and external fistulous openings are established. The symptoms in the stage of retraction are those of chronic pleurisy with dilatation of the chest, and present, therefore, the same variableness. But oedema of the affected side, which is some- times so striking a symptom of chronic pleurisy when the effusion is considerable, is here not noticed. The physical signs alter somewhat, according to the presence or absence of fluid in the pleural sac. When none exists, respiration is heard all over the lung as a feeble inspiration with prolonged expiration, or as an indistinct blowing ; and now and then a friction sound may be * Legroux, Arch. Gen. de Med., Aug. 1873. 424 MEDICAL DIAGNOSIS. caught. When the pleura Still contains liquid, these signs occur at the upper portion of the chest, and a much more absolute dulness on percussion, an absent voice and vocal fremitus at the lower part denote that fluid has there accumulated. The heart is found either in its normal position or still displaced. The force with which contraction takes place may pull it over to the side on which the shrinking is going on. Wasting of the muscles of the shoulder and sensory changes on the affected side of the chest have been observed as a result of chronic ad- hesive pleurisy.* Now, it is evident that chronic pleurisy, when leading to re- traction of one side of the chest, cannot be mistaken for diseases attended with thoracic distention ; but it may be mistaken for affections like pulmonary cancer, tubercle, and chronic consolida- tion, which also occasion a flattening of the chest-walls. From cancer we distinguish it by the absence of the peculiar expectoration, and of hemorrhage ; by the want of signs of per- fect consolidation ; and by the dissimilar history. We distin- guish it from tubercle by the diminution of the chest in the latter not being confined to one side; by the physical signs indicative of deposit and softening at the upper portion of the lungs ; by the presence of rales ; by the occurrence of hemorrhage ; by the greater emaciation ; and by the tubercle bacilli in the sputum. Chronic interstitial pneumonia presents, on the whole, most points of resemblance. But there is this difference : the shrinking of the side in this disease is less marked, and is confined to the part involved, — usually the lower lobe of the lung. The retrac- tion is much more general in chronic pleurisy ; or where it is partial, it is the upper segment of one side of the chest which is flattened, — the loM'er is prominent, and sounds very dull on per- cussion, shows no change on respiratory percussion, and yields the ordinary physical evidence of a fluid. In the former malady the blowing respiration, or the enfeebled inspiration and prolonged expiration, and the distinct voice are heard only over the consoli- dated lobe ; in the other lobes the breathing is plainly vesicu- lar. In chronic pleurisy the same abnormal signs, except per- haps the increased voice, are either manifest over an entire Th6venet, Lyon Med., 1894, No. 5. DISEASES OF THE LUNGS. 425 side, or are perceived over the narrowed portion of the chest, and at the lower part the respiration, voice, and fremitus are abolished. In that form of chronic pulmonary induration attended com- monly with dilatation of the bronchial tubes, to which the name of cirrhosis of the lung,* or fibroid phthisis, has been given, the flattening of the affected side is as obvious as it is in pleurisy. In truth, the two disorders bear a strong relation to each other. The increased formation of connective tissue in the pleuritic ad- hesions passes on into the lung, occasioning an interstitial pneu- monia, — though the fibroid change oftener begins in the lung; as this progresses and the lung shrinks, bronchial dilatations usu- ally follow. We distinguish cirrhosis of the lung by the copious and peculiar sputum which attends the bronchial aifection ; by the rales; by the harsh or bronchial or tubular or feeble respiration ; by the dulness on percussion with an occasional tympanitic note ; by the marked resistance of the chest-walls ; by the increased vocal resonance ; by the narrowing of the intercostal spaces ; and by the displaced apex beat, — rforced up, if the disorder be on the left side, one or several intercostal spaces, or so covered by the expanded left lung, if the disorder be on the right, as to be imperceptible, unless the shrinking of the affected lung be considerable, when the heart may be found drawn over on the diseased side. Fur- ther signs of the complaint, when the malady is left-sided, are that in the second intercostal space to the left of the sternum a double beat of the pulmonary artery is perceptible, and that whichever side is diseased shows the diaphragm greatly displaced upward, and a marked vesicular resonance in a line along the edge of the sternum caused by the overlapping of the healthy lung, and in strong contrast with the line of dulness of the cir- rhosed organ. f The affection is a very chronic one, and unat- tended with fever or laryngeal symptoms. Loss of flesh and of strength is very gradual, and night-sweats are slight or incon- stant. Dilatation, or hypertrophy with dilatation, of the right side of the heart, and dropsy, are not infrequent, and haemoptysis is still oftener met with. It is a, mistake to suppose that it occurs * Coirigan, Dublin Quart. Journ., vol. xiii. ■j- Nothnagel, Sammlung Klinischer Vortrage, 1874. 27 426 MEDICAL DIAGNOSIS. only when tubercles are present, or in what is called the bacillary variety of fibroid phthisis.* The disease has among its causes the inhalation of fine particles, such as of steel, of coal-dust, of iron-dust, of cotton. It may have an obscure beginning, or it may clearly date from an acute pneumonia, especially an acute or a subacute broncho-pneumonia, or a plastic pleurisy. It may become complicated with tubercle, and then tubercle bacilli are found in the sputum. The fibroid condition of the lungs — also called by some fibroid phthisis — in old tubercular lungs or around cavities is an evidence of a disposition toward healing, a local fibroid change, and is not fibroid jDhthisis, though this term is limited by some to cases of indurated lung of tubercular origin. Pulmonary cirrhosis often proves fatal from an acute affection, a pneumonia or a broncho-pneumonia, of the previously healthy lung. In very rare instances it is double.f The connection of pleurisy with the cirrhotic lung has just been mentioned ; and, though the origin of interstitial pneumonia from invasion through the pleura is in dispute, I hold the view to be correct. We must, however, not forget that primitive dry pleurisy is found also under other circumstances, and may give rise to retraction of the chest. Firm fibrous bands may result from organization in the pleura after a dry pleurisy, or after absorption of the effusion ; or the dry pleurisy may be of tuberculous origin. It is then usually double-sided. Osier J mentions some remark- able vaso-motor phenomena when these primitive dry pleurisies affect the apex and probably involve the first thoracic ganglion, such as flushing or sweating of one cheek or dilatation of the pupil. A collapsed state of the lung, resulting from a plug of mucus in the bronchial tubes, may yield the manifestations of chronic pleurisy with partial retraction. No signs distinguish such cases, except the more limited depression ; the absence of any disease above the flattened spot ; the want of friction sound, and of ten- derness on pressure ; and the rapid disappearance of the physical * Sir Andrew Clark, Lancet, July, 1892. t MoColIora, New York State Med. Assoc, 1885. X Practice of Medicine, 1892. DISEASES OF THE LTJNGS. 427 phenomena after an effort of coughing has removed the obstruc- tion.* Where external fistulous openings exist, the shrinking of the side; as already stated, is carried to the highest degree. These fistulse, whether produced artificially or by nature, may close after they have served the purpose of evacuating the fluid in the pleural cavity. But they often persist for months or years, and keep on discharging offensive, purulent matter. The patient emaciates under this continued drain, yet not so quickly as might be imagined. More or less troublesome cough annoys him, but it is not ordinarily accompanied by much expectoration. Every now and then, however, he discharges for days a quantity of fetid, purulent sputum. It is then very likely, as Traube has observed, that the pus has softened part of the pulmonary pleura sufficiently to soak through the lung into a bronchial tube. It seems certain, as far as physical signs can prove, that it is not the liquid in the pleura which is being vpided through a distinct perforation of the pulmonary tissue, for the physical signs of pneumothorax are absent. The clubbing of the nails is often extremely marked, and may exist to an extent far greater than in phthisis. The nail is rounded and bluish, and the whole end of the finger looks en- larged. This appearance is even more striking than the curve of the nail. The nails and last joints of the toes show the same alteration. The fistulous opening is situated ordinarily in the intercostal space below the nipple. It may, however, be seated at the back of the chest, and communicate by a tortuous sinus with the intes- tine and other abdominal viscera. A pleuro-bronchial fistula may form ;. if the opening pass into the lung, the physical evi- dences of pneumothorax are present, but the side is still retracted, and striking the chest elicits a mixture of a dull and a tympanitic sound. Where merely an external opening exists, no signs of pneumothorax occur, because no air finds its way into the pleural cavity. A fistulous opening into the pleura is not difficult of diagnosis. * An interesting instance of the kind is related by Prof. William Pepper the elder in the American Journal of the Medical Sciences for April, 1852. 428 MEDICAL DIAGNOSIS. It is easy to establish the fact that the fistula is not simply pro- duced by caries of the rib ; for a probe may be run into the chest for two, three, or four inches. I base these statements on a number of instances of chronic pleurisy attended with external fistula which have come under my notice. The seat of the opening near the nipple ; the peculiar nail ; the occasional flow for days of a most offensive sputum from the bronchial tubes, without any traces of pneumothorax ; the ease with which the fistula could be probed, and its depth ; the gradual emaciation ; and, I may add, the decided improve- ment under the persistent use of cod-liver oil and tonics, — be- longed to them all, and justify the description given. SECTION 11. DISEASES OF THE HEART. The heart is kept from rolling about in the chest by the great vessels which spring from its base, and by the attachment to the diaphragm of its membranous covering, — the pericardium. It lies obliquely in this membrane, with its long axis directed down- ward and toward the left. Its base points backward and upward toward the right shoulder ; its under side rests upon the central tendon of the diaphragm. The interior of the heart is lined by a serous membrane, — ^the endocardium, — which is reflected over the valves. These valves all lie in close proximity to one another, and within a space of less than an inch square. The relations the different parts of the organ bear to the chests walls are as follows. The auricles are on a line with the third costal cartilages ; the right auricle extends across the sternum to the right side of the chest. The right ventricle is placed partly under the sternum, and partly to the left of it. Its inferior bor- der is on a level with the sixth cartilage. The left ventricle lies within the nipple, between the third and fifth intercostal spaces. The apex is seated between the cartilages of the fifth and sixth ribs, to the inner side of, a: d from an inch and a half to two DISEASES OP THE HEART. 429 inches below, the left nipple. The base of the heart corresponds posteriorly to the sixth and seventh dorsal vertebrse, from which it is separated by the aorta and oesophagus. The greater portion Fig. 43. Topography of the heart. The relations of each portion of the heart to the walls of the chest are shown. The dotted lines mark the lungs. The figure is la^ed upon several careful dissections. of the anterior surface of the heart is removed from the thoracic walls by the lungs. The right lung extends to the middle of the sternum. The left lung spreads out as far as the fourth cartilage, and covers the whole of the left ventricle, except the apex. The part of the heart which remains exposed consists thus mainly of the lower portion of the right ventricle ; it presents the shape of a rude triangle. The position of the valves can be learned by running needles into the chest before the viscus is taken out. In this manner it is ascertained that at the left border of the sternum, on a level with the third intercostal space, lies the mitral valve, and in front of 430 MEDICAL DIAGNOSIS. this, more directly under the sternum, and but a few lines lower, the tricuspid valve. The pulmonary orifice is seated opposite the junction of the cartilage of the third rib with the left edge of the sternum. Near it, very slightly lower, but placed more obliquely, are the aortic valves. The aorta then proceeds from left to right, and ascends to the upper border of the second costal cartilage on the right side ; thence it crosses, under the stei'num and in front of the trachea, to the left side. The pulmonary artery is found in the second intercostal space on the left side, enclosed in the pericardium, and passes to the cartilage of the second rib, where it bifurcates. The size of the heart is about that of the closed fist. Its mean weight in adults is between eight and nine ounces. Only in very large persons does it exceed this. The organ exhibits, when in action, a wonderfully perfect mech- anism and regularity of movement. , Its cavities contract on both sides at the same time, and distend on both sides at the same time. It then rests for a short period. The contraction of the ventricles occasions the impulse which is seen and felt in the fifth intercostal space. While the blood is flowing in and out of the heart, the valves are kept in constant motion. Their play makes itself known by two distinct sounds of unequal length, which are produced mainly by their opening and closing. The first sound, long and dull, is caused by the forcible closure of the valves at the auriculo- ventricular openings. Yet it is not a purely valvular sound. The stroke of the heai't against the walls of the chest, the muscular contraction itself, and the flow of blood into the aorta and the pulmonary artery aid in its for- mation. The first sound corresponds, therefore, to the closure of the auriculo-ventricnlar valves, to the impulse of the heart, to the opening of the valves at the orifice of the aorta and of the pulmonary artery, and to the passage of blood along the arteries. The second sound is short, abrupt, and ringing. It results from the sudden closure of the semilunar valves. During its occur- rence the blood rushes through the opened mitral and tricuspid valves, and dilates the ventricles. DISEASES OF THE HEART. 451 Exammation of the Heart by tlie Different Methods of Physical Diagnosis. Before proceeding to examine the heart, we inquire into the history of the case, and into such symptoms as the expression of the face; the appearance of the eye; the condition of the capillary circulation ; the presence or absence of dropsical swell- ings and of cough ; the state of the breathing ; the character of the pulse; and the frequency and violence of the palpitations. The cardiac region is then explored by the eye and by the hand ; the size of the organ is estimated by percussion ; aud, lastly, its sounds are studied by the stethoscope. These different methods are most conveniently practised when the patient is in an easy position, leaning back in a chair or propped up with pillows in bed. To examine them more in detail : INSPECTION. Inspection detects on the chest of some healthy persons a slight protrusion over the seat of the heart ; yet this is far from being constant or even the general rule. When the heart is hyper- trophied, or when fluid has accumulated in the pericardium, we perceive a marked prominence in the prsecordial region. A de- pression at the lower part of this region may be natural ; a very evident depression is almost always the result of an attack of pericardial inflammation. Yet neither prominence nor depression is a very important sign. One much more so, which inspection shows, is the impulse of the heart. This is seen where the apex beats against the walls of the chest : between the fifth and sixth ribs, about an inch inward from the nipple and two inches downward. It is for the most part confined to this point, and appears as a brief raising of the integ- ument, occurring with great regularity of succession. In lean persons it is very distinct ; in fat persons it is generally not at all perceptible. Its seat, even in those who are in perfect health, is not always exactly the same. It is changed by different positions, and by the distention of the stomach after a full meal or by flat- ulence. It is most modified by the acts of respiration. During a long-drawn inspiration the heart descends somewhat and the 432 MEDICAL DIAGNOSIS. expanded lung sweeps it inward, and the impulse becomes dis- cernible in the epigastrium. During a fixed expiration the beat moves upward, and appears more extended and weightier. The changes produced in its situation by disease, both thoracic and ab- dominal, are many. It is tilted upward and outward by the left lobe of an enlarged liver. It is displaced by diverse affections of the lungs and pleura. It is forced up by a pericardial effusion. It is visible lower down and over a larger surface in enlargements of the heart ; but even then it is most distinct at the apex. The apex beat lies without the line of the nipple in most children up to the fourth year.* The alterations in the character and force of the impulse are as diversified as those of its seat. But they are more readily appreciated by the hand than by the eye. PALPATION. Palpation is, so far as the exploration of the heart is concerned, much preferable to inspection. Many an impulse can be felt which cannot be seen. The rhythm of the motion is changed by a large number of cardiac affections, both functional and organic. So are the extent and force of the beat. Both are temporarily increased by powerful excitement; both are permanently augmented by hypertrophy. In dilatation and pericardial effusion, the extent over which the stroke is felt is greater than in health ; but the impulse is feeble, and in the latter disease irregular and wavy. Softening of the texture of the heart, diseases of the brain, some morbid states of the blood, and a low condition of the system will also enfeeble the beat. The hand, when laid on the prseeordial region, perceives at times two impulses. This double impulse is oft«n recognizable in health, especially in thin persons. It becomes still more evident in hypertrophy with dilatation of the ventricles. One of the beats is systolic ; the other corresponds to the diastole. Bouillaud cites examples in which the diastolic stroke was double. The systolic beat is occasionally split into several parts when the pericardium adheres to the heart. * J. Mitchell Bruce, Enlargement of the Heart, in Keating's Cyclopaedia of the Diseases of Children, vol. ii. DISEASES OF THE HEART. 433 All these modifications of the impulse stand in direct connection with the action of the ventricles. The auricles, save in some rare instances in which they are dilated and their walls thickened, give rise to no perceptible movement in the chest-wall. Besides the impulse of the heart, other phenomena may be studied by placing the hand over the cardiac region. The sounds of the heart can be analyzed by means of the touch. They will be felt, the one as a long and dull, the other as a short and dis- tinct, vibration. The motion is due to the play of the valves, and disappears with their destruction. The fingers applied over the heart perceive at times a peculiar thrill, or a rubbing movement. The first — called by Laennec, from its resemblance to the purr of a cat, the purring tremor — is nearly always indicative of a valvular lesion. The second is caused by the to-and-fro motion of a roughened pericardium. A more accurate means of studying the varying impulse than is afforded by the fingers has been sought to be attained by instru- ments which record the beat of the heart. The cardioscope of Alison and the cardiograph of Marey and of Galabin have been used for the close analysis of the cardiac impulse, as have the sphygmographs of Pond and of Brondgeest. But as yet these instruments have not proved to be of marked diagnostic value. PERCUSSION. Percussion affords the readiest means of judging of the size ol the heart. The patient is placed in a recumbent position ; then, by a series of moderately strong taps, we proceed downward from near the middle of the left clavicle, until a dull sound, accompanied by decided resistance, tells that we are striking over a solid organ. The point at which this dull sound begins is over, or immediately at the lower border of, the fourth cartilage. It corresponds to the upper limit of the portion of the heart which is left uncovered by the lung. The superior border of the duluess having been thus ascer- tained, we next percuss on the right side of the sternum, on about a level with the fifth rib, and progress across the bone. At, or very near to, its left edge we find marked resistance and a duller sound. Here we draw our second line, and continue to strike straight across the cardiac region up to the point at which a 434 MEDICAL DIAGNOSIS. clear, full note demonstrates that the pulmonary tissue is resound- ing. This determines the transverse diameter of the heart, — at least so far as it can be mapped out on the chest. The apex of the organ and its inferior surface remain to be fixed. The first is readily done by advancing in an oblique direction from the already ascertained right border. But we can save ourselves this trouble by feeling for the impulse or by listening for it with a stethoscope. The inferior surface can be circumscribed by prolonging the line of the dulness on percussion of the upper border of the liver, and then judging by the greater amount of resistance and the fall in pitch that the heart has been reached. These are not easy to appreciate ; nor is it indeed often, necessary to define the contiguous edges of the left lobe of the liver and of the heart. If the other boundaries have been correctly drawn, the size of the heart can be accurately estimated, — accurately enough, at least, for any practical purpose. The dulness elicited by percussing the cardiac region is not so absolute as that of the liver or of some other solids. It is mixed with the sound of the lung-tissue, or with the resonance of the sternum. Nor is it a representation of the size of the entire organ. It simply portrays the more super- ficial portion, which is uncovered by the lungs. In women it is particularly difficult to define these limits. It can be done only by having the mammary gland drawn to one side while percussing. It is equally difficult in children, as the space over which the dulness is perceived is very small. In adults the dulness ordinarily spreads over two, or nearly two, intercostal spaces. Its transverse diameter in a grown person of medium size is about two inches and a half. In tall, broad-chested men it is upwards of three inches. Such, at all events, is the result of measurements I have made. The range of the dulness is changed by a number of causes, physiological as well as pathological. A full inspiration alters it materially, by bringing the lung down over the heart, and by displacing the organ itself The upper border of the percus- sion dulness shifts to the extent of an intercostal space. Below the nipple, between the fifth and six ribs, the sound becomes clear ; but over the dislodged lower part of the heart, the beat of which is distinctly seen under the cartilages of the ribs, at a DISEASES OF THE HEART. 435 point varying from three-fourths to one and a fourth inch from the median line, there is dulness with resistance to the finger. A full expiration produces, for the most part, converse phenomena. It enlarges the boundaries, especially in an upward and transverse direction. The dulness reaches nearly, or even entirely, across the sternum. Auscultatory percussion enables us to fix the per- cussion limits more closely. Sansom's pleximeter also conduces to greater accuracy in cardiac percussion.* The area of dulness is diminished in emphysema. It is in- creased by a shrinking of the left lung, and by diseases of the heart and of its membranes. Prominent among these are hypertrophy, dilatation, and an effusion into the pericardial sac. AUSCULTATION. When the ear or a stethoscope is applied over a healthy heart, it detects two sounds of very dissimilar character: the first is long, dull, heavy, and qprresponds to the impulse against the walls of the chest ; the second is short and flapping, and occurs after the impulse. These sounds are audible at all parts of the prsecordial region, but not everywhere with equal distinctness. The first, being more ventricular in origin, is best heard over the lower part of the heart ; the second, a more strictly valvular sound, is more defined at the base. It has been already stated that these sounds are, to a great ex- tent, produced by the play of the valves. Each of these forms a separate sound, or at least a portion of one. Now, experience teaches that there are points at which the sounds of the several parts of the heart may be isolated. Some of these points accord with the anatomical seat of the valves ; others do not. None do so very closely ; and the proximity of the valves to one another is such as to make it desirable that the localities selected for listening to them should be some distance apart. Clinical observation sanctions the following : the sounds of the aorta are to be studied at the right edge of the sternum, in the second intercostal space ; from there the stethoscope may be car- ried to the second costal cartilage of the right side, the " aortic * See paper by William Ewart, Lancet, Aug. 1891. 436 MEDICAL DIAGNOSIS. cartilage," and down to the left edge of the sternum opposite the third intercostal space ; that is, not far from the seat of the aortic valves. The pulmonary orifice lies very close to them ; but the artery itself ascends to the second costal cartilage on the left side. Tig. 44. ^or^i'c 'VO'Zves- '■ulmonary arfery valves U tral, Diagram allowing the points at which the separate Talves may be listened to. Its sound may, therefore, be isolated in the second intercostal space, near to the left edge of the sternum. The mitral is listened to immediately above the beat of the apex. The sounds of the tricuspid and of the right ventricle may be sought for in the vicinity of and somewhat above the ensiform cartilage. Both sounds are discerned at each of these points. But the DISEASES OF THE HEAET. 437 same sound varies in different situations. The first sound over the left ventricle near the apex of the heart is dull, heavy, and prolonged ; that over the right ventricle is clearer, shorter, and of liigher pitch. The second sound heard there presents no constant and appreciable variance from that over the left ventricle ; yet it is less ringing and distinct than the second sound of the pulmonary artery and aorta. Even these two are not precisely alike. The second sound of the latter, when compared with that of the former, is found to be sharper and more accentuated. The first sound, however, does not differ materially from that of the pul- monary artery. But the first sound of both does differ most materially from that over the ventricles. Compared with the first sound over the right ventricle, the first sound of the pulmonary artery is much duller, more indistinct and like a vibration, and not of so high a pitch. Compared with the first sound at the apex, the first sound of the aorta lacks the weighty, prolonged character which belongs to the ventricular sound. These statements are based on a series of observations made, some with an ordinary, some with a double, stethoscope. They certainly seem to favor the view of Skoda, that the first sound, as heard over the great vessels, is not merely a transmitted sound, but is one which is partly, if not entirely, generated by the arteries themselves when the blood rushes into them. The sounds just considered undergo various modifications, both when the heart is affected and when it is free from disease. They may be audible over a larger space of the chest than usual ; they may be changed in character and in rhythm. Their transmission over a larger space is an unimportant sign. They are undoubtedly perceived over a more extended surface when the heart is enlarged, or when the surrounding tissues are condensed ; even in perfect health their range is very diversified. During a full inspiration, the sounds at the interspace between the second and third costal cartilages on the left side disappear almost entirely, and become faint at the aortic cartilage. The first sound at the apex lessens also very much in distinctness, but it is better heard at a new point of impulse, visible toward the median line and just below the cartilages of the ribs. During a full expiration, the extent over which the heart-sounds are per- ceived is increased. 438 MEDICAL DIAGNOSIS. The sounds grow in loudness in any functional disturbance of the heart. When the organ is palpitating violently under strong nervous excitement, they may become short and sharp, and some- times so loud and ringing as to be audible to the by-standers. They are often permanently louder than in health, and are shorter and more clearly defined when the walls of the heart ai'e thinned. This is particularly the case with the first sound. When the walls of the heart are thick, the first sound over the hypertrophied por- tion is apt to be dull and prolonged. The first sound is weakened if the structure of the heart be softened : hence it is feeble in some low fevers, and in fatty degeneration of the organ. It is also less distinct when there is a want of tone in the muscle, or when the mitral and tricuspid valves are thickened. To determine whether a dull first sound at the apex be due to an injured mitral valve, or to an alteration of the muscular power of the heart, Flint advises to place the stethoscope over the apex of the heart, and then on the outside of the left nipple to isolate the element of impulsion, which unites with the valvular element to form the complex first sound. If there be a marked impulsion over the apex, but if by means of the stethoscope placed to the left we perceive no sound at all which possesses a valvular char- acter, or hear a sound which is but faintly valvular, we infer that the mitral valves are more or less damaged. The second sound is not so liable to be changed as the first. It is rendered somewhat duller by a thickening of the semilunar valves ; on the other hand, it is more ringing when they are thin, and in great functional excitement of the heart, and in altered blood conditions, as in lithsemia or in gout. The sound, indeed, always becomes more distinctly accentuated if the column of blood closes the valves forcibly. This occurs not unfrequently in hypertrophy of the ventricles, especially the left, and in the in- creased tension of the vessels in contracted kidney ; it aifects the second aortic sound. Accentuation of the second sound also takes place where a decided obstruction exists to the passage of blood through the lungs, and in mitral valvular disease. In both the latter conditions it is over the pulmonary artery alone that this accentuated second sound is audible. Both the sounds are occasionally obscure and seem to arrive at the ear from a distance. This happens when fluid has ac- DISEASES OF THE HEAET. 439 cumulated in the pericardium. The sounds may be changed in their relative proportion to each other, and the pauses between them be lengthened or shortened, or else the sounds may intermit from time to time. From this perverted rhythm we do not derive any definite instruction as to the condition causing it. It serves only to show that the heart is acting irregularly, and thus directs our attention to the state of the organ. It may be associated with organic disease or exist without it. The same may be said of reduplication of the sounds of the heart. The second sound is the one which is generally split. Yet both of them may be doubled, or one may be doubled over one part of the heart and not over another ; so that four or three sounds are counted to each beat of the pulse. The cause of the reduplication is the want of synchronous action of the two sides of the heart. The direct value for diagnosis of the altered movement is not great; but indirectly it teaches a most important lesson: it tells us that each side of the heart forms its own sounds, and that, to arrive at accurate conclusions, each side has to be separately examined. Yet there is some diagnostic value to be attached to the changed rhythm. Thus, the peculiar alteration of the sounds, which causes us to hear three sounds during the action of the heart, two of them in the diastole, producing the rhythm that has been likened to the gallop of a horse, is often found in con- tracted kidney and in arterio-sclerosis. It is particularly heard over the mitral and the tricuspid region. Fraentzel * has noted the frequent occurrence of this cantering rhythm in typhoid fever and in croupous pneumonia, and looks upon it as a sign of grave cardiac weakness ; it is also a sign of serious import in chronic Bright's disease. Such, then, are the modifications which the healthy sounds present. At times we meet with sounds which do not in the least resemble those naturally heard, and which overshadow them or take their place. They are called murmurs, and are mainly produced either within the heart or on its surface. Those murmurs that are endocardial have a common quality : they are more or less blowing. Yet the sound is not always of * Krankheiten des Herzens, Berlin, 1889 ; see also Cuffer and Barbillion, Arch. Gen. de Med., 1887. 440 MEDICAL DIAGNOSIS. the same character or pitch. It may be low-toned, it may be high- pitched ; it may be soft, it may be harsh ; it may resemble the blowing of a bellows, it may be musical ; it may be filing, or rasping, or sawing. The ingenuity of every listener exerts itself in tracing a similarity to some familiar noise ; but to little prac- tical purpose. These different sounds have not been proved to have a decided significance beyond that of a blowing sound. They teach us nothing certain as to its source. They are, more- over, not at all times the same in the same case, since the heart when excited may emit a sound different from that which it does when it is beating quietly. A blowing sound originates in the altered relation of the blood to the part over which it moves. This general statement opens the way to the consideration of the specially acting elements, both in the blood and in the heart itself. Usually a cardiac murmur springs from a change at one of the orifices. This may be either a narrowing or t roughening, which interposes a local obstruction to the flow of the blood ; or it may be an insufficiency to close the opening. In the latter case the blood regurgitates, and a murmur is occasioned by the de- viation of the direction of the current and the establishment of another. This subversion of the course of the circulating fluid, added to its increased velocity and force, is the chief source of those temporary blowing sounds not unfrequently perceived when a heart is greatly excited, while both its valvular apparatus and its muscular texture are healthy. But we meet every now and then with instances where none of these causes are present, and where altered blood is the foundation of the murmur. Thus, to sum up the subject, we find murmurs that depend upon organic change, and murmurs that are unconnected with any structural alteration ; and these inorganic murmurs are due either to an unnatural condition of the blood or to temporarily perverted action of the heart. The murmurs, however caused, have different effects on the sounds of the heart. They either accompany the sound through- out the whole or a part of its duration, and thus obscure it, or else they take its place and hinder it from being generated. In time of their occurrence they correspond to the contraction or to the dilatation of the heart, and therefore to the fii'st or to the DISEASES OP THE HEAET. 441 second sound ; at least, they do so practically. It is true, they may immediately precede or succeed either sound, or fill mainly the intervals of silence between them ; but attention to such minute divisions is irksome, and, for most purposes, unnecessary. In point of fact, it is often difficult enough to say whether the murmur we hear is systolic or diastolic. The readiest method of judging of the time of the production of a murmur is to feel with the finger for the impulse while listening with the stetho- scope. The blowing sound which agrees with the beat of the heart is systolic ; the one between the beats is diastolic. When a murmur is once established, it attends each motion of the heart that can give rise to it ; but it is not always equally perceptible. It may become very faint, or disappear entirely, by the patient changing his position. It is sometimes manifest only when the heart is acting strongly. Indeed, it alwaj^s requires a certain force and velocity in the passage of the blood to generate a murmur. Yet overaction of the heart may be as destructive of its distinctness as diminished action. This is, however, a matter that, should it be desirable for diagnosis, we can control by the administration of medicines like digitalis, aconite, or veratrum viride, provided their use be not contra-indicated. A murmur is sometimes heard by the patient himself, or is audible before the ear is placed over the heart. It may be per- ceived as an abrupt blowing sound, apparently coming out of the mouth. A gentleman, whose mitral valves permitted of regurgita- tion, was under my charge. When he held his breath and kept his mouth open, he, as well as I, could detect an abrupt blowing sound issuing from the oral cavity. This sound, when the heart's action was at all excited, accompanied regularly each impulse. Posture exerts a decided eifect upon murmurs. A blowing sound distinct in the recumbent position may become very faint or disappear when the patient stands erect ; and the reverse holds i^ood, although less common. The nature of the murmur — whether organic or inorganic — does not seem to influence the readiness with which it is affected by change erf posture, though ansemic murmurs are thought to be more intense in the recumbent position.* Pressure, too, has an influence upon the abnormal * James H. Hutchinson, Amer. Journ. Med. Sci , April, 1872. 28 442 MEDICAL DIAGNOSIS. cardiac sound ; it notably augments it, and often raises its pitch. Yet pressing the stethoscope against the chest does not occasion as much alteration in endocardial as it does in pericardial sounds. A murmur may be obscured by the respiratory sound ; but this is not apt to be a cause of error in diagnosis. It is not nearly so fruitful a source of mistake as considering the natural sounds of the lungs to be blowing sounds in the heart. Certainly the resemblance is often great ; but blunders may be readily avoided by listening to the heart while the patient suspends his breathing. Having ascertained positively the existence and the time of occurrence of an endocardial murmur, the next thing is to deter- mine its exact seat, and, if possible, its immediate cause. The seat of the murmur is judged of by the place of its greatest intensity, and by the relation this bears to one of the four points for the clinical examination of the heart above described. If it be most distinct at or near the apex of the heart, it is produced at the mitral orifice ; if immediately above or at the ensiform cartilage, it is generated in the right ventricle and at the tricuspid opening. If we hear it most plainly at the sternum, somewhat toward its left border on a level with the third intercostal space or even the fourth rib, and with equal or nearly equal distinctness at the second costal cartilage on the right side, we are enabled to decide that it is developed at the origin of the aorta. The pulmonary artery is not often the seat of a mui'mur. When it is, this is clearly perceptible in the second intercostal space on the left side, and extends, if the valves be diseased, to the junction of the third left cartilage with the sternum ; although we must bear in mind that occasionally in mitral aifections the murmur is loudest ia the pulmonary area, or, as Naunyn has shown, not exactly over the artery, but rather an inch and a half or more from the left edge of the sternum in the second interspace. Any of these situations may be the site of a distinct murmur occupying only one sound of the heart, or being produced in both, — one murmur taking place with, the other against, the current of blood. Yet it rarely happens that the murmur is strictly limited to one of these positions : it will mostly extend in various direc- tions from its point of intensity, growing fainter and fainter as this is left. A blowing murmur thus transmitted may drown the natural sounds of the heart at the parts not diseased. But when DISEASES OF THE HEART. 443 one orifice only is affected, we can usually hear the sounds at the other valves. They may be obscured, but still they exist ; and it is a vast aid when they are heard, since they set the limits to the disease. How important is it, then, to examine each portion of the heart separately, as much for the purpose of saying what is not as what is deranged ! If satisfied as to the seat of the murmur, we naturally turn to inquire into its origin. Is it caused by an alteration of the valves ? Is it unconnected with any appreciable change of structure in the heart ? There is nothing in the murmur itself which will tell us positively. As a rule, it is true that a harsh murmur results from organic disease, and a soft murmur is inorganic ; but we judge with much more certainty by the time of the occurrence of the blowing sound and by the accompanying phenomena. A murmur attending the distention of the ventricles shows that the orifices are injured. A systolic murmur may be either organic, or it may indicate simply a change in the state of the blood, or of the force and velocity with which it is circulating. In the latter case, how- ever, the abnormal sound is temporary, and disappears with the excitement. If arising from an impoverished state of the blood, it is generally soft, of low pitch, is perceived over the base of the heart, and is accompanied by a humming sound in the veins of the neck. It may be heard over the right base, or on the left side over the pulmonary artery ; although Balfour maintains that it is not really over the pulmonary artery, but about half an inch or more to the left of the pulmonary area, and is not an arterial, but an auricular sound. Throughout the consideration of the endocardial murmurs, they have been treated as originating at the seat of the valves. In truth, it is there that they are formed. Still, they are occasion- ally due to morbid states in the body of the ventricle, or in the auricle. But in either case, then, they are clinical curiosities. As regards the auricles, they yield no appreciable sound in health, nor are they in disease except rarely the source either of sound or of murmur. A blowing sound is not of necessity limited to the heart : it may be transmitted all over the arterial system. Yet it would be a great mistake to suppose that every murmur heard over the ai-teries is connected with a disease of the heart. It is often but 4-14 MEDICAL DIAGNOSIS. the sign of impoverished blood, or a sound dependent upon local roughening or narrowing of the tube. The latter may be tem- porarily produced by the pressure of a stethoscope, — a fact of which it is well to be aware. It is even stated that pressure over a healthy heart may generate a murmur ; but I have never been able to satisfy myself of the truth of this statement. It is cer- tainly incorrect as a general rule, and the murmur depends, when it happens, more likely upon the condition of the blood and the force with which it circulates. Let us now examine the sounds which originate on the outside of the heart. These pericardial murmurs have all a common source : they all result from irregularities on the membrane. Like the pleura, the smooth serous covering of the heart moves noiselessly in health ; but when it is roughened by a deposit of any kind, the friction of its surfaces gives rise to a sound which may be single, but which is usually double. The character of this sound is variable. It may be a to-and-fro rubbing murmur, or it may be grazing, or scratching, or creaking, or whistling, or clicking and resembling the valvular sounds. It has but one quality which is constant, and that is its superficiality. By this superficiality ; by the strict limitation of the sound to the region of the heart ; by its altering from time to time its precise seat ; by its greater extent and intensity when the patient bends for- ward ; by its occasional increase, and even change of character, on external pressure ; by its following, rather than occurring with, the movements of the heart; and by the sensation of friction which it communicates to the finger, — we know that the sound heard is produced on the surface of the heart. Yet, in spite of this array of points of difierence, it is often difficult to distinguish a pericardial from an endocardial murmur. An error not easy at times to avoid is the failure to discriminate between the presystolic apex murmur, regarded as characteristic of mitral constriction, and a pericardial friction localized near the apex. The only trustworthy points of distinction are that the pericardial sound changes in its quality .and loudness, that it is rendered stronger and changed in pitch by pressure exerted with the stetho- scojDe, and that the second sound at the left base is unaltered. A friction sound is prone to mask the natural sounds of the heart. At times, although heard over the cardiac region, it is not DISEASES OP THE HEART. 445 due to inflammation of the pericardium. The exudation may be on the surface of the pleura adjacent to the pericardium, and the murmurs be caused solely by the movements of the heart, with the rhythm of which they coincide. Sometimes, again, the sound heard in the cardiac region is in reality the rubbing of an inflamed pleura. If any doubt exist, let the patient be told to suspend his breathing. As this is stopped, the pleural sound ceases. Such is a brief description of the different physical signs met with in examining the heart, both in health and in disease. Their importance for diagnosis it is difficult to overestimate. A knowledge of the physical signs is the solid foundation, without which any structure that may be raised will soon tumble to pieces. The General and Local Symptoms of Diseases of the Heart. It is not easy to say what are and what are not the symptoms that belong to diseases of the heart. There are vital manifestations directing attention to the heart which are not associated with any change in its structure; and most serious changes in its structure may occur without any of these vital manifestations. Yet we often find a significant group of symptoms which accompany an affection of the heart. Some of these attest directly the organ disturbed, such as pain in the cardiac region, and palpitation. Others are the indirect and more remote expressions of its derangement, such as cough, dyspnoea, hemorrhages, dropsy, disorders of the brain and nervous system, engorgement of the abdominal viscera, a peculiar state of the arteries and veins, and the aspect of the face. . It is unnecessary to do more than mention some of these, since several have been already described in connection with pulmonary com- plaints, and there is nothing in the cough or in the shortness of breath by which we can absolutely determine it to be caused by a disease of the heart. The same with respect to the hemorrhage : there is nothing characteristic about it. It simply proves the efforts of the blood-vessels to relieve themselves of the strain which the disturbance in the flow of the blood has put on them. The capil- laries and the smaller blood-vessels give way first ; partly from the reason just assigned, and partly from the altered state of their coats, a common associate of cardiac disease. These hemorrhages 446 MEDICAL DIAGNOSIS. are prone to happen from the bronchial tubes and the lungs, and the blood is expectorated ; but they may also take place directly into the pulmonary tissue, or into or from any part of the body. Their danger is in proportion to the amount, to the importance of the function of the structures into which the blood is effused, and to the possibility of its finding an outlet. The peril is greatest when the blood is poured out into the brain. Cardiac Dropsy. — The dropsy caused by a disease of the heart is met with in different situations : in the cellular tissues, in the peritoneal and pleural cavities, in the pericardium, in the ventricles of the brain and under the arachnoid, in the air-cells of the lungs, — in fact, in any part where fluid can exude, and where there is a space which can receive. In anasarca dependent upon a cardiac lesion, the dropsical swelling begins about the ankles and feet : hence oedema starting in this situation is regarded as among the surest of the symptoms of a disease of the heart. The accumulation is much influenced by position : the feet are more puffy toward evening, when the patient has been all day in the erect posture, and least so when he gets up in the morning. What the condition of the heart is that gives rise to dropsy, has been made a matter of much dispute. It has been held to be uniformly connected with dilatation of the right side of the heart. It has been taught to be invariably linked to a valvular affection. Clinical experience shows us that it may or may not exist where these states are present. The dropsy is most constantly found to be associated with an impediment to, or disturbance in, the flow of the venous blood, and therefore Avith disorder of the right side of the heart, particularly with a dilatation of the cavities. It may be permanent or not. Its extent certainly does not bear a con- stant relation to the extent of the cardiac disease. It bears a more constant relation to the amount of venous congestion, and to the impoverishment of the blood. Derangement of the Circulation. — ^Unmistakable evi- dence of the obstruction to the flow of the blood through the veins is afforded by their prominence in different portions of the body. This is especially manifest in the superficial veins of the neck, which, moreover, when the tricuspid orifice is permanently open, exhibit a distinct pulsation with each beat of the heart. DISEASES OP THE HEART. 447 The turgid condition of the venous system is rendered equally obvious by the livid tinge of the skin and the bluish color of the lip, and by ramifications of fine bluish vessels on the surface. But the arterial system may also be gorged, and we may find the capillaries and the smaller arteries seemingly ready to burst. The conjunctiva is then highly injected, and the cheek has a coarse, red look. This change in the color and appearance of the face, the thickening of the eyelids, and the prominent eye, make up the peculiar physiognomy of a chronic cardiac malady. The state of the larger arteries is very variable, and mainly according to the nature of the disorder. The pulse may be small and tense ; it may be full ; it may be rebounding ; it may be very irregular ; and it is often out of all proportion to the forcible action of the heart. The derangement of the circulation of individual parts maui- fests itself by special symptoms. It shows itself in the brain by attacks of cerebral congestion ; by vertigo ; by violent headache, occurring in spells, or, less acute, in dull persistent ache, increased on exertion, — a form especially met with in children. We see evidences of the congestion of the nervous system in the disturbed dreams ; in the sudden starting up from sleep ; in the irregular action of certain muscles ; in the spots which float before the eye. It is possible that the strange sense of insecurity, and the irrita- bility, of which patients afflicted with a cardiac malady complain, are produced by the same cause. At any rate, whether produced thus or not, they are remarkable symptoms. There is no disease which unnerves more than a disease of the heart. Indeed, the mere fear of its presence gives rise to restlessness and gloom, and breeds timidity in those who would look any external danger boldly in the face. The disordered flow of blood through the abdominal viscera occasions organic changes aqd a disturbance of the functions of the several organs. Thus, the liver increases in size, or undergoes other alterations which interfere more or less seriously with the elimination of the bile ; or the kidneys no longer secrete as in health, but become much engorged and drain off the albumen of the blood ; or the spleen sustains textural transformations. These states all tend to give rise to more and more dropsy, and hence to more and more suffering. 448 MEDICAL DIAGKOSIS. The symptoms which point most directly to the heart itself are palpitation and irregularity of action, and pain. These symptoms imply that the function of the organ is disturbed, or that its in- nervation is in some manner deranged ; but they imply nothing more. They are, therefore, common to functional derangement which occurs associated with structural changes in the heart, and to purely functional derangement. Cardiac Fain. — Pain in or over the heart is met with both in acute and in chronic diseases ; yet it is not a regular or well-defined symptom of either. When we reflect that the heart may be pinched, may be torn, without exciting any suffering, it will be readily un- derstood why its disorders do not occasion much pain. Indeed, many a case of enormous enlargement of the heart, or of profound textural alteration of its walls or valvular apparatus, is unaccom- panied by pain. Still, we meet with instances in which distress at the heart and various uneasy sensations are among the more marked symptoms of a chronic cardiac lesion ; and we even find persons complaining of a persistent pain in the heart, which extends to the left side of the neck and arm, in whom this symptom has preceded the signs of a disease of the heart or of its great vessels. In the acute cardiac affections pain is a not inconstant symptom. Uneasy sensations, not amounting perhaps to absolute pain, are complained of in endocarditis. Actual pain is among the vital manifestations of inflammation of the substance of the heart, and of the pericardium. In the latter disorder it is usually increased by pressure, and is frequently very severe. But no suffering is so harrowing as that which happens in the obscure malady termed angina pectoris. Angina Pectoris. — Although the nature of thig complaint may be hidden, the symptoms are obvious enough. We do not know what the precise cause of this angina is ; but we do know that the disease occasions paroxysms of intolerable anguish. These paroxysms come on suddenly, and pass off as suddenly. Their main feature is an agonizing pain in the prsecordia, as if the heart were being firmly grasped by an invisible hand, or as if it were being torn to pieces. The pain is, however, not limited to the cardiac region ; it radiates in various directions, shooting to the back, to the neck, and especially down the left arm. But this is not all : worse than the pain are the intense anxiety and the DISEASES OP THE HEAET. 449 feeling of impending death. The heart palpitates during the fit ; yet, if we judge by the character of the pulse, its movements are not always materially disturbed. The beat of the artery at the wrist may be small, may be weak, may be irregular, may be accel- erated ; but it may also be full, strong, regular, yet not increased in frequency ; very generally the arterial tension is high. Again, there may be a decided difference between the pulses, the left being almost or quite imperceptible.* The face is generally pale. Difficulty in breathing, contrary to what might be expected, is not a prominent symptom, and is, in fact, often wanting, while sometimes the breathing is irregular and of the Cheyne-Stokes variety. Giddiness, spasmodic seizures, temporary coma, per- verted sensibility, occasionally attend or follow the cardiac attack, and so does pericarditis.f The duration of the fits is as uncertain as are the causes which excite them. They may cease in a few minutes ; they may last upward of an hour. They come on rapidly, without any assign- able reason ; they are reproduced by bodily ailment, by exer- tion, by fatigue, by exposure to cold, or by mental irritation. However provoked, they are always dangerous. The heart may stop beating during the paroxysm. " My life is in the hands of any rascal who chooses to annoy and tease me," was a saying of John Hunter. And in truth, after he had suffered for years from these seizures, his ungovernable temper brought on one in which he expired. It happens sometimes that the second attack follows at a short interval the one by which the disease first declares itself, and proves fatal. Latham J narrates the history of two cases of this kind. In one, life ceased in a fortnight after the first seizure; in the other, in ten days. Nay, it may be cut short even in the midst of the first manifestation of the malady. Such was the death of Arnold of Rugby.§ On the other hand, I have had a patient under my care who for weeks at a time has five or six attacks daily, kept in check, but not wholly averted, by nitrite of amyl ; and in another patient as many as forty occurred in one day. * Hamilton Osgood, Amer. Journ. Med. Sci., Oct. 1875. t Clin. Soc. Transact., vol xvii p. 82. J Lectures on Diseases of the Heart, vol. ii. g Stanley, Life and Correspondence of Thomas Arnold. 450 MEDICAL DIACf-NOSIS. The immediate conditions on which the symptoms of the attack depend are veiled in obscurity. Whether they be or be not pro- duced by temporary increase of weakness in an already-enfeebled organ ; whether a cardiac spasm occur or do not occur ; whether the pain and the sensation of approaching death be or be not caused by an acute distention of the heart with blood, — we do not know. All we do know positively is, that the excessive pain abruptly appearing and disappearing points to deranged innerva- tion. Yet Me can go a step further ; we can say with certainty that angina pectoris is not often an uncomplicated neuralgia. Modern research has taught us that these outbreaks of a cardiac neurosis are frequently linked to some structural change. This structural change, so far as we can now see, is, however, not at all times the same. The list of disorders of the heart and arte- ries which angina pectoris may accompany is, indeed, very long. There is hardly an affection of the walls or cavities of the heart, scarcely a morbid condition of the arteries that nourish it or spring from it, with which the distressing malady has not been observed to be associated. It has been found as an attendant on ossification of the coronary artery ; on every form of valvular disease ; on thinning of the parietes of the heart ; on their fatty softening ; on fungoid growths springing from the apex of the organ.* It has been thought that combined with all of these states is fatty degeneration, which thus would be at the root of the angina.f Whether this view be- correct or not, it is certain that fatty degeneration is more frequently conjoined with angina than is any other organic disease. Yet fatty degeneration occurs often without angina, as does disease of the coronary arteries, and we are thus forced to admit that, however frequent the asso- ciation, in either instance some unknown element is still the determining cause. During the attack, as Brunton h&s shown, there is a vaso-motor spasm of the smaller vessels, with a rise in blood-pressure and increased tension in the arteries. Angina pectoris is now very generally ranked among the vaso-motor neuroses. But evidence is not wanting, as Peter's cases prove,J * B. Travers, Medieo-Chirurgical Transactions, vol. xvii. t Qualn, Medico-Chirurgical Transactions, vol. xxxiii. I La Semaine Med,, March, 1892. DISEASES OP THE HEART. 451 that neuritis of the cardiac plexus, the neuritis itself being con- secutive to aortitis, is the cause of a certain number of cases. Angina pectoris is easy of recognition. The points to ascertain in diagnosis are, whether it is linked to an organic cause, and to what organic cause, or whether it is a pure neurosis, either primary or reflected. It may be a question whether those severe pains in the region of the heart, which occur in feeble ansemic persons after unaccustomed exertion, or which are brought on by the excessive use of tobacco,* or which happen in rheumatic or gouty subjects, especially while suffering from indigestion, are real angina, or whether they may be separated from this affection. They differ from it, irrespective of being far less violent and less radiating, by the circumstances leading to an attack, and by their constant association with palpitation. Intercostal neuralgia with palpita- tion might be mistaken for angina ; but the painful spots in the course of the affected nerve, and the comparatively slight suffer- ing, distinguish it. In truth, it is a complaint seated only in the thoracic walls, and referred by the patient to the heart. Great irritability of the heart, attended with faintness, with sensations of sinking, with flushing alternating with pallor, and with pain, due most likely to a neurosis of the cardiac plexus, is discriminated from true angina by the palpitations, and by their connection with pain which never rises to the anguish of angina pectoris. Often, too, this apparent or false angina is found in persons who are hysterical, or are subject to neuralgia, or are laboring under a disorder of one of the abdominal viscera, and is then clearly reflex. It must, however, be admitted that the distinction between true and false angina is one of degree rather than of kind ; for the cardiac plexus is precisely the point particularly involved in angina, and it is now generally thought that the disturbance of the heart in this painful malady occurs mainly through the influence of the sympathetic fibres which meet in the plexus. Another complaint that may be confounded with angina is what may be called cardiac epilepsy. In this rare affection in- tense pain in the region of the heart happens in paroxysms. But unconsciousness, however temporary, occurs also,, and the pain * Beau, Journal de Medecine et Chirurgie, July, 1862 ; Eulenberg, " An- gina," in Ziemssen's Cyclopsedia. 452 MEDICAL DIAGNOSIS. is apt to follow rather than to precede the unconsciousness.. Yet it may outlast it, and become associated with twitching of the muscles of the face and with other spasmodic movements. These, the unconsciousness, and the time at which the pain happens, distinguish the malady from those instances of angina in which, owing to the severity of the pain, the patient passes into a protracted faint. Palpitation. — This arises in various diseases of the heart. It happens at the beginning of acute aifections ; it is an unfailing accompaniment of some chronic lesions. It is especially dis-, tressing when the cavities are dilated and the walls of the organ thinned. But it bears no positive relation to any special cardiac malady, and is therefore not diagnostic of any. So, too, with irregular rhythm of the heart's action, with which palpitation is in truth often combined. It tells us nothing more than that the regular movements of the heart are disarranged. Frequently this disarrangement is due to a serious change in the valves or in the muscular structure. But palpitation, with or without irregular rhythm, may take place in a perfectly sound heart, — sound, at least, so far as our means of investigation enable us to determine. Often the pulsations of the heart become stronger, more exten- sive, and more perceptible, from mere nervous excitement. But it is not necessary to detail the symptoms of a purely nervous pal- pitation. Every one has experienced them. Every one knows that there is a feeling of slight constriction about the chest, with a hurried breathing, and a strange sensation as if the heart were leaping from its place. Every one is also aware that the organ is felt thumping against the walls of the chest, and with a foi'ce which shakes them. The popular notion, that the heart is the seat of the emotions, is based on these striking evidences of its disturbed action, and poets have seized upon and delineated with accuracy some of the even more strictly physical phenomena of the extended impulse under strong nervous excitement.* * Thus, Shakespeare, in the " Kape of Lucrece :" " His hand, that yet remains upon her breast (Eude ram to batter such an ivory wall I), May feel her heart, poor citizen, distressed. Wounding itself to death, rise up and fall, Beating her bulk, that his hand shakes withal." DISEASES or THE HEART. 453 But, apart from the increase of the beat by mere temporary agitation, a heart may act overfrequently and overstrongly and its action become sensible to the person, in other words, it may palpitate, from some more unremitting excitement dependent upon perverted innervation. This is the main cause of the altered impulse of the heart in the so-called functional disorders. Persistent rapidity of cardiac action, or tachycardia, may happen without obvious cause in persons apparently healthy. It is very common in irritable hearts and in exophthalmic goitre. Spender * has called attention to its occurrence among the earlier signs of rheumatoid arthritis. The extreme frequency of the action of the heart is in some instances remarkable. I have known it to beat over two hundred times in the minute. The disorder may occur in paroxysms, described as " cardiac nerve storms" by H. C. Wood.f Great rapidity may be joined to a condition in which the two sounds are precisely alike, and the pauses of equal length. This foetal rhythm, or embryo-cardia, is a sign of heart weakness. On the other hand, the deranged innervation may lead to very retarded movement, and the heart beat less than thirty times in the minute. We may find this slow action, brachycardia, both in functional and in organic maladies, though it is most likely that the nerve-centres are in both affected in the same way.| Brachycardia is often associated with atheroma of the aorta or of the coronary arteries. It is also met with in a number of instances of fatty heart and in old-standing valvular disease. Its associa- tion with jaundice, with feeble heart action during convalescence from fevers, with epilepsy, and with melancholia, is well known. FUNCTIONAL DISORDERS OF THE HEART. It has just been stated that the direct symptoms of a cardiac disorder — pain, palpitation, irregular action — are met with when no recognizable structural change has taken place. Under such circumstances the affection of the heart is termed functional, and its symptoms are those already mentioned, variously combined, sometimes the one predominating, sometimes the other. These * On Osteo-Arthritip, London, 1889. t University Medical Magazine, Marcli, 1891. X See a very interesting analysis of ninety-one cases, by Prentiss, Transact. Assoc. Amer. Pliys., vol. iv., 1889. 454 MEDICAL DIAGNOSIS. functional disorders are very much more frequent than the organic. They are, for the most part, produced by direct excitement of the heart, or by its being sympathetically disturbed by ^ome source of irritation existing remote from it, or in the system at large. The symptoms may be said to constitute the disease. Functional Disorders cliaraoterized by Palpitation, associated or not witli Change of Ehytlim, We have already briefly mentioned the causes of augmented action which are associated with organic changes, and those which occasion temporary disturbance of the heart. A more lasting form of palpitation is engendered when the organ is kept constantly excited by a deranged condition of some viscus re- mote from it ; by the use of stimulating substances ; or by some general morbid states. Thus, a disordered stomach or liver leads to a reflex disturbance of the heart, which ceases if the disorder of the stomach or liver be remedied. In gouty, lithsemic, and rheumatic persons the heart frequently pulsates with increased quickness, and sometimes with marked irregularity. Special articles of diet, especially tea or coffee, produce palpitation; so does the inordinate use of tobacco. Immoderate dancing, mas- turbation, and excessive sexual indulgence, but particularly mas- turbation, are prolific sources of continued palpitation. We see also those affected with it who, addicted to laborious studies, grudge themselves time for food, sleep, and exercise. Women who are hysterical, or whose uterine functions are disordered, suffer, or fancy that they suffer, from palpitation. So do so-called ner- vous people invariably complain of the beating at the heart. In those whose blood is much impoverished, the palpitations are often severe and constant, and they imagine themselves to be laboring under an incurable disease. There is, indeed, from the strong resemblance to an organic affection, apparent cause for alarm. The heart strikes sharply and abruptly against the walls of the chest ; its action is frequent ; the breathing becomes hurried on the slightest exertion. Nay, even the physical signs may be those of a structural lesion. The altered blood gives rise to a blowing sound in the heart, which is transmitted into the carotid and subclavian arteries. The difficulty of diagnosis is at DISEASES OF THE HEART. 455 times considerable. The age; the sex; the ansemic look; the presence of a continuous humming sound In the veins of the neck ; the strict synchronism of the murmur with the Impulse ; Its want of harshness ; Its seat commonly at the base of the heart, — furnish a clue to the nature of the case. Still, we have often to judge as much or more by the absence of the signs of cardiac enlargement, and of Impediment to the flow of the blood, whether the heart be affected In its valvular apparatus, or whether It be simply functionally disturbed and circulating watery blood. A troublesome kind of palpitation Is that attended with marked irregularity of the action of the heart, displaying Itself by the beat being now slow, now fast, or occasionally intermitting. Suf- ferers from lithsemla or gout, or old persons with feeble digestion, are particularly liable to It. This form of palpitation Is not without danger. It Is very prone to be associated with an altera- tion In the structure of the heart, such as flabbiness of the walls, which may not be sufficient to yield any distinctive physical signs, but which Is nevertheless suificlent to be a source of apprehension. Some who experience fits of palpitation faint away during them. But the almost complete suspension of the movements of the heart which characterizes an attack of syncope has no definite connection with any form of palpitation, nor, indeed, with any form of cardiac disorder, organic or functional. In those who are subject to attacks of palpitation or to irregular action of the heart, the organ may finally become enlarged. A peculiar Irregular action of the heart has been much discussed under the name of hemisystole. Leyden pointed out that there were cases In which with every two beats of the heart only one beat of the pulse was felt, and attributed this to the right ventri- cle contracting alternately with the left. Different explanations have been given of the fact, but the observations of Riegel and Lachmann, while they do not strictly confirm the alternate action of the ventricles as the cause of the phenomenon, point to Irreg- ular contraction of the muscles of the heart as the cause.* We sometimes meet with a singular form' of functional disturb- ance of the heart which leads to textural changes, and to which * Virchow's Arohiv, Bd. xliv. ; Deutsches Arch. f. Klin. Med., Bd. xxvii. p. 393. :456 MEDICAL rilAGNOSIS. Graves called particular attention. It consists in a long-continued excitement of the organ, as evidenced by its increased force and rapid and irregular action, which is followed by a swelling of the thyroid gland, pulsation of the arteries of the neck, and promi- nence of the eyeballs. This disease, exophthalmic goitre, is most commonly observed in women, and connected with hysteria, neu- ralgia, or uterine disturbance ; it has in some instances an evident origin in shock. It is generally considered to be owing to an affection of the cervical sympathetic nerve. But its cause is far from certain. There are those who hold it to be a neurosis of the nerve-centres, especially of the vagus centre ; and the detec- tion of ptomaines in the urine is thought to be a proof that this apparent neuro-cardial malady is really consequent upon second- ary disturbance of the nervous system due to poisonous products from the thyroid. The most characteristic sign, the greatly accelerated heart's action, varies much in extent. All the signs may remit or may become aggravated from time to time, and especially during a severe attack of palpitation. The turgescence of the thyroid gland arises quite independently of the usual exciting causes of bronchocele. It is accompanied by a pulsating thrill similar to that of an aneurismal varix, and by a distinct throb. At an ad- vanced period of the complaint, these signs subside, and the gland becomes more solid. Indeed, the whole affection may disappear, and the gland, the eyes, the beat of the carotids, the action of the heart, may be all brought back to a normal condition. On the other hand, hypertrophy and dilatation may result from the car- diac palpitations. And the malady may be noticed in association witli valvular disease, under circumstances M'^hich make it a ques- tion whether this has followed it or is a mere concomitant. The protrusion of the eyeball is often combined with a symp- tom that Graefe particularly observed, — a want of agreement be- tween the movement of the lid and the raising or depressing of the glance. The spasm of the elevator of the upper eyelid is held by Abadie * to be pathognomonic. Another symptom of im- portance is trembling of the hands. This tremor, Charcot points out, affects the whole hand, but not the individual fingers. There * La Prance Meclicale, vol. ii., 1881. DISEASES OF THE HEAET. 457 is also, as Charcot shows, greatly-lessened bodily resistance to the galvanic current; but this sign is not of much value, as Cardew * has found the electric resistance to diminish greatly when the skin is moist. Other symptoms are cramps, usually at night, epistaxis, oedema of the legs and eyelids, lessened respiratory • expansion, moderate elevation of temperature, sen- sation of heat, increased sweating, paroxysmal attacks of diar^ rhoea, atony of the large intestine, intermittent swelling and pain in the joints, pigmentation, bulimia without gain in flesh, gly- cosuria, migraine, rheumatic symptoms, and mental derangement. All the physical manifestations of the disease are double-sided ; and this, with the unchanged state of the pupils, serves to dis- tinguish it from those rare c.ises described by Eulenberg,t where a thyroid growth pressing on the sympathetic on one side pro- duces symptoms of exophthalmic goitre, including the palpita- tions. In the distinction from ordinary goitre, the absence of eye and heart symptoms is of most value. There is also no murmur heard over the enlarged thyroid gland ; whereas in Graves' dis- ease a continuous murmur there is most common, and is, indeed, looked upon by Guttmann as of the greatest diagnostic importance, especially aiding us in those doubtful cases in which the exoph- thalmos is wanting. My own experience confirms this statement. There is another form of functional disorder of the heart, so peculiar as to demand a special notice. It is the curious cardiac malady of which we saw so many examples in soldiers during our civil war, to which I gave the name of " irritable heart," and which we also find occurring in private life. Its main symptoms are habitual frequency of the action of the heart, constantly-recur- ring attacks of palpitation, and pain referred to the lower por- tion of the precordial region. The palpitations come on chiefly during exercise, but may also take place when the patient is quiet, and in many cases happen most often, or indeed entirely, at night, thus interfering with sleep. Those who are subject to the disorder complain much of headache and of dizziness, and especially of being thus affected when suffering from palpitation. The pain * Lancet, Peb. 1891. ■)• Ziemsien's Cyclopaedia. 29 458 MEDICAL DIAGNOSIS. is genei-ally dull and constant, but is often also described as shoot- ing, and as taking place only in paroxysms. Its chief seat is near the apex, and it is combined commonly with excessive cutaneous sensibility. Often there is pain nowhere else in the body ; but in some instances the cardiac distress is associated with pain in the back, which itself is not unusually connected with the excretion of oxalate of lime by the kidneys. The action of the heart is very rapid, and in many instances its rhythm is irregular. The impulse is slightly extended, but not forcible, like that of hypertrophy : it is rather abrupt and jerky. As a rule, to which I have met with but few exceptions, the sounds of the heart are modified as follows : the first sound is short, sometimes sharp, resembling the second sound ; at other times it is extremely deficient and hardly recognizable ; the dis- tinctness of the second sound is much heightened. We either hear no murmurs in the heart or in the neck, or they are incon- stant. The area of percussion dulness does not appear to be augmented. The pulse is almost always easily compressible ; it may or may not share the character of the impulse. It is usually very much influenced by position, falling rapidly twenty beats or more when the erect posture is exchanged for the recumbent. The increased frequency of beat is not connected with increased fre- quency of respiration, for often with a pulse of one hundred the respirations scarcely exceed twenty in the minute. The disorder is very obstinate, and improvement comes but slowly. The cause of the morbid cardiac impressibility is difficult to ascertain. It seems in many instances to have followed fatiguing marches ; in some it occurred after fevers or diarrhoea ; it was not connected with scurvy, or with the abuse of tobacco. That it was not due to anaemia, was proved by the general aspect of the men, which was often that of ruddy health. Similar conditions of the heart occur from excessive dancing, excessive smoking, and certain occupations, such as glass-blowing. For a fuller con- sideration of the subject I refer to observations elsewhere de- tailed.* * Medical Memoirs of the U. S. Sanitary Commission, 1867 ; American Journal of the Medical Sciences, January, 1871 ; and the Third Toner Lecture, Smithsonian Institution, 1874, " On Strain and Overaction of the Heart," where also the forms of irritable heart occurring in civil life are described. ' DISEASES OP THE HEART. 459 Yet another form of functional cardiac disorder is the one which I have described under the name of cardiac asthenia, or heart exhaustion. It shows essentially the signs of a weak heart, and follows long-continued worry and overwork. There is rapidity of cardiac movement with very feeble action, and a great tendency to faintness. The breathing is singularly undisturbed. The impulse of the heart is weak, the first sound short, valvular, the capillary circulation defective. The duration of the cases is a long one, and recovery comes but gradually. In the cases that are not purely nervous, but in which the heart-muscle is enfeebled, shortness of breath and functional dynamic apex murmurs are often noticed.* These, then, are the principal varieties of functional disorder of the heart. It is hardly necessary again to state that the phys- ical signs present the most certain, if not the only, means of dis- tinguishing the functional from the structural aflPection. They show us that neither the size of the organ, nor its sounds, M'ith the exceptions above mentioned, are materially diiferent from what they are in health. The irritable heart just described, as indeed other forms of functional heart disorder, may pass into organic cardiac disease by the constant overaction of the heart. And averaction or strain may also, as I have proved in the publications just referred to, lead to valvular affection, sometimes by preceding hypertrophy, at other times by a slow process of inflammation or disorganization en- gendered at or near the seat of the valve. Of this I published several instances in the " Memoirs of the Sanitary Commission." Others have been brought forward by Allbutt f which happened among persons engaged in vocations requiring sustained and oft- repeated muscular effort, — such as lifters, smiths, sawyers. And in his elaborate monograph Seitz J has detailed several fatal cases in which the symptoms of a fatigued heart, due to strain, were followed by extensive dilatation without valvular disease. Ley- den, too, has added to our accurate knowledge of the subject.§ * Amer. Journ. Med. Sci., April, 1894. t St. George's Hospital Keports, 1872. % Die Ueberanstrengung des Herzens, 1875. j Die Herzkrankheiten in Folge von Ueteranstrengung, Berlin, 1886. 460 MEDICAL DIAGiiTOSId. ORGANIC DISEASES OP THE HEAET. Organic diseases of the heart may be classified as follows ; Organic Diseases op the Heakt. Diseases affecting the walls of the heart and mostly changing the size of the cavities. Diseases affecting chiefly the walls alone. . of membranes. Inflammations I of muscular I structure. Diseases of the valvular apparatus Diseases affecting the pericardium. , Congenital diseases.., Hypertrophy. Dilatation. Atrophy, f Fatty degeneration. Parenchymatous degeneration. Fibroid heart, cardio-sclerosis, eic. Malformations. Eupture of the heart. Injuries and wounds. Aneurism of the heart. New growths and parasites. / Endocarditis. I Pericarditis. <. Myocarditis (Carditis). J Valvular diseases. r Chronic pericarditis. Hydropericardium. H semopericardium . ' Pneumo-hydropericardium. I New formations on pericardium : l^ cancer, tubercle, etc. Abnormal positions. Closure of openings of right heart. Opening between the ventricles. Narrowing and closure of pul- monary artery, etc. These are the organic diseases of the heart, save the rarest. But let us study the cardiac maladies according to their symptoms and signs rather than according to their anatomical classification. Acute Diseases presenting Pain in the Cardiac Eegion; the Symptoms of a Disturbed Circulation ; and a Change in the Sounds of the Heart, or their Replacement hy Murmurs. All the acute affections of the heart come under this head. In all, the sounds are either changed in their character or are replaced by murmurs. This is certainly true of the only acute diseases of which we have an accurate knowledge, — endocarditis and peri- DISEASES OF THE HEART. 461 carditis. All the acute disorders give rise, further, to more or less pain, and to anxiety of expression ; in all there is fever ; all are prone to occur in connection with other morbid conditions, and especially with a contaminated state of the blood. In all, more- over, the symptoms of a disturbed circulation are met with : pal- pitation, irregular action of the heart, deranged flow of blood through the capillaries of different organs, and a tendency to dropsical accumulations. That these symptoms are not so clearly defined as in some of the chronic cardiac maladies, is owing to the shorter time the complaint lasts. Acute Endocarditis. — Acute inflammation of the lining membrane of the heart arises from exposure to cold, or without any cause being discoverable. It sometimes results from violent efforts, or from blows or other injuries to the chest. It is often connected with an acute infective process or a vitiated condition of the blood, as in puerperal fever, in pneumonia, in chorea, in can- cer, in scarlet fever, in pyaemia, in Bright's disease, or in diabetes. But its most frequent association is with acute articular rheumatism. The chief source of danger in endocarditis is the tendency the inflammation has to limit itself. It is confined to, or is most strikingly developed at, a part which bears least of all any im- pairment, — at the valves, — and often leaves behind it some perma- • nent disorganization of their delicate structure. But it does not generally affect the entire valvular apparatus : that of the left side is usually alone the seat of disease. What morbid anatomy thus teaches, explains the occurrence and situation of the principal sign by which endocarditis is recognized. The roughness of the surface over which the blood flows, or the lymph deposited on or in the neighborhood of the valves, interfering with their function, occasions a distinct murmur, which is mostly confined to the mitral and aortic openings, and may be preceded by an altered character of the first sound. Besides this blowing sound, there are other signs worthy of note. It is true, they do not form so leading a feature of the disease ; still, they aid in its correct appreciation. The excited heart beats with augmented force, and sometimes with great ir- regularity, as the not unusual doubling of the second sound at the base proves. The size of the organ is not notably increased, except iu those cases in which its cavities are choked with blood 462 MEDICAL DIAGNOSIS. or fibrin-clots. The pulse corresponds to the action of the heart ; yet not so closely as might be expected. It is, for the most part, frequent and strong, and rather forcible at first ; sometimes it is small and frequent. It becomes irregular, one beat being strong, the next weak, if the circulation through the heart be seriously obstructed. But it may be feeble while the heart is thumping with violence against the walls of the chest. Occasionally at the onset of the attack it has been observed to be slower than natural. The general symptoms are not uniform. There is usually a sense of uneasiness around the heart, with a fever showing a tem- perature ranging from 101° to 103°, a short cough, palpitation and some irregularity of cardiac action, diificulty of breathing, and anxiety depicted on the countenance. To these are not un- commonly added turgescence of the face, headache, slight delirium, gastric irritability, diarrhcea, and rigors, followed by sensations of heat. Pain in the heart is rare, and is not likely to happen unless the pericardium or the muscular walls be implicated. In some cases an eruption of subcutaneous fibrous nodules occurs, especially in the rheumatic endocarditis of children. Now, where these symptoms are present; where they manifest themselves in one whose system is in a state in which endocarditis •is apt to take place; and where they are accompanied by a blow- ing sound recently and rather suddenly developed, — we are cer- tain that inflammation is working its changes in the lining mem- brane of the heart. Yet some circumspection is requisite before arriving at this conclusion, and before the patient is subjected to enei'getic treatment with the view of saving him from the sup- posed damage which his heart is about to undergo. A murmur may be attended with febrile signs and not be dependent upon acute endocarditis. The sound may be of organic origin; or it may be engendered in the course of an idiopathic fever, and the lining membrane of the heart be unaltered. In the first instance the murmur is old, and results from some chronic injury to the valve, the attending fever being an accidental complication. Here is undoubtedly a difficult case for diagnosis. We see the patient for the first time; he has fever; his heart is acting strongly; a distinct blowing sound is perceived over it. How are we to tell that his complaint is not acute endocarditis ? We have no absolute means of deciding that it is not. Yet by DISEASES OF THE HEART. 463 careful inquiry we can usually come to a knowledge of the truth. If the patient do not recollect to have suffered previously from dyspnoea, palpitation, or other signs of an affection of the heart ; if the cardiac excitement and irritation be well defined ; if the face denote distress ; if the accompanying symptoms indicate a state that is prone to be complicated with endocardial inflam- mation, — it is this disease under which he is laboring. I may add another and very important element of distinction deduced from the study of the blowing sound, to wit, that the murmur of endocarditis is not so rough, is not often heard during the dis- tention of the heart, and may be changeable in its seat, which an old-standing murmur never is. Besides, it is not associated with those signs of enlargement which are invariably found when the valves have been for any length of time affected, unless the acute inflammation occur in a heart the valves of which have been previously spoiled. Under such circumstances, we can only con- jecture what is going on within the organ from its increased ex- citement, and, if I may take my own experience as the general rule, from the character of the blowing sound being altered. It is rendered often less distinct, nay, it is even entirely muffled, by the products of the recent inflammation. But how are we to distinguish between the soft murmur arising in the course of fevers, and that resulting from effused lymph? It, too, is not rough. It, too, happens with the impulse. It, too, is preceded, as some cases of endocarditis are, by a lengthening of the first sound. Here is assuredly a strong resemblance ; yet by no means an identity. The blowing sound in fevers does not exist until the blood is profoundly altered. In endocarditis it takes place almost as soon as the disease begins, — certainly as soon as we are able to recognize positively its beginning. The heart in fevers may be softened, but it is not so directly disturbed in its action. "We do not find those symptoms, local as well as general, which show that the circulation is obstructed. The blowing sound is rarely at the apex, but more over the body of the heart. To this some weight may be attached, since the murmur of endocar- ditis is very apt to be heard at the apex. But to no fact ought as much weight to be attached as to the one first mentioned, that the murmur takes place early and not late in the disease. Throughout this description of endocarditis, only simple, un- 464 MEDICAL DIAGNOSIS. complicated cases have been kept in view ; yet it is not often that the malady is seen in so pure a type. It is more generally accom- panied by the friction sounds and other signs of acute pericarditis, and by the swollen joints, the painful movements, the acid per- spirations, of acute rheumatism ; or by the characteristic appear- ances on the skin of erythema marginatum ; or by tonsillitis ; or by the kidney symptoms of Bright's disease ; or by the evidences of chorea, or of gonorrhoea, pysemia, or septicsemia. Nor is a murmur in endocarditis invariable. If the question be asked, " Can endocarditis occur without a blowing sound ?" it must be answered in the affirmative. When the seat of the inflammation is not near the valves, no murmur is generated. There may be also none if no vegetations exist on the valves, and perhaps in states of the exudation with which we are at present unacquainted. We cannot, under such circumstances, detect an attack of endocarditis. Yet it may be even then strongly suspected to be present if great excitement or irregularity of the heart manifest itself in a person who is laboring under a disease which predisposes to endocardial inflammation, such as rheumatism. Cases of this nature are, however, exceptional. They do not happen sufficiently often to invalidate the statement that the development of a murmur is the sign indicative of endo- carditis. Still, they happen sufficiently often to impress upon us that our knowledge of endocarditis is not complete. The clinical study of endocarditis is, in truth, a comparatively recent study. There are some points about it which are as yet unknown, and others which have not been long cleared up. To this class belong the interesting researches on the formation of clots of fibrin in the heart, and on the effects produced when they or the vegetations which stud the valves are washed into the cir- culation. The fo7-niation of clots in the cardiac cavities, if at all extensive, announces itself by a sudden appearance or a sudden augmentation of the symptoms of obstructed circulation : the skin is cold, and the surface may be bluish ; there is a struggle for breath, the pulse is frequent and feeble, the action of the heart becomes exceedingly irregular, its sounds are indistinct, or a more or less distinct murmur is heard, and the extent of the prsecordial percussion dulness is somewhat increased. Great anxiety of coun- tenance, nausea, vomiting, excitement of the nervous system and DISEASES OF THE HEART. 465 delirium, turgid veins in the neck, and fits of fainting, are also among the manifestations of the clogged flow of blood through the heart. Yet these phenomena are not absolutely distinctive ; for Walshe records that the effects of a rupture of a sigmoid valve or of a tendinous cord, during the acute endocardial disease, will give rise to symptoms exactly similar to the obstruction of the circulation resulting from polypoid concretions in the heart. Portions of the clots, or of the vegetations on the valves, are sometimes washed into the current, and the embolism occasions symptoms which, before we were aware of the damages to which the detached masses may give rise, appeared inexplicable. But now — when we see the circulation speedily diminished or arrested in a limb, and the limb becoming painful, swelling, or beginning to mortify ; when we find that the flow of the blood through the brain has become suddenly disturbed, and the muscles of one side drop paralyzed ; when the difficult breathing becomes rapidly still more difiicult, while there are no signs of a supei-added affection of the lung, nay, while the power fully to expand the lungs re- mains unimpaired, or while an effusion of fluid into the air-vesi- cles follows the dyspnoea — we know what has happened : we know that a broken-off piece of fibrin has been driven into the arteiy of the limb, or into the brain, or into the branches of the pulmo- nary artery, and, being too large to go any farther, has stuck fast, and has given rise to all these sudden and sad consequences. Sad indeed they are; for, even if the plugs do not lead to an immediately fatal result, they lay the groundwork for structural alterations in any tissue in which they become impacted. But let it not be understood that the detachment of vegetations from the valves, or of fragments of clot formed in the cavities of the heart, happens in endocarditis only. Pieces may be separated from valves that are in a state of so-called ossification. And the blood in the heart may clot from any interference with the current, from heart palsy, or from changes in the vital fluid wholly uncon- nected with inflammation. But when it coagulates, from what- ever cause, the symptoms are the same as those just described. A murmur, too, is not uncommonly produced, which is not distin- guishable from that due to endocardial inflammation, but which is not of long duration, since death generally follows the impediment in the heart in a few days at farthest. 466 MEDICAL DIAGNOSIS. Inflammation of the aoii,a may occasion many of the symptoms of acute endocarditis ; at all events, it may do so when the upper part of the aorta is implicated. But it cannot be said that it is a condition which may be discriminated with certainty. The most significant signs are hurried respiration, a sharp, rapid pulse, tu- multuous action of the heart, pain in the prsecordial region, often greatly increased by movements, and also felt along the course of the spine, burning pain referred to the sternum, great anxiety. The history of the case points to gout, alcoholism, syphilis, or malaria. There may be paroxysms of pain such as occur in angina, and a loud systolic blowing sound. When the abdominal aorta is affected, we notice strong local pulsation, and a marked murmur will be heard with greatest distinctness at or near the seat of the inflammation. In some cases of aortitis. Bright * observed an extremely high degree of morbid sensibility over all parts of the body, which caused the patient to scream Avith pain when his wrists were merely touched. The disorder is most apt to happen in cachectic persons ; and it has been repeatedly observed in those attacked with erysipelas, or after operations and injuries. f Dissimilar causes may lead to different sites of endocardial inflammation. Thus, puerperal endocarditis is apt to localize it- self in the right heart. It has pulmonary complications, and the progress of the disease is often slow ; it may last several months.J There is a form of endocarditis which may be here briefly mentioned, — ulcerative endocarditis. It is not common in this country, although I have seen a number of instances. It occurs mostly in connection with low forms of rheumatism or with blood-poisoning, and the symptoms of this, or of pyaemia or a low septic fever, are apparently the prominent features of the case, or it may happen subsequently to pneumonia.§ The ulceration perforates the valves, and may extend into the muscular structure of the heart ; pneumonia or pleurisy, embolic formations, and in- farcts and metastatic abscesses in various parts of the body are among the common attendants. The perilous affection shows an endocarditis with the ordinary physical signs developing amidst * Guy's Hospital Reports, vol. i. f Chevers, ib., vol. vi., and 2d Series, vol. i. ; Osier, Gulstoiiian Lectures. J Luzet et Ettlinger, Arch. Gen. de Med., Jan. 1891. § Arch, de Physiol., August, 1886. DISEASES OF THE HEART. 467 the symptoms of profound blood-poisoning and prostration, al- though these physical signs may be masked by a pericardial com- plication. Marked and recurring chills, like those of malarial fever, but coming on irregularly; a temperature of 105° to 107°. ; an extremely rapid pulse, becoming suddenly much slower, though very irregular ; profuse sweats ; vertigo ; delirium followed by stupor; dry tongue; vomiting and diarrhoea; jaundice; tender- ness over liver and spleen ; and scanty, albuminous urine, — are among the prominent features of the malady. As regards the thoracic symptoms, there may be oppression, dyspnoea, and pain, as ordinarily in endocarditis, yet these symptoms may be wholly wanting. In some instances a peculiar diffused rose rash, here and there mixed with papules and spots of ecchymosis, is noticed. By some, ulcerative endocarditis is looked upon as diphtheritic ; indeed, when it has happened during puerperal fever diphtheritic exudations have been found on the mucous membrane of the vagina and uterus. It is certain that micro-organisms are con- stantly present, generally streptococci and staphylococci, and are found not only in the heart, but also in the infarcts in the spleen and liver which are common in the aifection. Death is the com- mon ending, — either from gradual exhaustion, or suddenly by the tearing away of the injured valves. The disease is extremely rare in children. It is more often mistaken for typhoid fever than for any other disease. But it is also mistaken for typhoid pneumonia, for cerebro-spinal fever, and for hemorrhagic smallpox. When ulcerative endocarditis happens in connection with malarial poisoning, a not infrequent association in Africa, its seat of predilection is in the aortic valves.* The most common type of the disease is the typhoid type. The malignant endocarditis may become engrafted on a chronic valve lesion. Its clinical association with a suppurative wound or puer- peral disease is common. The cardiac symptoms may be very obscure, and the occurrence of embolism during a febrile process be the first sign to explain their meaning. Rigors are common, and are the cause of malignant endocarditis being frequently mistaken for malarial fevers. High fever is the rule, and is an important element in the diagnosis. But I have met with in- * Lancereaux, Arch. Gen. de Med. , April, 1881. 468 MEDICAL DIAGNOSIS. stances, proved such by the autopsy, in which fever was almost absent. Acute Pericarditis. — Acute inflammation of the serous mem- brane of the exterior of the heart is very similar to that of its interior. It is developed under the same circumstances. It is found in rheumatism, in gout, in Bright's disease, in scurvy, in alcoholism, in scarlet fever, in septic processes, or as an extension of inflammation from pleuro-pneumonia. The pericardial malady exhibits the same frequent association with rheumatism as the endocardial malady ; it presents the same symptoms. Nature has not, indeed, drawn a very strict line of demarcation between tlie two diseases. When one exists, the other is very apt to attend it. Yet we do meet with endocarditis without pericarditis, and more often still with pericarditis without endocarditis. The anatomical eifects of inflammation of the pericardium are like those of acute endocarditis, and resemble still more closely those which inflammation of the adjoining serous membi'ane — the pleura — occasions. The pericardium becomes injected and dry ; plastic lymph accumulates on its surfaces, and especially on the surface which fits tightly around the heart. This stage of the disease corresponds to the dry stage of acute pleurisy. It may have the same termination by the two roughened surfaces adhering. But it is often followed by a stage similar to that of pleural effusion. The bag in which the heart lies is filled with fluid ; the effusion may remain stationary or be absorbed, and the rugged portions of the membrane be placed again in apposition. From a knowledge of the anatomical changes, the physical signs may be foretold. It is obvious that there must be at first a friction sound ; that then the fluid which distends the pericardium will increase the area of percussion dulness over the heart, and prevent the sounds and the impulse from being distinctly per- ceived. Yet the friction sound is not always the same in extent or in character, because the deposited lymph is not always the same in extent or in character. The sound is like the crumpling of parchment, or the creaking of new leather, or it is grazing, or like a series of irregular clicks. It is a single or it is a double sound, and is prone to mask the natural sounds of the heart. But these are all points which have been already described : we shall merely add that when the friction develops itself under our DISEASES OF THE HEART. 469 observation, and with signs of excitement of the heart, it is as distinctive of inflammation of the pericardium as a recent blowing sound is, under the same circumstances, distinctive of inflammation of the endocardium. When the pericardial effusion takes place, it ceases ; but only gradually, and not always completely ; and in any Pig. 45. niuatration of the positinn of the heart in pericarditis, and of the disteritiun of tlie pericardium with fluid. The heart-sounds are in- distinct, except above tlie effusion ; the impulse is feeble. The extent and sliape of tlie percussion dulness may be judged of by the appeal ance of the distended sac. case it is not uncommon for the ear still to recognize the murmur at the base of the heart and around the origin of the great vessels. The percussion dulness due to the effusion is generally consider- able ; and its contour is characteristic. As the fluid gravitates to the lower portion of the sac, this distends, of necessity, more than the part where the pericardium adheres to the vessels. The conse- quence is that the dulness, when the patient is in the erect posture, is pyramidal ; when he lies on his back, or changes from side to side, the outline of the flat sound is somewhat altered. Rotch,* in an * Boston Med. and Surg. Journ., 1878, vol xcix. ; also article " Diseases of the Pericardium," in Keating's Cyclopaedia of the Diseases of Children, vol. li. 470 MEDICAL DIAGNOSIS. elaborate inquiry into the matter, points to the dulness in the fifth intercostal space to the right of the sternum as occurring even in small effusions, and as an available diagnostic sign ; and Roberts,* in his excellent monograph, speaks of the valuable aid afforded by it to surgeons about to tap the pericardium. Another signifi- cant sign connected with the dulness is that, as Bamberger has taught us, an area of dulness near the angle of the scapula which coexists with bronchial breathing and increased fremitus, and which is perceived when the patient is erect, is greatly influenced by position. It disappears, and with it the other signs mentioned, as he leans forward, to return as the erect posture is resumed. In cases of considerable effusion, the intercostal spaces of the cardiac region widen, the eye recognizes a distinct bulging, and the dulness on percussion reaches far upward, to the second, or even to the first, rib. Within the space of dulness is sometimes seen an irregular, wavy motion; and what the eye detects the hand feels. But no movements, or only slight movements, may be perceptible in the prsecordia. The heart, with its point pushed upward and outward by the accumulating liquid, has to struggle to reach the walls of the chest. Its contractions are irregular ; its impulse is feeble, or all appreciable impulse has ceased. The sounds heard through the mass of fluid seem distant and mufiled. Yet the second sound over the upper part of the stei-num and at the base of the heart retains its sharpness. During the stage of absorption the apex returns to its nat- ural position ; the dulness gradually disappears ; the sounds and the impulse regain more of their normal character ; the friction murmur reappears, and then ceases, leaving frequently the two surfaces of the pericardium adhering, — a condition which is not harmless, since it leads to dilated hypertrophy, or to dilatation. We cannot foretell how long it will take the disease to run through its different stages. Death may occur in less than thirty hours, the heart being paralyzed by an enormous effusion ; on the other hand, the acute attack may last for as many days, and then leave serious traces. But whatever stage the malady be in, it can be recognized only by the physical signs : by the friction, the pe- culiar percussion dulness, the enfeebled impulse and heart-sounds. * Paracentesis of the Pericardium, Phila., 1880. DISEASES OF THE HEAET. 471 There are no general symptoms that prove a pericarditis to exist. There are symptoms by which we may infer that peri- carditis is present ; but there are none which absolutely belong to it and would prevent it from being overlooked. The symptoms usually met with are those of inflammation of the endocardium, but with more decided local evidence of disorder. We find the anxious expression; the fever, not generally high; the oedema; the same uncertain or irregular pulse. But there is more pain over the heart, — acute, severe jiaia, shooting to the left shoulder, augmented by movement, increased by pressure, and associated with epigastric tenderness; there is more dyspnoea, because the distended sac presses on the lung ; a dry, irritative cough ; and sometimes difficulty in swallowing. Yet every one of these symp- toms may be absent. The pulse may be regular ; the breathing not perceptibly accelerated or laborious ; and even the symptom regarded as the most important of all — the pain — may be want- ing from the beginning to the end of the disease. When the action of the heart grows weaker and weaker, the circulation becomes more irregular. The beat of the artery at the wrist is feeble, and intermits ; the veins of the neck are prominent ; the skin is cold and pale ; the extremities are oedem- atous. These are always symptoms of grave import. If next we inquire with what complaints acute pericarditis is likely to be confounded, inflammation of the endocardium and inflammation of the pleura occur at once to the raind. To con- trast the signs of the first two maladies, for the slight difference in their symptoms has already been mentioned : Endocarditis. Peeicakditis. Blowing sound ; excited action of the Priction sound ; excited action of the heart. heart. Slight, if any, increase of percussion In stage of effusion, marked and ex- dulness. tended percussion dulness. Impulse strong. Impulse wavy and feeble. Sounds normal or more distinct, ex- Sounds feeble and muffled, except at cept at site where murmur is heard. base ; no blowing sound. Such is the distinction of pure cases of each disease. Still, as already stated, the affections are often combined. It is not uncommon to hear with the friction sound a distinct endocardial murmur. But there is sometimes a difficulty of another kind in 472 MEDICAL DIAGNOSIS. the way of a precise diagnosis. The murmur produced on the outside of the heart may simulate so closely the murmur produced in its interior that it is almost impossible to discriminate between them. The former may completely possess the blowing characters of the latter. Mostly, however, it is rougher ; more prone to be double ; and each division is like the other, equally rough, equally superficial-sounding, equally lacking in strict correspondence to the systole or to the diastole. And, above all, the sound alters at times both in situation and in character with amazing rapidity. Perceived now as an ordinary bellows murmur on the left side, it is after the lapse of some hours heard as a rough rasping sound on the right. These changes have a high degree of value. But they are not of constant occurrence ; and to say that it is some- times impossible to tell a pericardial from an endocardial sound is to say no more than is borne out by every-day experience. In the stage of effusion pericarditis is not likely to be mistaken for endocarditis. Pleurisy gives rise to some of the same symptoms and signs as pericarditis. It develops a friction sound : it occasions dulness on percussion, dyspnoea, and cough. But the physical signs are in different situations. In one disorder they are in the region of the heart, and are confined there ; in the other they are spread over the whole side of the chest, and are most perceptible at the back. This is true of the dulness, and, for the most part, of the friction sound, which, when of pericardial origin, is rarely heard posteriorly. At times, however, we meet with very puzzling cases. A fric- tion sound discerned over the heart may be in reality produced in the adjoining pleura. The patient is directed to suspend his breathing ; the friction sound does not stop. Now, the inference from this would be that the sound originates in the pericardium ; and in the large majority of instances this is a correct inference. But it is not always so. The friction may have its seat in the pleura and be caused by the movements of the heart. There are no absolute means, besides the intermission of the sound during some of the beats of the heart, as well as during some of the acts of breathing, especially in expiration, of detecting in these rare cases the true seat of the disease. To confound the dulness on percussion caused by liquid in the pericardium with that due to liquid in the pleura, is a mistake DISEASES OP THE HEART. 473 more likely to happen, because the two serous membranes, and indeed the lung, are often implicated in the same inflammation. But a pericarditis uncomplicated with pleurisy or with pleuro- pneumonia does not change the clear sound at the back of the chest save in very rare cases of enormous accumulation of fluid. Effusion into the pleura gives rise to a flat sound anteriorly ; to a still more perceptible dulness at the inferior portion of the chest posteriorly ; and the sounds of the heart remain unaltered, unless its investing membrane contain fluid also. These, then, are the diseases with which acute pericarditis is liable to be confounded. There are several chronic cardiac mala- dies which will occasion some of the same signs and symptoms : such are thinning of the ventricles with distention of the cavi- ties, and a dropsy of the pericardium. But the history of these affections is different, and their signs, although similar, are not precisely the same. The dropsy of the pericardium is associated with dropsies elsewhere, and with some obvious cause accounting for the watery exudation, and at no stage of its existence does it exhibit a friction sound. But there is another acute complaint of which iDericarditis some- times borrows the garb. The thoracic symptoms may be latent, but the disease may produce the symptoms of extreme gastric irritation or inflammation. There are nausea and vomiting, and tenderness on pressure in the epigastric region. All the remedies are directed to the stomach ; and at the post-mortem examination the physician stands amazed at finding this viscus healthy and the pericardium full of serum or pus. An inquiry into the state of the heart might have saved him from a serious blunder. Another grave error which may be thus obviated is the mis- taking of some cases of acute pericarditis, on account of the wild delirium they present, for acute inflammation of the brain. Now, both in endocarditis and in pericarditis this active delirium may throw all the other symptoms into the background. It is difficult to see why a pericardial inflammation should give rise to such vio- lent disturbance of the brain. It is not at all unlikely that it has its origin, in part, at least, in the contaminated state of the blood which occurs in the affections, as rheumatism or Bright's disease, with which pericarditis is often associated. However occasioned, it is necessary to be aware that the cerebral symptoms arising in 474 MEDICAL DIAGNOSIS. inflammation of the membranes of the heart may entirely draw off attention fi'om the serious lesions within the chest. A fixed delusion of having committed some crime appears to Flint* to be a distinguishing feature of the mental wandering ; while Sib- son f in his exhaustive analysis points out, what I have known to happen in more than one instance, that the desponding and taci- turn or, as he calls it, sombre delirium lasts from two or three weeks to as many months. Can we by the symptoms or physical signs tell the character of the fluid in the sac ? We cannot by the signs, and by the symp- toms we can only suspect pus if there be recurring chills, and irregular but high temperature, and if the pericarditis have arisen in the course of a malady that makes the presence of pus likely, Hemorrhagic pericarditis can also only be distinguished as a prob- ability by the history. It happens in scurvy and in purpura, and may be an attendant upon cancer of the pericardium. Cancerous pericarditis, however, produces also serous or purulent effusion. It is never a primary disease, and it has no characteristic symptom, except it be, in some cases, darting pain in the prsecordial region attending the signs of pericarditis. It is by the history and by the evidence of deposit elsewhere that we have to judge. The same is true of tubercular pericarditis. Here the pericarditis is often dry, and the membrane much thickened. Yet an enormous effusion may occur, as happened in a case recorded by Musser. J Before dismissing the subject of pericarditis, let us inquire in how far one of its terminations — by adhesion or agglutination of the surfaces — can be recognized. In many of such cases, whether or not there be coexisting dilatation, or hypertrophy, or that rare condition, cardiac atrophy, or even probably when the heart is of normal size, we find changed rhythm and dyspnoea. Yet these are not special signs of pericardial adhesion. Nor is the " abrupt, jogging, or trembling motion" of the heart, described by Hope, pathognomonic ; nor the extinction of the second sound, on which Aran dwells. For the pericardial surfaces may be found most thoroughly glued to each other where neither of these signs is present. But it must be admitted that the double jog, the rebound, * Diseases of the Heart. f Article " Pericarditis" in Reynolds's System of Medicine. J Medical Diagnosis. DISEASES OF THE HBAET. 475 is often felt, especially if the enlargement of the heart be exten- sive ; enfeeblement or absence of impulse, while it may happen, is much rarer. Yet there is not a single symptom or sign constant, or characteristic of pericardial adhesion. The most trustworthy signs are those given by Skoda : * a drawing up Tof the heart's apex during the contraction of the ventricles, with a depression in the intercostal spaces becoming visible at the same time, and some- times with a simultaneous sinking in at the lower half of the sternum ; the limits of the dull percussion sound remaining un^ affected during inspiration and expiration ; and a confused instead of a distinct and punctated beat of the impulse against the finger. Gairdner,f too, lays stress upon the marked movement of the in- tercostal spaces over the heart ; while Waishe J thinks that the systolic dimpling and the undulatory movements in the prsecordia only happen if there be, in addition to the pericardial adhesions, pleuritic adhesions in front of the organ, or if the agglutination of the pericardium be combined with cardiac hypertrophy. In the latter case, too, jogging, trembling action of the heail may be highly developed. Friedreich! has called attention to a rapid emptying of the veins of the neck during the diastole of the heart, while with the systole they swell up; and Riessjl has told us that, owing to the close bringing together of the heart, diaphragm, and stomach, the heart-sounds resound with a metallic ring. When the pericardial surfaces are very extensively and firmly united, the eye is struck by the evident depression of the prsecordial region. When the pericardium is adherent to the sternum and bands pass off compressing the aorta, — " indurated mediastino-pericarditis," — a pulse vanishing with each full inspiration — pulsus paradoxus — has been described by Kussmaul.T[ The same sign has been noticed by Irvine in cases of adherent pericardium and pleura, and by Traube ** in exudative pericarditis where the mediastinum was not implicated. Duroziez ff regards as the most certain sign of pericardial adhesion a visible sinking in of the surface, while the hand of the observer feels the shock of the impulse ; the nipple * Zeitschr. der k. k. Gesellsch. der Aerzte zu Wien, April, 1852. t Edinburgh Medical Journal, 1851, 1859, etc. X Diseases of the Heart, 4th ed., p. 244. ? Virchow's Archiv, Bd. xxix. II Berliner Klinische Wochenschrift, No. 51, 1878. % Ihid., No. 37, 1873. ** Charite Annalen, 1876. ff Traite clinique des Maladies du Cceur. 476 MEDICAL DIAG>fOSIS. may be in perpetual motion. Aran has proved the tendency to sudden death in complete pericardial adhesion. Closely connected Avith the subject of inflammation of the pericardium is that rare affection in which air is present in the pericardial cavity, pneumo-pericardium, or, more strictly speaking, on account of the frequent association with fluid, pneumo-hydro^ pericardium. It occurs as the result of injuries, of communication established by disease between the pericardium and the neigh- boring organs, and in very exceptional instances is due to decom- position of liquids in the sac. Its chief diagnostic features are abnoi'mal resonance over the cardiac region, and a metallic char- acter of the heart-sounds. The tympanitic resonance alters in a most marked manner with changes in the posture of the patient, and is limited by a distinct line of dulness caused by the fluid. The metallic sounds may at times be heard at a distance, and may be attended with sounds of most extraordinary kind, friction sounds mixed with splashing and gurgling, the so-called water- wheel sound, the bruit de moulin ; generally an intermittent sound, at first metallic, which Reynier * has informed us has not a bad prognostic meaning, except when the pericardium is not intact, as in cases of traumatic opening. The symptoms of pneumo-pericar- dium are vague, generally those of a pericarditis, with great diffi- culty in breathing and failing circulation. In point of diagnosis we must be careful to take all the symptoms and signs into account, and not be misled by the modification of the cardiac sounds and the splashing and metallic phenomena due to a dilated stomach. From pneumothorax, even when encapsulated near the heart, we distinguish pneumo-pericardium by the dulness on per- cussion to be found over the displaced heart in the former malady, and the amphoric or metallic respiratory sounds that are heard in addition to the metallic heart sounds. The entrance of air may happen, as in the cases of Meigs f and of Miiller,! by a rupture brought about by the pericardial exuda- tion, — in the one case into the oesophagus, in the other into the lung. These cases of ulcerative perforation almost all end fatally. Myocarditis. — The substance of the heart itself undergoes at times inflammation. Of this there are several varieties, two of * Arch. Gen. de Med., May, 1880. f Amer. Journ. Med. Sci., Jan. 1875. J Deutsches Archiv fiir Klinisclie Medicin, Bd. xxiv., 1879. DISEASES OF THE HEART. 477 which are the most distinctive, — the acute inflammation of the muscular walls, and the chronic myocarditis or fibroid degenera- tion of the heart. The acute gives rise to infiltration among the fibres of the heart of blood-corpuscles, of granules of exudation, and of leucocytes, and local softening and circumscribed abscesses, and even gangrene and perforation of the ventricle, may result. But, though familiar with the post-mortem appearances, we are not enabled to foretell the state of the heart during life, mainly because the muscular structure is rarely affected without the endo- cardium, or still more frequently the pericardium, being impli- cated, and thus the manifestations of these disorders occur mixed up with those of the carditis. On analyzing the cases on record, I cannot, indeed, find either a symptom or a sign which can be considered as in the least pathognomonic. Extreme pain in the cardiac region is the most usual and the most prominent of the symptoms. It is sometimes excruciating and sharp, at other times dull, yet distressing and constant. The breathing is generally much oppressed; delirium is often present; the skin becomes cold ; the heart fails in power ; and the patient dies in a state of utter prostration or appears to suffocate. The pulse, as in endocarditis or in pericarditis, exhibits no uniform character. The statement that it is invariably intermittent, feeble, and quick, is not correct. It is so as the disease advances, but it has been reported to be full, and not above eighty, long after the distress in the chest was unbearable.* The signs of cardiac failure are quickly developed. In purulent myocarditis the temperature shows marked remissions and exacerbations, and rigors and sweatings are usual, f Acute myocarditis may occur in rheuma- tism, but it is most common in pysemia and in phlebitis. Its occa- sional association with gonorrhoea has been pointed out, and it may be found with or without gonorrhoeal rheumatism. J In chil- dren there is a distinctly cerebral form.§ • * Salter, Medico-Ohirurgical Transactions, vol. xxii. In several of the cases on record, for instance in the one mentioned by Graves in his Clinical Lectures, there was coexisting valvular disease, which, of course, invalidates the state- ments as regards the character of the pulse, and, indeed, as regards many of the other symptoms. t Bramwell, Diseases of the Heart, Edinb., 1884. X Councilman, Amer. Journ. Med. Sci., Sept. 1893. 2 Mitchell Bruce, Keating's Cyclopsedia of the Diseases of Children, vol. ii. 478 MEDICAL DIAGNOSIS. Acute interstitial myocarditis and parenchymatous myocarditis, the muscular fibres in both being infiltrated with granules, have no distinctive symptoms. They occur in fevers, particularly in typhoid fever, yellow fever, and smallpox, and in pericarditis, and may be suspected under these circumstances from the feeble heart action. Chrcmic myocarditis, or fibroid degeneration, often results from rheumatism, or attends pseudo-hypertrophic paralysis. A very common cause is disease of the coronary arteries, especially ob- literating endarteritis of syphilitic origin. The disease is most common in men, and may lead to aneurism of the heart. The diagnosis of chronic myocarditis is as uncertain as that of the acute form. The symptoms are those of a feeble heart : oedema, gi'eat dyspnoea, cough, hemorrhages into different organs, venous congestions, have been especially noted. In some cases there is pain over the heart. The percussion dulness in the cardiac region is somewhat increased. The first sound is indistinct, the second over the aorta very weak. The most characteristic sign is a want of correspondence between the heart and the pulse-beats ; these are unequal and irregular.* Some stress may be laid on the signs of pericardial adhesions, if present. Chronic Diseases attended with Increased Estent of Percussion Dulness, but with Normal or almost Normal Heart-Sounds, We often meet with a group of affections which present the phenomena of extended dulness on percussion in the cardiac region, associated with sounds like those heard in health : they may be louder or less loud, better defined or less well defined, still they are the natural sounds of the heart, and no cardiac murmur is detected, unless the disorder be no longer uncomplicated. To this group belong those diseases which affect the walls of the heart or its cavities, without having involved the valvular apparatus, such as hypertrophy and dilatation, — types of the two different states of force and of weakness, but both exhibiting an extent of percussion dulness greater than in health, and hearts sounds not materially changed. Hypertrophy. — Hypertrophy of the heart is an overgrowth of its walls, and usually also of its cavities; for, although we * Kuhle, Archiv fur Klin. Med., 1878. DISEASES OF THE HEART. 479 may have the muscle thickening without the cavity's enlar^ng, nay, even with its diminishing in size, neither this simple nor the concentric hypertrophy occurs, save in rare instances. It is evi- dent that any one of the chambers of the heart may alone become hypertrophied. But, practically, the state we mean when speak- ing of cardiac hypertrophy is an increase of the ventricles, and especially of the left ventricle, in its wall and cavity, with a simi- lar, although much slighter, expansion of the right side. Whether the auricles be enlarged or not, is a matter always more of conjec- ture than susceptible of proof. The physical and vital manifestations of the heart having out- grown its natural dimensions are these. The pulse is full and strong, and somewhat tense. The face is florid, or else it is pale ; and the mucous membranes of the lips and eyelids are injected. The eyes are bright, and apt to be prominent. The carotids pul- sate forcibly under the least excitement. Some persons suffer from headache and giddiness ; in fact, all the symptoms denote a circulation actively, too actively, carried on. Yet the symptoms directly referable to the heart are not marked. There is, as a rule, no pain or irregular action of the heart, nor do violent fits of palpitation occur. What the patient comes to consult his physi- cian about, are rushes of blood to the head ; or a ringing in the ears; or a feeling of weight in the epigastrium which troubles him after a full meal ; or shortness of breath ; or in consequence of the powerful action of the heart, when lying in bed, attracting his attention ; or because he is alarmed about a dry cough, and believes himself the victim of pulmonary consumption. The physical signs are mor^ uniform than the symptoms. We observe a fulness or arching of the prsecordial region, and an impulse, strong, heaving, and extended over several intercostal spaces. The apex does not strike the chest-walls between the fifth and sixth ribs, but its beat is perceived lower down, usually an inch or more to the outside of the nipple line. The extent of percussion dulness increases, both longitudinally and transversely; and particularly in the latter direction, if the right ventricle be much enlarged. This peculiarity in the expansion of the area of dulness on percussion forms, in truth, with the greater dyspncea, and with an impulse more directly perceived over the right side of the heart, near the pit of the stomach, and often out of proper- 480 MEDICAL DIAGNOSIS. tion to the compressible and rather small radial beat, and with the increased distinctness of the second sound of the pulmonary Fig. 46. *>(u.m^^jN^ An Iiypertrophied heart lying in its position in tlie chest. The canee of the lowered apex beat, and of the extension of the impulse, as well as of the somewhat squarer outline of the iDcreased dulness over the enlarged organ, is obvious from the shape and position of the heart. artery, the sign that hypertrophy with dilatation has principally aifected the right side. The first sound of an hypertrophied heart is duller than in health, but- prolonged and weighty. The second sound is not particularly changed. There are no murmurs, except under rare circumstances, which will be mentioned in discussing valvular dis- eases. Thus, the greatest value of auscultation is that, by showing the sounds but little altered, it enables us positively to exclude a lesion of the valves ; just as the chief service of percussion, with reference to an enlarged heart, consists in permitting us to distinguish the excited motions of the simply disturbed organ from the action of a heart the walls of which are thickened ; and as the main use in noting the impulse is that it serves as a means DISEASES OF THE HEART. .481 of discrimination between hypertrophy and those affections in which the beat is weakened, such as dilatation or a pericardial effusion, or between the dulness in the prsecordial region due to hypertrophy and that caused by deposits in the pleura, in the mediastinum, or in the lung. Where there is contraction of the left lung, as from pleurisy or fibroid change, more of the heart is exposed, and the dulness on percussion in the cardiac region is increased, as well as the impulse, which is felt over a larger space and to the left ; but the cardiac sounds are unchanged, and deep inspiration alters the extent of cardiac dulness but little. Hypertrophy may be combined with decided dilatation of the heart. This kind of hypertrophy presents a less dull, prolonged first sound, and the pulse, though full, is likely to be more com- pressible. Hypertrophy may affect specially any part of the con- stituents of the muscular walls. Thus, the connective tissue, as Quain has particularly called attention to, may be alone concerned in the morbid action. Hypertrophy of the heart is found much more frequently among males than among females. Its causes are various. It is common in Bright's disease and in general arterial sclerosis ; continued functional excitement produces it ; so does any kind of strain and overaction, and perhaps excessive nourish- ment. It is found to be common among inordinate beer-drinkers. But the main cause is an obstruction to the circulation, either in the heart or in other organs. It is for this reason that the com- plaint is so often met with in connection with diseases of the valves or of the large arteries, and that the right side of the heart enlarges when the pulmonary air-vesicles are overdistended. We also, as we have seen, encounter hypertrophy of the heart as a consequence of the obliteration of the pericardial sac by its two surfaces adhering. In the hypertrophy of Bright's disease re- duplication of the first sound of the heart is often noticed. There is a form of hypertrophy of the heart to which atten- tion has been particularly called by Fothergill's description, — the so-called gouty heart. Generally, although not always, there is coexisting disease of the kidney of the chronic contracting form. In the first stage of the affection, when well marked, we find de- cided hypertrophy with accentuation or booming of the second aortic sound, high blood- pressure, tense pulse, hardened arteries, and the passage of large amounts of pale urine of low specific 482 MEDICAL DIAGNOSIS. gravity. The renal changes may or may not be evident ; we may or may not detect albumen in the urine. In a subsequent stage of the malady there is failure of the circulation, and with the signs of the heart-failure, very often going hand in hand with fatty degeneration, the bulk of urine diminishes and the renal affection becomes more marked. The cardio-vascular phenomena are early made perceptible by the sphygmograph. The full, tense pulse gives a full up-stroke, a broad summit, and a retarded down- stroke ; the " square-headed tracing" formed is very characteristic of the malady, and bespeaks the fibroid change in the kidney, whether or not albumen be found. In some instances there is considerable dilatation as well as hypertrophy, and then severe palpitations result. The high blood-pressure is due to the waste- laden blood ; and the defective nutrition is apt to show itself also in atheromatous arteries, which in part account for the sphygmo- graphic tracings. The skin oftens exhibits little twigs of dilated vessels ; the ear is usually deep red, with a large glistening lobe ; or in spare persons the lobe looks withered ; the teeth become blunt and worn down in time ; the hair is apt to be iron-gray. There is the history of gout, acqxiired or hereditary, but there may have been no active outbreak of gout, rather the condition of imperfect assimilation and increased uric acid, known as lithsemia. Dilatation. — Dilatation of the heart is the reverse of hyper- trophy. By this it is not meant that because the cavities are dilated the walls may not be increased. But it is meant that the morbid condition in which the cavities have been stretched out of all pro- portion to the thickness of the muscular walls is the reverse of the condition in which the walls are stronger, firmer, and more powerful than in health ; in other words, the latter state is very different from the former, and when it predominates we call the affection hypertrophy ; when the former is in excess we speak of the disease as dilatation, no matter whether the walls be slightly thicker than normal, or of natural thickness, or thinner, and apparently hardly capable of supporting the weight of the blood. From these almost opposite pathological states, almost opposite physical signs or symptoms might be expected. And so we find it. In dilatation we look in vain for the activity and power with which the blood is forced out of an hypertrophied heart. Every- DISEASES OF THE HEAET. 4(33 thing indicates inaction and stagnation. There is a strong ten- dency to venous congestions and to dropsies. The portal system is gorged. The liver increases in size. The bowels are consti- pated. The urinary secretion is interfered with, and sometimes albumen is passed. The hearing may become dull. The patient is languid and feeble, and his intellect obtuse. He suifers from chilly sensations, and from uneasiness in the cardiac region and palpitations. The pulse is small and irregular, and the veins of the surface are swollen. The skin around the ankles, and often at other parts of the body, pits on pressure. But, since it is the right side of the heart which is usually the most affected, the lungs show most plainly the effects of the venous stagnation. Difficulty in breathing, making itself at times manifest in parox- ysms attended with wheezing respiration ; a chronic cough ; a collection of serum in the pulmonary structure, — all add to the misery which the perilous malady entails. And as it is commonly some obstructive disease in the lungs, such as emphysema, which has given rise to the dilatation of the right side of the heart, so this again augments the morbid state of the lungs, and aggravates the symptoms. The physical signs are very unlike those of hypertrophy. The same extended dulness on percussion exists ; but it is associated with a feeble and fluttering impulse, which is in strong contrast with the heaving, powerful blow of an hypertrophied left ventri- cle, and which at times may be seen, yet cannot be felt. The sounds are not always the same. When the walls are thin, they are clearer, sharper, and more ringing than in health : if, however, the muscular structure be at all disorganized, the first sound is faint and very ill defined. The second is often split, giving rise to the so-called gallop rhythm. But no murmurs are perceived, unless a watery state of the blood produces them, or unless it happens — and it does not unfrequently happen — that the dilata- tion of the heart is conjoined to valves incompetent, either tem- porarily or permanently, to prevent regurgitation. Such is the description of cases of marked dilatation. All cases are not, however, so distinct, nor are they uncomplicated. Or- ganic affections of the heart are, indeed, indefinitely blended, and dilatation is met with in different combinations and in every pos- sible degree. Accordingly, its symptoms and signs are somewhat 484 MEDICAL DIAGNOSIS. dissimilar. But one constant feature it certainly preserves: it always holds up to view both the vital and the physical manifes- tations of a weak heart. Indeed, when an hypertrophied heart dilates, the signs of relative weakness become superadded, the impulse is not so strong as before in comparison with the percus- FiQ. 47. A dilated heart, the right Tentricle opened. In this case there was no valvular disease. Hence the characteristic physical signs; the iii- creased dulness on percussion, the extended but weak impulse. The first sound was feeble, for the organ was soft as well as dilated. sion dulness, and dropsy becomes a marked symptom. Pure dilatation is likely to be confounded with the diseases in which enfeebled action of the heart is encountered, and these are fatty degeneration and a pericardial effusion. Fatty Degeneration. — This is one of those disorders with the anatomical characters of which we are far better acquainted than with their clinical history. The microscope has revealed to us that the soft flabby heart, which appears to the eye little changed from health, has had its muscular fibres atrophied and transformed into fat-granules and oil. It has thus explained to us why a heart seemingly so little altered should rupture, or why death should set in with all the evidences of failing circulation. DISEASES OP THE HEART. 485 when nothing in the whole body can be found sufficiently diseased to account for the termination of the vital action. But our power to recognize the fatty change during life has not kept pace with our power to recognize it after death. There is as yet no sign discovered by which we can positively say that the dangerous dis- organization of the muscular fibres of the heart is in progress. We may, however, suspect it, if the signs of weak action of the heart — feeble impulse and ill-defined sounds — coexist with oppres- sion, with a tendency to coldness of the extremities, with a pulse permanently slow or permanently frequent and irregular, and be met with in a person who is the subject of gout or of a wasting disease, or is very intemperate, or has arrived at a time of life at which all the organs are prone to undergo decay. Something more than a suspicion is warranted if, in addition, there be proof of atheromatous change in the vessels, or of fatty degeneration elsewhere, such as an arcus senilis;* or if it be ascertained that the patient suffers from pain across the upper part of the sternum and from paroxysms of severe pain in the heart; that he sighs frequently; that he is easily put out of breath; that his skin has a yellow, greasy look ; that he is subject to syncope, or to seizures during which his respiration seems to come to a stand-still ; and that he is liable to vertigo, or to be stricken down with repeated attacks having the character of apoplexy, save that they are not followed by paralysis. Now, here are certainly a group of phenomena dissimilar to those of a dilated heart. Let us add that the extent of the cardiac percussion dulness remains unaltered, except in those instances in which hypertrophy or dilatation coexists, that dropsies and local congestions are not prominent symptoms, or indeed do not happen at all, and the dissimilarity becomes still greater. A differential diagnosis would, under such circumstances, be anything but diffi- cult. But in point of fact the matter is generally not so easily decided, and there are several reasons why it is not. One is, that all the features described are rarely combined in the same case ; * But the arous senilis may be absent. Fothergill points out that there is a false as well as a true arcus. The latter alone is significant of fatty degenera- tion and tissue-decay. It is a ring around the cornea of yellowish hue with blurred out ines, and the cornea itself is cloudy. 486 MEDICAL DIAGNOSIS. indeed, some of the more marked, such as the seizures like apoplexy, the Cheyne-Stokes breathing, are uncommon rather than common, and the peculiar breathing occasionally occurs in other cardiac maladies. The second is, because non-fatty soften- ing, the result of a granular infiltration, as met with, for instance, in fevers, may present much the same vital and physical mani- festations. The third is, because a fatty heart has a tendency to become dilated, and the symptoms and signs of the former disease are then merged into the symptoms and signs of the latter, throwing us back for a diagnosis into the province of conjecture and probability. With the organ in such a condition, the prac- tical value of a differential diagnosis is, however, not great ; for both affections require that the power of the heart should be sustained. Decided dropsy would indicate that dilatation had happened. The remarks about fatty heart' apply particularly to that va- riety of the disorder in which the muscular structure in middle- aged or elderly persons has slowly undergone decay. But we also, although far less frequently, meet with fatty heart in young persons and in a more acute form ; and we encounter it in chlo- rosis, in pernicious anaemia, after repeated hemorrhages, and after phosphorus poisoning. Poisonous doses of acids, such as nitric, sulphuric, oxalic, are said by Von Dusch also to give rise to the cardiac change. Persons who have fatty hearts are subject to attacks of faint- ness, preceded or attended with sensations of great coldness, or a chill. Sometimes these attacks happen daily, or every few days, and in such a manner as to give rise to the impression that they are due to malaria. A number of instances of the kind have come under my observation, and I have met with them particularly at the end of fevers or other debilitating diseases happening in those affected with feeble hearts. The seizures, though bearing a resem- blance to intermittent fever, are unlike it in being associated with signs of great weakness of the circulation or heart failure, some- times joined to a sense of impending dissolution ; in their irreg- ular accession ; and in their not being followed by fever. In doubtful cases the thermometer, by showing the absence of the great rise of temperature of the malarial disorder, will materially assist us in the diagnosis. DISEASES OF THE HEART. 487 Heart starvation, to which Fothergill * has called attention, has, in the feeble circulation, the cold extremities, the tendency to vertigo, and the pseudo-apoplectic attacks, symptoms common with those of fatty heart. But there is not a true arcus, and the malady is not associated with disease of the arteries. It is often an attendant upon general ill nutrition, and worry, and long hours of work and short hours of sleep. A fatty heart sometimes ruptures. Now, in spite of the care with which the physical signs of this mishap have been detailed, we know nothing positive about them ; for death usually takes place far too rapidly to permit of any observations. The symp- toms that are mostly noticed are these : the patient is suddenly attacked with intolerable anguish in the heart ; he presses his hand to it, then faints, and soon expires. Or else he lives for a short time, suffering from faintness, cramps, and difficulty of breathing, and with death plainly written on his face. Where there is fatty accumulation on the heaii, without fatty change of its fibres, — a condition we sometimes find in persons whose internal viscera are loaded with fat, — the manifestations are those of a feeble heart, and different from fatty degeneration only in degree. The first sound of the heart is weak and toneless ; the pulse is feeble, but, as Walshe tells us, regular. The percussion dulness in the cai'diac region is somewhat increased. A sensation of oppression over the region of the heart, or even actual pain, is complained of. There is shortness of breath on taking exercise. Atrophy of the heart is so rare a condition that its symptoms are scarcely understood. All we know is that at times in certain wasting diseases, such as tubercular phthisis and suppurating bone affections, the heart atrophies ; it may also do so when the coronary arteries are calcified, or the pericardium is tightly adherent ; and cardiac atrophy is said to happen occasionally after pregnancy and chlorosis. It has not a single symptom nor a single sign by which it can be recognized with certainty. Theoretically, the diminished percussion dulness, clear sounds, and feeble impulse should enlighten us; but, even in cases where there is no co- existing fatty change, they are too uncertain to be made a basis for diagnosis, or attending lung conditions throw doubt on several * Edinburgh Med. Journ., May, 1881. 488 MEDICAL DIAGNOSIS. of them. There is great tendency to palpitation, and the pulse, Hayden tells us, is quick, all but inappreciable, yet regular. Pericardial EflFusion. — Pericardial effusion also presents the signs of a weak heart with increased dulness on percussion in the cardiac region, and is very liable to be mistaken for a dilatation of the organ. Where the effusion forms part of a general dropsy, the detection of the cause of the latter, in connection with the dif- ferent signs which fluid in the pericardium occasions, will prevent error. Where the liquid has remained after an inflammation of the membrane, both signs and symptoms are like those of the state of effusion in acute pericarditis, and, although there are points of resemblance to a dilated heart, there are also points of contrast, as the subjoined table shows : Chronic Pericarditis with Dilatation or thb Heart. Effusion. Percussion dulness increased in ex- Percussion dulness increased, but tent, but square in outline. often of pyramidal shape. Impulse in epigastrium. Impulse in third or fourth left inter- space, apex tilted upwards. Heart-sounds clear and sharp; some- Heart-sounds feeble and distant- times, however, feeble. sounding at the apex, but distinct near the upper part of the sternum. No friction sound. Often friction sound still heard at.the base of the heart. Dropsy ; signs of venous stagnation ; Neither dropsy nor venous stagnation severe cough, and dyspnoea. is observed ; or, if at all, only in .a very limited degree. Cough and dyspnoea are not such prominent symptoms. The history of the disease shows it to The history frequently points to the be gradually developed. acute attack. These, then, are the marks of distinction presented by a chronic pericardial effusion, a fatty heart, and cardiac dilatation ; in other words, between the main morbid states which occasion the signs and symptoms of a feebly-acting heart. Before proceeding, let us glance at one more condition, fortunately infrequent, which may give rise to some of the same phenomena as those described, — an accumulation of blood in the cavities of the heart. Like dilatation, this increases the area of percussion dulness, and is often associ- ated with perverted rhythm. The chief differences, as far as our limited knowledge of the subject permits us to define them, are DISEASES OF THE HEART. 489 these : the impulse is generally much more labored and irregular, is sometimes strong, sometimes weak, not so almost uniformly indistinct or tremulous. There is much more venous congestion of the face, with greater dyspnoea, and we often find some acute malady, such as endocarditis or pneumonia, giving rise to the cardiac engorgement. But the matter is a very difficult one to determine ; for many of the same states which lead to dilatation may produce an accumulation of blood in the heart ; nay, dilata- tion itself predisposes to it. We must bear in mind also that an acute dilatation sometimes happens from shock or sudden fright. Diseases of the Heart exMbiting more or less of the Signs and Symptoms of Enlargement of the Organ, and accom- panied by Endocardial Murmurs. Valvular Affections. — These, when not due to congenital malformations, are most commonly the result of rheumatic endo- carditis, of slowly progressing sclerotic changes, or of heart- strain. A certain number of cases have their origin in some of the fevers, as in scarlet fever, and in septic conditions and blood- changes, as in ulcerative endocarditis. The different valves are not affected by these "causes alike. Rheumatic endocarditis is the principal cause of disease of the mitral valve, especially of mitral insufficiency; but among prominent causes of this are also alter- ations in the muscular wall of the ventricle or in the tendinous cords. Aortic insufficiency is generally due to slow sclerotic changes in the valvulets, whether attended with atheroma or not, or to subacute or chronic endocarditis from heart-strain ; it may be also owing to the sudden rupture of a valve previously dam- aged. Mitral constriction is mostly brought about by atheroma^ tons or calcareous alteration, as is aortic constriction ; but in mitral constriction we may have also a history of endocarditis in early childhood subsequent, to rheumatism, an exanthematous fever, or chorea. In insufficiency of the tricuspid valve we can trace usually the result of overdistention of the right heart, such as follows pulmonary congestion caused by mitral disease, or of an obstructive disease of the lung, such as emphysema or cirrhosis. Tricuspid stenosis, and the other very rare valvular affections of 31 490 MEDICAL DIAGKOSrS, the heartj — those of the pulmonary artery, — are commonly con- genital. To find the sounds of the heart clearly and well defined, is to know that no disease of the valves exists. When the valvular apparatus is disordered, the mischief betrays itself, for the most part, by a murmur. If, therefore, a murmur of any permanence be met with in the heart, especially if it be associated with the signs of either hypertrophy or dilatation, the inference that val- vular disease exists will in the vast majority of cases be a correct inference. Yet it will not be so always ; for there are other morbid states besides valvular affections which engender a murmur, which may be even accompanied by all the manifestations of enlargement of the heart. Malformations, such as communications between the auricles or between the ventricles, or between the great vessels near their origin, or impoverished blood, or a misdirected blood- current, may occasion a murmur. Ifow, with reference to malformations, their presence in adults, or in children that have passed the days of infancy, is exceedingly rare. The most trustworthy symptom they present is that in- dicating the admixture of arterial and of venous blood ; in other words, the symptom of cyanosis, the bluish discoloration of the skin. In addition, we may perceive the signs of disturbed circu- lation in the lungs, such as dyspnoea and cough, and irregular action of the heart, and a blowing sound in the cardiac region ; hypertrophy of the heart, especially of the right heart, is also very generally present. Still, the recognition of these malformations is always more or less a matter of conjecture. With the aid of more such researches as those of Moreton Stills,* of Peacoek,t and of Hochsinger, % we shall become more accurately acquainted with the different lesions, and perhaps be able ultimately to discern them with certainty during life. At present it is in their rarity that the safety against errors of diagnosis lies. * Amer. Journ. Med. Sci. , July, 1844. f Treatise on Malformations of the Heart ; see also th& valuable treatise of Keating and Edwards on Diseases of the_ Heart and Circulation in Infancy and Adolescence, 1888; Osier's article on "Congenital AflFeotions of the Heart," in Keating's Cyclopsedia^ of the Diseases of Children, and Hirst's, in Starr's American Text-Book of Diseases of Children . J Die Auscultation des Kindlichen Herzens, Wien, 1890. DISEASES OF THE HEAET, 491 As a few points of assistance, it may be mentioned that com- munication of the ventricles through the septum gives rise to a systolic murmur at or near the base of the heart not propagated into the arteries, but according to Roger and to Sansom also heard between the shoulders ; that the passage of blood through an open foramen ovale very rarely engenders any sound, though presenting marked cyanosis j and that, whether coexisting with these lesions or not, the majority of instances of cardiac malfor- mation, after the age of twelve, present signs of obstruction at the orifice of the pulmonary artery. In this instance either a systolic or a diastolic murmur may be there perceived ; in the first case the second sound of the heart is weak or wanting in the second interspace on the left side. Mitral disease of congenital origin is veiy rare. Thrill over the precordial region is seldom met with, except when congenital defect in the septum exists. Loud, vibratory systolic murmurs heard most distinctly over the upper third of the sternum without attending hypertrophy of the left ventricle point to persistence of the ductus Botalli. A curious result of cardiac malformation has been observed, — abscess of the brain without appreciable cause.* The resemblance borne by cases oi functional disturbance of the heart, associated with impoverished blood, to valvular aifections, has already engaged our attention. The age ; the appearance of the patient ; the seat of the bloAving sound at the base of the heart, and its soft character ; the venous hum ; the fact that the cardiac murmur is followed by a sharp second sound, — are all points upon which some stress may be laid ; yet not so much as upon the absence of the phenomena of an enlarged heart. But if the question be asked, Are the latter absolute demonstrations of the existence of an affection of the valves ? cannot an hypertrophied or a dilated heart, with sound valves, be combined with a condition of blood capable of producing a murmur? — we are forced to answer that such is possible. Under these circumstances, the tact of the physician may help him to a well-judged decision ; but the only proof of a well-judged decision is afforded by time, or by the result of treatment that restores the blood to its normal state. * Ballet, Archives Generales de Medecine, June, 1880. 492 MEDICAL DIAGNOSIS. A murmur caused, in violent excitement of the heart, by mis- direction of the current, due chiefly to temporary interference with the closure of the valves, or perhajDS owing to altered tension of the valves,— causes the exact working of which I have elsewhere inquired into,* — may become a troublesome source of error in diagnosis, especially when heard over a heart in a state of dilated hypertrophy or of dilatation. Fortunately, a blowing sound of this origin and in this combination is comparatively rare, and we are enabled to discriminate it from an organic valvular murmur by its not being persistent. It is much more likely to be heard at the apex, or rather, according to my own observations, some- what above the apex, than is a murmur owing to changes in the blood ; and it differs from the systolic blowing sound of mitral disease partly by the peculiarity of seat just mentioned, palrtly by its non-diffusion, its usual absence at the back of the chest, the want of harshness in the inconstant murmur, and the low pitch. Murmurs of this kind are also caused by obstructive diseases of the lungs, without disease of the heart being present. They may be brought out, as John K. Mitchell has shown, by suddenly closing the hand tightly, f At times a murmur is heard which is not dependent on a cardiac affection, but on lung changes. "We find, for instance, in consolidation of the left apex, especially if the lung be also con- tracted, a murmur, almost invariably systolic, over the site of the pulmonary arteiy ; or we may encounter over large cavities with tljin walls situated in the neighborhood of the heart a systolic, eardio-pulmonary murmur, caused, most likely, by the agitation of the air in the cavity, the heart being quite sound. These, then, are the causes which impair the value of the car- diac blowing sound as a sign of a valvular lesion. Yet they do not happen often enough to prevent us from regarding a persistent murmur as eminently indicative of an organic affection of the valves. Let us suppose that we are convinced that the murmur is due to a structural lesion. Can we say what its precise nature is? Can we accurately foretell that the valve is merely roughened, or that it has undergone calcareous transformation, or that it has * On Functional Valvular Disorders, Amer. Journ. Med. Sci., July, 1869. t Transact. College of Phys. of Phila., 1802. DISEASES OF THE HEAET, 493 been bound down, or that it is lacerated, or that vegetations spring from it, or that its muscular attachments are sound or unsound ? No, assuredly not. The most we can do is to judge whether the orifices through which the current flows be narrowed, or whether, by the valves not closing, they permit of regurgita- tion ; and to distinguish even this we have to take into account more the time of the occurrence of the sound than its particular character or pitch. Indeed, all distinctions based entirely on either of these are not borne out by clinical experience. Valves incompetent to close the openings at which they are seated may permit a murmur to be generated of any character and of any pitch. It is true that a harsh murmur, like that of a saw or of a rasp, is for the most part occasioned by a contracted orifice with rigid valves ; but many contracted orifices with rigid valves exist without producing such a rough noise. A cardiac sound- which is rare, but which, when present, is most generally associated with a narrowed orifice, is a distinct musical tone heard at the mitral or aortic valves. It resembles the cooing of a pigeon; or the auscultator listens and listens again, and directs the patient again and again to suspend the respiration, before he becomes convinced that the sound is not a sibilant rale in the lung. It is sometimes perceived merely at the end of an ordinary bellows murmur, and disappears and reappears from time to time. Where this rare sound is met with, the valves after death are commonly found to be rigid and unyielding. Yet this is not always the case. Sometimes the musical note is pro- duced by the vibrations of clots which impede the rush of blood through the apertures of the heart, or by the loose edge of a valve flapping to and fro in the current. Occasionally, too, we hit upon it in chlorosis ; but only very occasionally, and never unless it be then equally or more marked in the arterial system. We have the authority of Stokes for the observation that it may be suddenly developed and precede the signs of structural altera- tion of the heart. Schroetter maintains that the musical murmur is due to the vibration of a fine fibrous band stretched across the ventricle or a valvular orifice.* It has been already stated that we judge best of the condition of * Wien. Med. Blatter, No. 1, 1883. 494 HEDICAL DIAGNOSIS. the orifices and of the valves by ascertaining the time at which the bellows sound occurs. To do this it is necessary to recall in what state the orifices are during the movements of the healthy heart. During the contraction of the ventricles, the valves at the auriculo-ventricular openings are closed, to prevent regurgitation into the auricles ; and the valves of the aorta and Fig. 48. Narrowing of the aortic oriiice by vegetations springing from the valves, the structure of which was indeed, to a great extent, destroyed. The engraving illustrates also the physical signs of aortic constriction. pulmonary artery are open, so as to permit the blood to pass along the arterial trunks. During the dilatation of the heart the re- verse takes place : the valves at the origin of the great arteries are shut, to keep the blood which has just been sent forth from regurgitating, and those valves the function of which is to act as DISEASES OP THE HEAET. 495 gates to the aunculo-ventricular apertures are swung back, to allow the stream to flow into the ventricles. If thus a murmur occur with the contraction of the heart and the first sound, it is owing to the blood either regurgitating from the ventricles into the auricles, or meeting with difficulty in passing into the aorta or pulmonary artery; if it occur after the con- traction of the heart, and correspond to the second sound, it is due to the blood passing through a nan-owed mitral or tricuspid orifice, or streaming back into the ventricles tlirough incompetent aortic or pulmonary valves. But can we distinguish at which valve the mischief lies ? Generally we can. By attending to the site of greatest intensity of the murmur, Ave become aware of the seat of its production, provided it be borne in mind what are the points at which to listen to the different valves. It is, how- ever, also necessary to recollect that, as the whole heart is some- what lowered, these points are rather below what they are in a natural state of things. Now, we cannot always say whether more than one valve is affected. A blowing sound in the heart, no matter where gen- erated, is usually transmitted all over the organ. If it mask the natural sounds at other valves, it is very difficult, nay, it is often impossible, to tell positively how many of the valves are injured, unless several spots be detected at which the murmur is intense yet not alike in character. The valves that most frequently show coexisting disease are the mitral and the aortic, particularly insufficiency of both, or aortic narrowing with mitral insufficiency. Diseases of mitral and tricuspid are also found to coexist, whether the lesion be regurgitation or narrowing. In all instances the precise character of the murmur at the different sites of the heart is of the greatest significance. Thns the blowing sound is the most conspicuous and most con- stant sign of a valvular lesion. The other signs and symptoms vary in individual cases. Where the valves are but slightly affected, let us say slightly roughened, as they sometimes are after an attack of rheumatic endocarditis, the heart does not undergo any decided change in size ; the circulation is carried on regularly ; and, in spite of the abnormal sound in the heart, the patient's health remains unimpaired, or it is only occasionally that he suf- fers from palpitations. An alteration of the valves of the heart 496 MEDICAL DIAGNOSIS, of any extent produces, however, an alteration either in the capacity of its cavities or in the thickness of its walls, and the symptoms of dilatation or hypertrophy make their appearance along with the physical signs of extended percussion dulness and feeble or heaving impulse. Ordinarily it is the latter we meet with, because the valves of the left side are so very much more frequently diseased, and their derangements lead to hypertrophy rather than to dilatation. Affections of the tricuspid valves are usually connected with dilatation of the organ; hence dropsy, venous turgescence, and albuminous urine are in them more especially observed ; and Blakiston has taught us their frequent Insufficient mitral valves permitting regurgitation of the blood. The position and time of occurrence of the most significant sign of the affection are indicated in the engraving, association with engorgement of the vessels of the brain, and how this becomes the predisposing cause of cerebral apoplexy when in connection with cardiac disease. "We also find in them, or rather in tricuspid insufficiency, what Mahot has more particularly called attention to, — a pulsation of the liver corresponding to each sys- tole of the heart, perceived by gently depressing the abdominal parietes with the hand on the epigastrium. In combined tri- DISEASES OP THE HEART. 497 cuspid and mitral narrowing we may have the signs of pulmonary- artery regurgitation.* In high degrees of aortic insufficiency, a systolic apex murmur, as pointed out by Flint, is very often pro- duced by dilatation of the mitral orifice. The murmur differs from that over the damaged aortic valves, and may be presystolic in time. In coexisting aortic and mitral insufficiency the com- pensatory hypertrophy is arrested. In some cases of mitral re- gurgitation the mitral murmur occupies only the middle or the latter part of the systole.f In instances of disease of three valves, both obstruction and insufficiency, as in the case reported by Shattuck,J double murmurs of dissimilar kind may be heard over the area of the different orifices. All valvular lesions may be combined with pain in the prsecor- dia, palpitations, restlessness, and disturbed dreams. And accord- ing as the deranged circulation through the heart interferes with the circulation in other parts, special symptoms show themselves prominently. Thus, we find those who labor under a mitral dis- ease suffering most from cough, from dyspnoea, and from attacks of cardiac asthma, since it is the lung which has to bear the brunt of the embarrassed flow of the blood. If we examine this organ closely, the physical sounds afford direct proof of its disordered condition. Here and there are heard plentiful moist sounds from fluid which has leaked into the air-tubes ; here and there the re- spiratory murmur is roughened, and percussion elicits impaired clearness. This loss of the natural resonance is at times very manifest at the upper part of the lung, and I have known it to lead to the suspicion of tubercular deposit in cases in which the autopsy showed the pulmonary tissue to be healthy, though in a state of extreme congestion. Respiratory percussion renders the sound again clear. Mitral insufficiency generally leads to hyper- trophy of the heart ; mitral stenosis not unusually becomes asso- ciated with dilatation, or there is only hypertrophy of the right ventricle. When the ax)rtic valves permit of regurgitation, this gives rise to effects which are perceptible along the track of the arteries. * Dyce Duckworth, Clin. Soc. Transact., Jan. 1888. t Crozer Griffith, Amer. Journ. Med. Sci., Sept. 1892. J Boston Med. and Surg Journ., 1891. 498 MEDICAL DIAGNOSIS. These all look superficial, and beat with apparent violence, from the force with which the thickened left ventricle is driving the blood through the tubes. The pulsation of the vessels may be even seen in the retinal vessels with the aid of the ophthal- moscope. Yet, when the finger is apiilied to the artery at the wrist, the strength of the beat is not so great as is expected. A short, abrupt, jerking impulse is indeed communicated to the finger ; but then the artery immediately recedes, proving that it was only imperfectly filled. This pulse is the only one which gives us any real information as to the state of the orifices of the heart. In general terms, it may be stated that the pulse is small and rather tense when the openings are narrowed. Still, no stress can be laid on this in a diagnostic point of view. The want of correspondence between its sti ength and the force with which the heart is acting is often amazing. More information than by merely feeling the pulse can be ob- tained by studying it with the sphygmograph. But even with this, as thus far developed, we gather in valvular diseases rather corroborative evidence than knowledge which is not attainable by other means of diagnosis. Perhaps with further research the in- strument may be made available to inform us with certainty of the degree of the valvular imperfection ; and this would be a great step in advance. As regards the most distinctive graphical signs, we obtain them in aortic regurgitation, — a vertical line of ascent Fig. 50. .KKKT ■ , ,-■-..,,-.■ Sphygmogram taken from a patient with aortic iiisrufficiency. The line of ascent does not terminate in as sharp adjoint, nor is the descent assuddeu, as 'we sometimes find ir. Fig. 51. Sphygmogriiin taken Irum a patieut preHenting the signs at miti-al regurgitation. of great amplitude, a pointed summit, and a suddeu descent, with comparatively little dicrotism. If there be also marked aortic obstruction, the line of ascent is oblique, or rather the first part is MSEASES OF THE HEAET, 499 vertical, and following the sharp point is a gradual curve-like rise ; if senile changes in the artery complicate the aortic insuiBcieucy, the sharp- pointed process terminating the line of ascent passes into a more or less horizontal plateau. In instances of decided un- complicated aortic obstruction there are sloping up-strokes and down-strokes. In mitral regurgitation the pulse tracing is usually very irregular, such as is seen at times in aneurism ; the line of ascent is short and unequal, and the line of descent is disposed to be oblique and to present marked dicrotism. In mitral constriction there is also, usually, irregularity ; it is asserted by Mahomed * that the up-stroke is vertical, and that there is, especially after giving digitalis, a secondary and very characteristic contraction of the ventricle manifest in the dicrotic wave. Sansom f agrees in the main with this observation. But, instead of entering into a detailed description of the pulse, however studied, or of any separate symptoms of valvular dis- ease, let us group them together with the physical signs, according to the combination in which we are wont to meet them : Table of Valvular Diseases. Qijim rtx. twtt.,«.t« Seat of Pis- Chahactee of Correlative Physical Signs and Symp- BEAT or muEMDR. ^^^^ DISEASE. TOMS. Mcrmcr most in- Mitral orifice. With impulse, In mitral disease the heart very coni- tense at or near means i n a u f- moiily undergoes dilated hypertrophy, apex of heart. ficiency of especially the right ventricle. When valves, permit- thereisalsohypertrophy of the left ven- ting of regitrffi- tricle, it is not simply mitral narrowing. Uttian; after The second sound of the pulmonary impulse, and artery, heard in tho second left inter- runuing into space, is sharp, accentuated. The car- or correspond- diac mnrmur is often distinctly por- ing to the sec- ceived posteriorly on the left side, near end sound, or, the angle of the scapula. Dyspnoea more accurately and dropsy are prominent symptoms, speaking, gen- especially dyspntea. Cough is not nn- erally preceding usual, and the pulse is not unfrequently the iirst sound, found to be feeble and irregular. In presystolic, some forms of mitral narrowing, where means narrouj- the curtains are not too rigid, the mur- wg of the ori- mur is always rough. This is the case fice. usually with the presystolic murmur, which is pre-eminently regarded as the sign of mitral constriction. . But in this afiection all murmur may be absent, * Medical Times and Gazette, May, 1872. f Diagnosi.? of Diseases of \hs Heart, 1892. 500 MEDICAL DIAGNOSIS. Table of Valvular Diseases — (Cotitinued.) Seat of Murmdr. Murmur most in- tense at or near the middle of the sternum, or heard with equal distinctness close tothesteraumin the secoud inter- space on the right side, and thence propagated i[ito the arterial sys- tem. Seat of Dis- ease. Aortic orifice. Murmur moat in- tense at or very near to the en- siform cartilage, and OTer the lower part of the right ven- tricle. Tricuspid ori- fice. Charaoteb of Dx6£ASe:. With impulse, means narrow- ing, or obstruc- tion; with dias- tole, and taking the place of the second sound, or occurring in both sounds, tbe first murmur short, means re- gurgitation. With impulse, re~ gurgitation ; with diastole, and t akl ng therefore the place of the sec- ond sound, or preceding the first, narrowing. Correlative Physical Signs and Symp- toms. either temporarily or permanently. In mitral narrowing a thrill in the cardiac region can be often felt. Mitral nar- rowing is frequently associated with contracted kidney. Hypertrophy of left ventricle, often to a very great degree, the compensation being very decided. All the cartiiac sounds may be normal, except at the aortic valve, although they are obscured by the murmur. This is distinct in the carotids, and is sometimes as well heard at the ensiform cartilage as over the stprnum and on a line with the third intercostal space, — a fact necessary to be aware of, so as to avoid confounding the aortic lesion with one of the tri- cuspid valve. When the orifice is con- stricted, a purring thrill is frequently observed to attend the harsh or musical systolic murmur. The symptoms in aortic valve disease are often remark- ably latent. There is very commonly neither dropsy nor dyspnoea. The pulse in regurgitation is abrupt and receding, and all the superficial ar- teries and the capillaries pulsate. It is not unusual to find a double aortic blowing sound attending aortic regur- gitation, probably from slight coexist- ing obstruction of the orifice, though this is not always found ; a double mur- mur is also heard in tbe carotids and femorals. A mitral apex murmur may be also noticeable. Tricuspid regurgitation exists usually in combination with dilatation of the right ventricle, and therefore with the symp- toms of this condition : with venous con- gestions, with dropsies, with difficulty in breathing. On account of the open state of the orifice, the cervical veins may pulsate during the movements of the heart ; and in all cases they are distended. The pulsatile motion in the neck becomes eppecially visible when the breath is held in expiration. The cardiac murmur is ordinarily soft, of low pitch, ia not transmitted into the arteries, and is not heard above the level of the third rib. In some cases it is so feeble as to be with difficulty discerned. Id tricuspid narrowing, a very rare dis- ease, there are presystolic murmur and thrill, cyanosis of the face and lips, and great dropsy. DISEASES OF THE HEART. 501 Table of Valvular Diseases— (Con^mwec?.) Seat of Murmur. Munnur most in- tense at the tliird left costal car- tilage near the sternum, or even somewhat lower, or in the second iDtercostal space to the left of the sternum. Seat of Dis- ease. Pulmonary orifice. Character of Disease. With impulse, is narrowing; taking the place of the second sound, regurgi- tation. Correlative Physical Signs and Symp- toms. ; We have little knowledge, derived from clinical observation, of diseases of the pulmonary valves, of all the valves the ones most rarely affected. Nor does a murmur in the situHtiori indicated, and hardly audible over the left apex or along the sternum, or in the course of the great vessels, having therefore the characteristics of a pulmonic murmur, ■warrant a diagnosis of disease of the valves : for it may be due t« aniemia ; be caused by deposits at the upper part of the left lung; or be observed immediately after or during the continuance of hem- orrhage from the lungs. But these re- marks scarcely hold good with reference to a diastolic murmur, and not at all as regards a double murmur. If tliia be present, and attended with thrill and with signs of dilated hypertrophy of the right heart, we are justified in con- cluding the disease to be a lesion of the pulmonary valves, or at the origin of the artery. But as regards the association with signs of hypertrophy especially, wo must bear in mind that in rare instances of mitml disease, especially regurgita- tion, the murmur is loudest at the pul- monary area. Pulmonary narrowing is almost always congenital. Pulmonary inauflBciency may be also congenital, or be due to malignant endocarditis. In this manner are the symptoms and signs of valvular affec- tions associated. It is not exactly the combination and precisely the way in which they happen in every instance. There are too many circumstances which modify them ; disorders of several valves are too constantly conjoined ; at the same orifice both nar- rowing and a state permitting of regurgitation are too often found to coexist^ — to permit any tabular representation to express either all the symptoms or all the signs which may occur in individual cases. Apart from this difficulty, there is another : even where the affection of a second valve has been correctly fixed upon, the irregularity of the heart's action may be such that it is impossible to say whether the blowing sound heard be systolic or diastolic ; whether, therefore, the orifice be narrowed or the valves insuffi- cient. But this is not a matter of so much consequence ; the 502 MEDICAL DIAGNOSIS. matter of consequence is, to determine that a disease of the valves is present. Presuming that we have been enabled to fix, and to fix accu- rately, the state of each aperture, there is a point whei'e all our skill invariably comes to a stand-still. We cannot tell how long it is possible for life to continue, or under what circumstances death will happen. It may take place suddenly and most unex- pectedly in cases in which the amount of disease in the heart is not found to be great ; and, on the other hand, life, and even a tolerable degree of health, may be maintained with valves so rigid and unyielding that the point of the knife can, at the autopsy, hardly be forced through them. In mitral disease the patient is liable to be worn out by the dropsy and by the increasing dif- ficulty of breathing ; and so, too, in that still more serious lesion, — tricuspid regurgitation. In aifections of the aortic valves the patient sufifers less, but he is more liable to sudden death. Before dismissing these valvular afiections, there are a few other matters which claim consideration, though the limits set to this work will prevent their full discussion. The blowing sound has been insisted upon as the diagnostic sign of a valvular lesion, and to insist upon this is to do no more than universal experience war- rants. But there are undoubtedly instances in which no murmur reaches the ear to show that the valves are damaged. I shall cite two examples. A man, thirty-five years of age, came under my care, complaining of palpitation of the heart, of occasional attacks of bronchitis, and of shortness of breath. His health was otherwise good. A physical examination of the chest showed the action of the heart to be extremely disturbed : the impulse was strong, and the extent of dulness in the prsecordial region increased. A blowing sound was heard near the apex, but, owing to the great irregularity of the movements of the heart, it was impossible to say whether it corresponded in time to the con- traction or to the relaxation of the organ. The pulse was small, frequent, and intermittent. The patient continued in this state for seven months, the beat of the heart becoming more and more tumultuous ; but the murmur gradually disappeared. A peculiar clacking sound took its place, which was most distinct near the apex, and was faintly transmitted to other portions of the heart. It occurred with but one sound of the heart, — with which could BISKASES OF THE HEART. 503 not be determined. For some time before his death he had con- siderable cough, with a frothy expectoration and great difficulty in breathing. His face and hands had begun to swell. The imme- diate cause of death was pulmonary apoplexy. The heart was found in a state of dilated hypertrophy, and the mitral valves had been converted into a calcareous mass, which had left but an extremely narrow chink for the blood to pass through. The next case presents, in several respects, a striking similarity. A gentleman, about fifty years of age, who had led a gay and somewhat dissipated life, noticed that he experienced difficulty in breathing on the slightest exertion. He complained also much of loss of appetite and of distention of the stomach. I could not find any cause beyond flatulence to account for this. But to the dyspnoea, an inquiry into the state of the heart furnished a clue. The size of the organ was evidently augmented, and its rhythm very irregular. The impulse was strong ; but the sounds were normal, except near the apex, where, taking the place of one, was heard a dull but very marked clack. When the hand was applied over this point, it felt a vibration of very much the same character as that which the ear could hear, and, like this, it Was limited, or certainly only distinctly perceptible, at or near the apex of the organ. The diagnosis of disease of the mitral valves Was made, and it proved to be correct. The dyspnoea became greater and greater; the feet, and subsequently the abdomen, were distended with fluid ; and the patient died with all the symptoms of an unmistakable valvular lesion. My note-book would furnish me with many more such cases ; but these two present the main features of all. All the instances of valvular disease I have met with, unaccompanied by blowing sounds, have been instances of disease at the mitral orifice, and of extreme narrowing of that orifice. They were all attended with excessive irregularity of the action of the heart, and with hyper- trophy. They all produced difficulty of breathing. They all pre- sented the peculiar clacking sound most marked near the apex. In some, another sound, more like that heard in health, followed it ; in others, not. In some, the blowing sound gradually disap- peared ; in others, none was perceived when first Examined ; and in others, again, it could be caught occasionally, as a very short whiff, along with the clacking sound. In all, the impulse was 504 MEDICAL DIAGNOSIS. Btrong and very variable in its rhythm, and a peculiar movement was felt near the seat of the apex,— not the purring tremor which so commonly accompanies the movements of a heart the valves of which are damaged, but a more localized vibration, similar, as far as such similarity can exist, to the sound the ear hears. These cases are probably of the same nature as those that are every now and then reported as valvular lesions in which the sounds of the heart were normal. I cannot think that with a disease of the valves they ever are so. There may be no blow- ing sounds present, but the sounds of the valve affected must be different from what they are in health ; and it may again, in all truth, be said that to hear the natural sounds of the heart well defined is to be able to exclude a valvular disease. The other subject to which we may advert is the possibility of valves having been insufficient to perform their functions during life, and yet no signs of their incompetence being detected after death, at least none being indicated by any structural change in the valves. That such cases occur, is attested by more than one observer. In explaining them we must take into account those blowing sounds which are produced by mere abnormal action of the structures of the heart, the functional murmurs above de- scribed, and which may occur in hearts of healthy texture or in states of hypertrophy or dilatation. Valvular disease may be at times suddenly developed, from rupture of a valvuld or of a papillary musole by a severe strain. I have known such cases to happen where there was nothing in the history to lead to the belief of previous disease, though often there is some preceding disorganization, such as a granular or a fatty change. One of the most striking diagnostic features is the quickly-originating organic murmur attending the signs of dis- ordered circulation and cardiac distress ; another, the occurrence of pain in the region of the heart. Rupture may happen in the affected valve of an ulcerative endocarditis without any extraordi- nary strain. The previous history, the sudden aggravation of the cardiac symptoms, may furnish an explanation of the accident. Let me also here briefly discuss another question, — whether the valvular affection shows any signs by which we can recognize it before the development of a murmur. We cannot do so with any certainty ; although marked alteration — such as dulness of sound DISEASES OF THE HEART. 505 confined to or most obvious at a particular valve, the signs of preceding or of growing hypertrophy, and, where the aortic valves are concerned, a distinct accentuation of the second sound, while the first has become dull and changed — might make us suspect what is about to hajipen. A doubling of either the first or the second sound, especially of the latter, is often, according to the observations of Sansom, an early sign of the development of mitral narrowing. Displacements of the Heart, The heart is a very movable organ. Its apex is tilted upward by an enlarged liver, by an abdominal tumor, or by a pericardial effusion. It gravitates toward the median line when the walls of the heart have increased in weight and firmness. But these changes are hardly of a nature to attract as much attention as finding a heart beating on the right side of the sternum. Now, it is not very uncommon to meet with it there ; and the question immediately arises, What does this strange alteration in its situation signify, and how is it brought about? It is usually produced by pressure exercised on the heart by accumulations of fluid or of air in the left pleural cavity, and therefore denotes, as a rule, a pleuritic effusion or a pneumothorax of the left side, and is accompanied by distention of that side. In rarer instances, the heart is pushed across by a highly-distended emphysematous lung; in still rarer instances, it is drawn over to the right side by a shrinking of the lung, attended with dilatation of the bronr chial tubes, the so-calkd pulmonary cirrhosis. It is sometimes found on the right side, because it had been forced there by a pleuritic effusion and had formed adhesions, so that when the fluid was absorbed it was unable to return to its natural place. In this case the left side will be markedly retracted, and not the right, as it is if cirrhosis of the right lung be the cause of the abnormal position of the heart. The displacement may further have been brought about by a cancerous or an aneurismal tumor, or by any of the abdominal viscera having slipped into the chest through a hernial opening in the diaphragm ; or it may be congenital. But these all are causes which seldom exist. Practically speaking, transpositions 32 506 MEDICAL DIAGNOSIS. of the heart are met with in connection with diseases of the lungs. We shall merely add that a congenital displacement cannot be diagnosticated unless all other causes capable of producing a dis- placement have been, proved to be absent ; and that a dislocated heart is able to perform all its functions. It may even be at- tacked by acute disease ; the recognition of which,* under such circumstances, belongs to the triumphs of physical diagnosis. SECTION III. THORACIC ANEUETSM. An aneurism of the aorta, whether caused by a disease of the coats of the artery or not, whether true or false, may affect any part of the vessel. Yet it is chiefly at the ascending portion and at the arch that it is met with. When it occurs just after the artery has left the heart, it is prone to elude discovery. Higher up, nearer to or at the arch, it more rarely escapes detection. The tumor manifests itself by a local bulging, varying in extent and situation according to the extent and situation of the aneurism. A single rib alone may be raised, or nothing but a fulness may be observed. But some prominent spot is generally detected, and when this is percussed it is more resistant, and returns a duller sound, than normal. Yet neither the bulging nor the dulness on percussion is of as much significance as finding a distinct pulsa- tion remote from the beat of the ^eart. Every time the latter is perceived, an impulse is communicated to the finger at the point in the chest-walls which appears to project ; that is, usually on the right side of the sternum in the second intercostal space, or in the same interspace on the left side, or immediately under the top of the bone. Occasionally the beat is double, at times so violent as to shake the head of the listener, and almost always, unless the aneurism be filled with solid clots, stronger than the beat of the heart. * As by Stokes. See Diseases of the Heart, p. 463. THOEACIC ANEUEISM. 507 The impulse may be accompanied by a distinct thrill. But this is not always present, and, when present, is not always con- stant ; since it may disappear and reappear. It is thus a serious mistake to regard the thrill as the requisite sign of an aneurismal enlargement ; yet there is no mistake more common, except, per- haps, one, — to consider that the motion of the blood in the sac must necessarily engender a murmur. The ear, applied o.ver the prominence, hears often nothing that in the least resembles a murmur, but sounds like those of the heart, sometimes two, the first weighty and prolonged ; sometimes but one, and that one longer and more intense than the corresponding first sound over the ventricles. Thus, then, neither thrill nor murmur is essential to the diag- nosis of an aneurism. What is much more essential, is to find two points of pulsation in the chest, — two hearts, apparently, each with its own distinct beat, its own distinct sounds. An aneurismal tumor in the chest gives rise to symptoms which vary somewhat according to its seat and size. Prominent among them stand those occasioned by pressure. The sac presses on the adjacent air-tubes, and shortness of breathing, or peculiar cough and signs counterfeiting those of a chronic laryngeal disease, are the result ; or it presses on the oesophagus, and the patient suffers from difficulty in swallowing ; or it presses on the subclavian ar- tery, and the pulses at the two wrists are noticed to be strikingly different, both in volume and in time ; or on the carotid, and pain in the head, dulness of mind, occasional giddiness, and flashes of light before the eyes, are complained of ; or on the venous trunks, and the superficial veins of the neck and thorax are seen to be engorged, and the skin becomes very puffy and swollen ; or pn the trunk of the sympathetic nerve or on its ganglia and their communications, and marked contraction, or, in rarer instances, dilatation, of the pupil of the eye on the side of the aneurismal swelling, is perceived, or profuse sweating becomes an annoying complication. All these signs, then, denote pressure, and pressure connected with a pulsating tumor in the chest means an aneurism. I say with a pulsating tumor, because a cancerous or other in- tra-thoracie morbid growth may produce exactly the same signs of compression as an aneurismal tumor, — the same stridor, the same cough, the same feebleness of repiration in one lung from partial 508 MEDICAL DIAGNOSIS. obliteration of its bronchial tube. But the solid tumor, large though it be, does not pulsate, or, if it do, pulsates but very feebly, and not with the heaving motion of a distending aneu- rismal sac. The tumor, which for the most part has its seat in the mediastinum, renders a large surface dull on percussion, and communicates a much greater feeling of resistance to the percuss- ing finger. Yet the ear listens in vain over the prominence for the weighty sound with each beat of the heart, or for the hoarse murmur of the blood streaming through the sac. It is only where a solid growth presses on the artery that any murmur is per- ceived ; and this is different from the superficial loud sounds or murmurs of an aneurism. Further, a tumor is not confined to the course of the aorta ; it is more commonly connected with a distended state of the veins of the neck and thorax, and with oedema of the arm and chest ; the pain it occasions is often more continued, and less neuralgic in its nature, and the dyspnoea is not infrequently paroxysmal. Moreover, as most thoracic tumors are cancerous, the violent constitutional disturbance, the formation of external swellings, the enlargement of the glands in the axilla and the neck, and the peculiar currant-jelly expectoration, aid us in arriving at a correct conclusion. Sarcoma, lymphomata, and lymphadenomata of the mediastinum come next in frequency to cancer.* They all tend to grow inward rather than outward, and affect the anterior mediastinum far oftener than the other two spaces. Then the history is of some value in the diagnosis. In aneurism it points to gout, to aortitis, to atheroma, to alcoholism, to syphilis, to strain, to an embolic infarct, to infectious arteritis from mycotic invasion of the aorta. The most difficult diagnosis — it is often an impossible one — is between an aneurism filled with solid clots and a tumor. The history of the case is here of the greatest importance ; and there is generally less pain in these altered aneurisms than in tumor. The physical signs will not help us. As a rule, it may be said that we do not find in the latter the ringing second aortic sound, or the shock with this, which happens in aneurism, — happens mostly even when it is filled with clots. As regards abscess of the mediastinum, we do not find the * Hare, Mediastinal Disease, 1889. THORACIC ANEURISM. 509 pressure signs generally so marked as in aneurism, and we may be able to detect fluctuation at the edge of the sternum or at the supra-sternal notch. The pain is usually very great ; the eleva- tion of temperature is significant. The sounds over the mass are not those of an aneurismal sac ; there are certainly no distinctive murmurs, and we find no marked expansile pulsation. This absence of distinct pulsation was the main point of dissimilarity between an aneurism and an abscess of the mediastinum some time since under my care, which, after lasting a year, and simu- lating aneurism most closely in the pain, the dulness on percus- sion, the difficulty of breathing and of swallowing, and the altered voice, — having, therefore, pressure signs much more marked than usual, — got well by breaking internally and by the discharge, as expectoration, of large amounts of purulent matter. In inflam- matory thickening of the mediastinum the impulse of the heart is weak and the sounds are faint.* The obvious inequality of the pupils, which is found in a certain number of cases among the signs of an aneurism, is of little aid in a difierential diagnosis from intra-thoracic tumor, for a thoracic cancer has been noted to occasion the same.f The rarity of a non-aneurismal tumor in the chest is, however, very great ; and, practically speaking, when the signs of intra-thoracic tumor are met with we shall be generally correct in thinking that it is an aneurism we have to treat, even should the pulsations not be very obvious. The sphygmograph will at times aid us in the diagnosis of an aneurism, though its value is not on the whole great. Its most distinct significance is in showing clearly the diiference between the two pulses. Of one radial the sphygmogram may be normal ; the other tracing furnishes what is a characteristic record, — a sloping up-stroke, a rounded apex, an obliteration of the secondary curves. Another sign of aneurism which has been of late much studied, and especially by MacDonnell,J is the so-called tracheal tug- ging. To obtain it the cricoid cartilage is firmly grasped and * Wilson Fox, Treatise on Diseases of the Lungs. t MacDonnell, Montreal Medical Chronicle, June, 1858 ; Gairdner, Clinical Medicine, and Ogle, Medico-Chirurglcal Transactions, vol. xll. J Lancet, March, 1891. 510 MEDICAL DIAGNOSIS. the trachea put on the stretch by pressing upward. If an an- eurism is adherent to it or near it, a significant tugging will be felt. In deep-seated aneurisms this sign is of special value, but it is not absolutely characteristic. It has been found by Grimsdale* and by Ewartf in other conditions, and even in healthy subjects. Let us suppose that we are satisfied, owing to a marked impulse, that we have not a solid growth or an abscess to deal with, — does a pulsation uniformly denote an aneurism? Can we say, on ac- count of the impulse, that it is an aneurismal enlargement? If there be also swelling and signs of pressure, we can; should these not exist, we cannot be so sure. For a pulsation in the chest not immediately over the region of the heart, although it is neai-ly always indicative of an aneurism, may be owing to other causes. Where the aortic valves are insufficient, there may be a pulsation in the aorta; an empyema may pulsate; a dilated auricle may occasion an impulse separate from that of the ven- tricles ; a pulmonary artery surrounded by consolidated lung may distinctly exhibit its beat. In all of these the signs of pressure on the surrounding parts are wanting ; and, on the other hand, they show phenomena which an aneurism lacks. Insufficient aortic valves are accompanied by hypertrophy of th^ left ventricle. So is at times a thoracic aneurism ; but, instead of the thi'obbing at the upper anterior part of the chest being attended, as in aneurismal swelling, with a natural or with an un- equal beat at the wrist, there, as well as in the larger trunks in the neck and arms, is perceived that strong and peculiar pulsation which is so characteristic of inadequate aortic valves. Then, again, a murmur is much more common in this affection of the valves than it is in aortic aneurism ; and is usually a loud double murmur, most distinct at the right base of the heart, and associated with a double murmur in the femorals made evident by pressure with the stethoscope. This is very rare in aneurism of the aorta; moreover, the murmur heard over an aneurismal pulsation is better marked over its seat than over the heart, and is mostly single, systolic and short, hoarse and of low pitch. In truth, it differs in * Practitioner, London, Feb. 1892. ■j- Brit. Med. Journ., March, 1892. THORACIC ANE0EISM. 511 distinctness as well as in quality from the murmur discerned at the base of the heart, which may be transmitted from the aneurism, or may depend upon coexisting cardiac disease. Then the sphygmo- graphic tracings may also bo of some value. Those of aortic regur- gitation, as above described, are for the most part characteristic ; while an oblique line of ascent, a loss of the summit wave, and a modification of the dicrotism are usual when an aneurism is seated on a main trunk after its origin from the aorta. When the aorta is dilated, as well as its valves diseased, the diagnosis as regards aneurism is much more difficult. But even then we lack the distinct throbbing, the signs of pressure, and the unequal pulses. While the diagnosis of aortic valve disease is under review, coarctation or constriction of the aorta, which in very rare cases is associated with the valvular aifection, may be mentioned. It gen- erally happens just at or below the insertion of the ductus arteriosus, and furnishes as its only special signs a dilatation of certain collat- eral vessels at the upper part of the thorax, and diminished size and feeble, retarded pulsation of the femorals. The arteries of the head and neck, as well as the epigastric and mammary arteries, throb, and there may be a marked thrill at the upper part of the chest near the sternum, and a murmur there louder than over the heart ; pressure signs are absent, and the dilated vessels are often the seat of a purring noise. A pulsating empyema is seldom met with ; yet a collection of fluid in the cavity of the chest may vibrate with the motion of the heart, and throb with such distinctness as closely to simulate an aneurism. To determine the real nature of the pulsation in these cases, we must attach importance to the situation of the expand- ing mass, which is not often that of an aneurism, and to the signs which point out that liquid has accumulated within the pleural sac. We also note the circumstance that over the seat of impulse there are no peculiarly marked sounds, no murmurs, no thrill ; moreover, the beat, which is wide-spread, is not apt to be so strong as that of the heart, which is displaced. The pulsation may happen both in acute and in chronic pleurisy, and be associated, as in Osier's * case, with persistent tenderness of the thoracic walls. * Amer. Journ. Med. Sci., Jan. 1889. 512 MEDICAL DIAGNOSIS. There may be a number of these pulsating tumors.* Pulsating pleurisies are nearly always left-sided and purulent ; there is gen- erally latent pneumothorax present, f In one of Wilson's cases J the pulsation disappeared immediately after aspiration. A dilated auricle, the walls of which are at the same time hypertrophied, may give rise to a movement separate from that of the beat of the ventricle. Bouillaud cites an example of this nature, in which a double motion was perceptible in the second intercostal space of the left side, in a person whose heart was extensively hypertrophied aud whose mitral valves were indu- rated. Such cases are exti-emely rare. The signs of an accom- panying valvular affection and of enlargement of the ventricles, and the probable presence of dropsy, would serve to distinguish a dilated auricle from aneurism of the arch. And this is the only form of enlargement of the heart which is likely to be mistaken for an aneurism. In cases of hypertrophy or dilatation as we ordinarily meet with them, there is but one motion dis- cernible, — that over the ventricles, — and not two beats at some distance from each other ; the signs of pressure, too, are wanting. In dilatation of the right auricle, Sansom notes a vibration to the right of the sternum and a wedge-shaped line of dulness joining the dulness of the liver. A pulmonary artery surrounded by consolidated lung-tissue may cause — especially if the vessel be somewhat widened — a distinct pulsation. But the seat of the dulness near the apex of the left lung ; its non-extension over the median line ; the limitation of the murmur to the site of the pulmonary artery, or, in some in- stances, to this vessel and the subclavian; the sharply-defined second sound of the pulmonary artery in the second interspace on the left side ; the symptoms and physical signs of phthisis, the most common cause of the consolidation, and a morbid condition which of itself would appear to exclude an aneurism ; the absence of pain and of the phenomena caused by pressure, — all these prove the murmur and the pulsation not to be due to an aortic aneurism. Absence of pain and of pressure signs, and accen- * Henry, Proceed. Phila. Co. Med. Soc, vol. iii. t Comby, Arch. Gen. de Med., April, 1889. J Transact, of Assoc, of Amer. Physicians, 1893. THOEACIC ANEURISM. 51S tuation of the second sound, are also the chief signs by which we distinguish those comparatively rare cases of murmur in the second interspace, close to the left of the sternum, which are due to retraction of the lung and uncovering of the heart and pulmo- nary artery. The murmur, which has been specially studied by Quincke* and Balfour,t is systolic and loud, and mostly disap- pears on deep inspiration. The pulsation is marked, though not so strong as that of the heart ; the singular murmur is supposed to be owing to compression of the pulmonary artery by the heart during the systole. In many respects it is like the murmur, which I have elsewhere investigated,J heard over the pulmonary artery in certain lung aifections. Another abnormal condition which may be mistaken for an aneurism is a malformation of the chest, particulai'ly when pi'o- duced by great prominence of the upper part of the sternum. This error is more especially apt to occur if there be coexist- ing disturbance of the heart, whether of functional or of organic origin. I have seen cases where the beating of the arteries of the neck, accompanied by an enlargement of the thyroid gland and by cardiac palpitation, was believed to be an aneurism, mainly because it was combined with very decided prominence of the upper portion of the sternum. But there were no distinctly localized tumefaction and pulsation, no altered sounds, no signs of pressure. I have also met with instances in which the active pulsation of the thyroid gland, both in exophthalmic and in ordi- nary goitre, gave rise to the idea of an aneurism, but in which no change of the chest-walls existed. In such cases the carotids and radials beat equally ; a blowing murmur, attended by a contin- uous hum, is heard — certainly in instances of exophthalmic goitre — over the enlarged gland ; there is nowhere a point of localized pulsation, and there are also no signs of pressure. Malposition of the aorta, due to rickets, may simulate an aneu- rism closely. Balfour § has pointed out how misleading may be the abnormal pulsation with the dulness on percussion, and the right-sided prominence of the chest. Moreover, thrill, murmurs * Berliner Klinische Wochenschrift, 1870. j- Lectures on Diseases of the Heart, London, 1876. i Amer. Journ. Med. Sci., Jan. 1859. § Diseases of the Heart, London, 1876. 514 MEDICAL DIAGNOSIS. loudest over the pulsating mass, and cardiac hypertrophy, may coexist. We must be guided in our opinion by the history of the case ; by the distortion of the spine ; by the extended superficial dulness on percussion, out of proportion to the extent and strength of the pulsation of the tumor, which is less forcible than that of the heart ; by the displaced position of the heart, which is tilted upward and thrown over more to the right ; and especially by the absence of any signs of pressure. The signs of pressure play, then, a very important part in the diagnosis of an aneurism. They are rarely absent, although they do not always manifest themselves in the same manner : some- times it is bone, sometimes lung, sometimes oesophagus, sometimes nerve-fibre, which bears the brunt of the distending swelling. These signs of pressure are wanting if the sac be very small or be absent ; or not prominent if the artery be simply dilated, in which case nothing but a constantly pulsating tumor can be de- tected. At times evidences of compression may be recognized by the attentive physician when no throbbing swelling can be discerned ; and from them he infers the true nature of the case, although utterly unable to discover any of the ordinary physical signs of an aneurism. Whenever, indeed, obstinate and anom- alous thoracic symptoms, which might be explained by the pres- ence of an aneurismal sac, occur in a person whose lungs and heart appear to be in every respect sound and whose general health is not materially affected, we may suspect an aneurism to be the source of the disorder. So, too, if any laryngeal affection, or if any difficulty in swallowing, exhibit rather peculiar symp- toms. It is, in truth, imperative in all cases of chronic disease of the larynx, or where there are indications of a stricture of the oesophagus, to examine the chest carefully, so as to avoid the grave error of overlooking what may be the only cause of the whole disturbance. The symptoms of chronic laryngitis especially are at times aston- ishingly simulated, and it may happen that the patient, trusting to his feelings, refers obstinately to the chest as the seat of the disorder, while the physician as obstinately sees nothing but the presumed affection of the larynx. There is, as in chronic laryn- geal disease, alteration of the voice, with stridor, and cough ; but the voice is not so uniformly changed. Often it retains much of THOEACIC ANEURISM. 515 its natural character ; and the loss is not so progressive, and the aphonia not so permanent. Hoarse the voice may be, but, as the direction of the pressure varies, it alters rapidly both in pitch and in power. The cough is most commonly loud and paroxysmal, and has a ringing sound. Dyspnoea is a very constant symptom ; it may be due to laryngeal disorder, — spasm or palsy of the mus- cles caused by pressure on the recurrent laryngeal nerve, — or to compression of the trachea and a large bronchus. It is often attended with wheezing or stridulous breathing, which is not per- sistent, and is sometimes produced only after a deep inspiration. The stridor, however, as Stokes points out, differs from that of an obstructive disease of the larynx by its seeming to issue from the notch at the sternum, and not from above, from the larynx itself. If, in addition, the respiration be found to be markedly unequal in the two lungs, the diagnosis of aneurism may be ventured upon ; and it will be confirmed by finding no change in the larynx, when examined with the laryngoscope, sufficient to account for the laryn- geal symptoms, or such a change — ^paralysis of only one cord, for instance, or paralysis of an abductor on one side — as could be readily explained by pressure on one recurrent nerve.* Of course, the detection of dulness on percussion, of sounds stronger than or otherwise diffi>rent from those in the cardiac region, or the occur- rence of a hemorrhage, would place the diagnosis beyond doubt. A systolic sound or thud in the brachial artery is also a sign to which importance may be attached, f In some cases of aneurism, pain is among the earliest symptoms, and the patient complains much of it before there is a single phys- ical sign indicative of the presence of a tumor. The pain is de- pendent upon pressure on the nervous filaments : it may shoot toward the shoulder or the neck, along the arm, or deep into the centre of the chest. Dull, deep pain, boring and constant, occurs when the pressure of the sac is leading to absorption of the ver- tebrte. Over the seat of the swelling there is often pain, asso- ciated with great tenderness. The severity of the pain may give rise to emaciation and ex- * In the chapter on Diseases of the Larynx, the forms of laryngeal palsy from an aneurism have been more specially examined into. I Glascow, New York Med. Joum., Sept. 1894. 616 MEDICAL DIAGNOSIS. haustion, and become a cause of death ; but death does not often take place from exhaustion. More usually the patient's life is cut short by the aneurism bursting, either externally or into internal parts, — into the trachea, bronchial tubes, oesophagus, peri- cardium, pleura, pulmonary artery, or spinal canal. Yet it is not always the first rent which leads to the fatal issue ; this, as we learn from the cases that Webb * has analyzed, may, when the aneurism breaks externally, not happen for weeks after the accident. Now, can we foretell the course of an aneurism, and the prob- able mode of death it is likely to occasion ? We cannot ; for in order to do so it would be requisite to determine accurately its seat, so as to know what tissues are likely to be encroached upon. And this is very difficult, nay, often impossible. It is true that, when the swelling gives rise to phenomena like those of angina pectoris, we may surmise it to be in the ascending portion of the aorta and near the cardiac plexus of nerves, and look for its breaking into the pericardium or the pulmonary artery ; when it is accompanied by laryngeal stridor or other laryngeal symptoms, it probably involves the posterior and lower portions of the arch, and will cause death by strangulation or by exhaustion ; when it produces much dyspnoea, it is apt to be seated in the descending part of the arch, and death may take place by the aneurism bursting into a bronchial tube, or by pneumonia. But in regard to all these matters we can usually do little else than conjecture ; because a tumor within the chest leads to such displacements that its relations to the surrounding structures cannot be clearly ascer- tained during life. The most valuable information we obtain is from a study of the physiological changes, — from the symptoms, therefore, of disturbed function. An aneurism of the descending aorta, between the arch and the diaphragm, produces, if extensive, dulness on percussion and bulging posteriorly, and may exhibit the same physical signs and symptoms as an aneurism in the neighborhood of the arch. A gnawing sensation in the vertebrae has been especially noticed. Yet, in spite of the most careful scrutiny, an aneurism of the descending aorta often escapes detection, or its physical signs, * Amer. Journ. Med. Sci., Oct. 1874. THORACIC ANEURISM. 517 as a case recorded by Walshe * proves, may exist to the right in- stead of to the left of the spinal column, because the vessel has been dragged across the median line by its enlargement. An aneurism of the heart may in exceptional instances produce localized bulging in the cardiac region. But, whether it does so or not, it is beyond the reach of positive diagnosis. We may suspect it if the bulging have been preceded by signs of fibroid degeneration of the walls of the heart. Obstructed coronaries producing the myocardial changes are its most common cause. Pericarditis with adhesions near the aneurism has been also noticed. In a number of instances we have a syphilitic history. In rare instances we find a varicose aneurism communicating with either the ascending or the descending vena cava. These aneurisms mostly present the ordinary signs of a thoracic aneu- rism ; but, in addition, great venous enlargement above the dia- phragm, with oedema of the face and hands and arms ; a purple hue of the face and the upper part of the body, and spots of ecchymosis in the skin ; a jerking pulse ; a purring thrill ; and a whirring systolic murmur,f diffused all over the front of the chest. The oedema and the symptoms of venous disturbance come on suddenly. In instances of occlusion of the vena cava the great venous distention is not accompanied by the physical signs of an aneurism, nor by the thrill, nor by the cyanosis and oedematous swelling. J Let us, in conclusion, glance at the other kinds of aneurism within the thorax, — that of the innominate and that of the pul- monary artery. An aneurism of the innominate artery is strictly limited to the right side of the body. It differs from that of the arch by the higher situation of the pulsating swelling ; by the displacement of the clavicle ; by the comparative absence of signs of pressure on the .larynx and oesophagus; and by the fact that compression of the right subclavian and carotid diminishes the beat of the tumor, while it exerts no effect on an aortic aneurism. Such are, at all events, the marks of distinction indicated by the observations in * Diseases of the Heart. f As in Mayne's civ,e, Dublin Quart. Journ. of Med. Sci., Nov. 1853; also in Glascow's case, St. Louis Courier of Med., Jan. 1885. J Arthur V. Meigs's case, Transact. Coll. of Phys. of Phila., 1886. 518 MEDICAL, DIAGNOSIS. Holland's * excellent memoir. An additional sign is mentioned by Wardrop.f It is that when the innominate is affected the diffi- culty will appear first on the tracheal side of the sterno-mastoid ; but on the cervical side if the aneurism be of the subclavian. In aneurism of the innominate, further, as the tumor is under the right sterno-articular articulation, percussion does not detect any distinct enlargement of the arch of the aorta. An aneurism of the pulmonary artery is a rare disease. Its main phenomena are : a strongly pulsating swelling, perceptible to the left of the sternum, and limited to the second intercostal space near the costal cartilages ; a marked thrill with each expan- sion of the aneurism ; and in some instances a rough murmur, which is not discovered at the notch of the sternum or above the clavicles ; lividity of the face ; dropsy ; and great difficulty of breathing.J The most significant points of difference between an aneurism of the pulmonary artery and an aneurism of the aorta consist in the symptoms just mentioned, and in the absence of obvious evidences of pressure. The situation, too, of the physical phenomena is important; yet we must bear in mind that an aneurism of the arch may occasion a pulsating tumor, mainly to the left of the sternum, and may even break into the pulmonary artery. A mere distinct beating of the pulmonaiy artery is dis- criminated from an aneurism of this vessel by the non-existence of a palpable swelling, of dropsy, of greatly-embarrassed breathing, of lividity of the face, and by the usually coexisting signs of some consolidation of the left lung. Occasionally we meet under the outer half of the left clavicle with a pulsating tumor presenting thrill and murmur, and dilated veins above. These signs may be supposed to indicate a sub- clavian or axillary aneurism ; but they often suddenly disappear. These " mimic" or phantom aneurisms § are apt to come back after excitement and after movement of the arms. They are thought to be due to temporary dilatation of the artery from vaso-motor paralysis, limited to a large vessel or to part of it. * Dublin Quarterly Journal, vol. xii. f Holmes's Surgery, vol. iii. p. 562. J In the case detailed by Skoda, Auscultation and Percussion, the dropsy was very great, and the face cyanotic ; there was a faint murmur over the base of the heart, but none over the pulmonary artery. I See paper by Samuel West, St Barthol. Hosp. Rep., 1880. CHAPTEE V. DISEASES OP THE MOUTH, PHAKYNX, AND (ESOPHAGUS. The diseases of this part of the digestive system need not here be described at any length, because many of them have already been considered in treating of the affections of the larynx and of the heart and great vessels. But with the maladies of this part of the body may be considered the enlargement of glands at the angle of the jaw, as happens in mumps.- MOUTH. Soreness of the mouth, pain in masticating, and a fetid breath are often complained of in diseases of the oral cavity. Let us suppose a patient to present himself with such symptoms. The interior of the mouth is exposed to a strong light, and its different parts are inspected. The gums are noticed to be swollen and injected, and the mucous membrane lining the cheeks reddened. — ^This is a state of things observed in the different forms of stomatitis. In the common diffused inflammation, the result of direct irritation, such as of the swallowing of hot liquids or of corrosive substances, or an accompaniment and consequence of gastric disorder, the redness is marked ; any attempt at chewing is painful ; the taste is impaired ; a flow of saliva takes place from the mouth, and superficial ulcer- ations occur at its various parts. In mercurial stomatitis there are much the same symptoms ; but the more copious discharge of saliva, the pain in the jaws, the loosening of the teeth, the enlarged tongue, exhibiting their impress, the painful and swollen state of the salivary glands, and the peculiar nauseous breath, testify to the specific character of the inflammation. The sore mouth of scurvy may be distinguished from either of the preceding forms by the spongy, purplish, or livid gums, which bleed on the slightest 519 520 MEDICAL DIAGNOSIS. touch, by the eruption on the skin, and by the other signs which attend a scorbutic state. The gums and the inside of the cheeks and lips are covered with a whitish curd-like exudation. — This constitutes the form of stom- atitis known as thrush, so frequent in infants at the breast, and so constantly associated with intestinal disorder, with diarrhoea, with colicky pains, and with a feverish heat of skin and a hot, dry mouth. Very similar to it, regarded indeed by some as identical, is the aphthous ulceration, to which adults as well as children are liable. Here, too, a whitish deposit is perceived in various parts of the mouth ; it is apt also to be combined with thirst and with gastric or intestinal disturbance, and the breath has a very disagree- able odor. The recognized difference consists in the presence of the small ulcers which may be detected when the white crusts that cover them are removed, and in the vesicular nature of the disease during its formative stage. Then more or less redness surrounds each spot, the ulcers are slightly raised at their borders, bleed easily on pressure, and may be irregular from several running together ; their grayish covering is found to be soluble in ether, and to present many oil-globules under the microscope. On the other hand, the microscope shows us in thrush a special parasitic formation, the Oidium, or Mycoderma, albicans. Ulcerations are perceived on the gums, tongue, and various parts of the mouth. — We meet with ulcers in the ordinary, in the mer- curial, in the scorbutic, and in the aphthous inflammation of the mouth. But ulceration is apt to exhibit its most horrible features in the sore mouth of syphilis, and in that essentially ulcerative disease called cancrum oris, or gangrenous stomatitis. In the former the fauces as well as the mouth are, as a rule, involved, and the ulcers show peculiarities which we shall presently study. The latter is an affection which prevails especially in enfeebled constitutions. It is seen chiefly in hospitals, and not uncommonly in epidemics. It begins with pain in the gums, and these soon swell, redden, and bleed readily. They are covered with a soft, grayish exudation, which often extends to the soft palate. If the layer of exudation be scraped away, a bleeding, ulcerated mucous membrane comes into view, provided the swelling be not so great as to render a careful examination of the mouth impossible. The breath is most offensive ; a profuse flow of saliva is noticeable ; DISEASES OF THE MOUTH, PHARYNX, ETC. 521 perforation of the cheek quickly takes place ; the bones may be laid bare, the teeth loosened ; there is usually fever, often of hectic type ; yet the disease does not uniformly progress with activity ; it may last for weeks. The tongue is red and swollen. — Changes in color and in ap- pearance of the tongue occur in general diseases of the system, and more especially in those of the alimentary canal. The tongue is also more or less involved, at all events its mucous membrane is, in the different forms of stomatitis. An abnormal state of the covering of the tongue is, therefore, far from being a sign that the organ itself is primarily affected. Occasionally, however, we do meet with affections of its deeper structures. Its nerves may be the seat of violent neuralgia ; its muscles may be paralyzed ; it may become hypertrophied or can- cerous ; it may undergo progressive atrophy ; or it may be in a state of aaide inflammation. The latter is, perhaps, the most frequent of its maladies, and is readily recognized by the red, swollen look of the organ, joined to a burning pain in it, and either to great dryness of the mouth or to constant di'ibbling. The swelling usually begins at the anterior portion, and may become so considerable as to threaten suffocation ; the inflamed tongue fills up the fauces and protrudes out of the mouth, and the unhappy patient can neither swallow nor utter a word. He has active fever, headache, great restlessness, and intense thirst, — symptoms which last for several days, and until the inflammation subsides. This may run on to suppuration or gangrene ; in some instances it leaves a permanent induration that may be mistaken for a cancerous nodule. Acute glossitis is a dangerous complaint ; fortunately, it is a rare one. Its most frequent cause, as now seen, is direct injury, either from wounds or the stings of venomr ous insects, or from the introduction of corrosive substances into the mouth. Its most frequent cause formerly was the abuse of mercury pushed to salivation. At times it is observed as a com- plication of scarlatina or of erysipelas. Other affections of the tongue connected with diseases of its structure have been mentioned in the first part of this volume. Cancer of the tongue produces the greatest alteration in the form and texture of the organ. Syphilis of the tongue gives rise to deep fissures, ulcers, and gummous nodules which may be difficult 33 522 MEDICAL DIAGNOSIS. to distinguish from cancer, except by the history and the absence of pain. As a sign of recovery from syphilis, the tongue may present a quite peculiar indented appearance, similar to what is seen in the syphilitic liver. FAUCES. The fauces — that is, the parts at the back of the mouth which are brought into view when the lips are widely opened, such as the half-arches, the uvula, the tonsils, the posterior wall of the pharynx — may be involved in the same diseases as the parts situ- ated in front. The contiguity of these structures is in fact such that any morbid action is apt to spread to them, or to extend from them either forward or downward into the pharynx, and even into the larynx. Moreover, on this very account a disorder is rarely found limited to any one portion of the fauces, but transfers itself generally from one to the other, from the tonsils to the soft pal- ate, from the soft palate to the tonsils. The most common affec- tions of the fauces are inflammation and ulceration, both of which occasion a feeling of uneasiness in the throat, and also difficulty or pain in deglutition, and both of which are readily enough detected by looking into the mouth when the jaws are widely separated and the tongue depressed. In the ordinary inflammation of the fauces, the simple angina, or sore throat, the parts are of a bright-red color, and the uvula is long and swollen, and by dropping on the tongue gives rise to a constant disposition to swallow, although the act of swallowing is attended with pain. Associated with the angina are coryza and febrile disturbance; and, owing to the inflammation travelling up the Eustachian tube, the sense of hearing is impaired. Tonsillitis. — When the inflammation penetrates the substance of the tonsils, or in quinsy, much the same general symptoms occur as in ordinary angina. But the sense of constriction in the throat is greater ; so is the difficulty in swallowing ; and liquids are apt to return through the nose. The voice is thick, and has often a peculiar sound ; it is painful to the patient to talk, and on looking into the throat the tonsils may be seen red, prominent, and covered with mucus which is not easily detached. Sometimes the swelling is so considerable that the tumid glands fill up the DISEASES OF THE MOUTH, PHARYNX, ETC. 523 space between the half-arches and leave but a small interval for the passage of food or drink. In some instances we cannot sep- arate the jaws suiBciently to get a view of the throat, and have to trust to the introduction of the finger to tell us the condition of the affected parts. Occasionally the inflammation extends from the tonsils to the salivary glands ; the submaxillary and parotid glands swell, and ptyalism takes place. It is necessary to be aware of this fact ; for, if a mercurial cathartic has been admin- istered, the profuse flow of saliva might be incorrectly attributed to it. There is not much likelihood of confounding this, a form of secondary parotitis, with mumps, in which an outwaiai swelling, visible beneath the ear, is found, but not a swelling within the throat, and in which no real difficulty in swallowing occurs, elcept, perhaps, when the tumefaction is at its height, and then only for a short time. Tonsillitis terminates by resolution or by the formation of pus. There are no positive means of ascertaining that the inflammation is going to end in suppuration, although we may suspect that this will be the case when much pain is felt at the angles of the jaws and shooting to the ear, and when the symptoms have been severe and persistent for more than four or five days. Sometimes the pus may be seen through the covering of the tonsils ; but often the vast sense of relief experienced by the patient, and the sudden improvement in deglutition, attended, perhaps, with an unpleas- ant taste, are the only signs that the collection of pus has been discharged. Attacks of tonsillitis are prone to be repeated, and may lead to permanent enlargement and induration of the tonsils. The enlarged tonsils, attended as they frequently are with cervical glandular swellings, may be mistaken for cancer of the tonsils. But in this affection sanious offensive discharges from the mouth occur, and, whether the disease be encephaloid or round-cell sarcoma, it extends rapidly ; the neighboring lymphatic glands are early involved, the palate and the pharynx become implicated, and hemorrhage is frequent, as are also difficulty of deglutition and attacks of suffocation.* Acute tonsillitis may be * Poland, Brit, and For. Med.-Chir. Kev., April, 1872; Newman, Amer. Journ. Med Sci., May, 1892. 524 MEDICAL DIAGNOSIS. seen in connection with malaria.* At times the tonsils become gangrenous.f Acute Follicular Tonsillitis. — There is a form of acute tonsillitis that is limited to the follicles and has well-marked clinical features. It begins with chilly sensations, to which a moderate fever, rarely exceeding 103°, succeeds. After a few days the fever disappears, a slight evening rise remaining, and in a week from the onset the patient is quite convalescent, though weak. At the height of the malady a swelling of the cervical lymphatic glands is often observed. But the characteristic feature of the disease is in the tonsils. These are red and slightly tumefied, and a thin yellowish or whitish .punctiform exudation is seen in the crypts and around the follicular openings. This comes away gradually ; in some parts much sooner than in others, and for days after convalescence from the general symptoms the appearance is found in some folli- cles. When cast off, superficial ulcerations on the glands may be noticed. This form of tonsillitis, called by some diphtheritic sore throat, is infectious, and various micro-organisms have been found in the exudate, particularly streptococci, staphylococci, and pyo- genes aureus. Diphtheria. — There is another kind of affection of the fauces which, in accordance with the clinical classification followed in this work, may be considered here, notwithstanding its specific character, — membranous angina, or diphtheria. Recent research leads us, indeed, to believe that the malady is primarily a local one, dependent upon the lodgement and multiplication of a specific bacterium. The constitutional symptoms are to be attributed to the absorption and action of the toxic products generated at the site of infection. The bacillus of diphtheria was discovered by Klebs, and more fully studied by Loefiler. It is about as long as the tubercle- bacillus, but nearly twice as thick. It is, as a rule, curved, but its form is variable. It has rounded extremities, which are some- times club-shaped. It is non-motile ; it does not form spores. It may be stained in cover-glass preparations with Loeffler's al- kaline methylene-blue solution, which consists of thirty cubic * Chassaignac, New Orleans Med. and Surg. rTourn., Oct. 1888. t Cragin, New York Med. Journ., Sept. 1, 1888. DISEASES OP THE MOUTH, PHARYNX, ETC. 525 centimetres of a concentrated alcoholic solution of methylene-blue and one hundred cubic centimetres of a 1 : 10,000 solution of Fig. 52. I. II. III. s0^^ ^%^ ^^h »?Va% fe^^ f^^^^,f^'^> t» Klebs-Lot^ffler bacilli, from specimens prepared by Dr. Goplin imd Dr, Bevan. Fig. I. Fresh culture upon glycerin agar-agar. Eye-piece IV , Beck ; Objective -^ ol. im. Leitz. Fig. II. Fresh culture upon blood-serum. Eye-piece IV., Beck ; Objective -^ ol. im. Leitz. This is also the appearance when obtained directly from the throat and subjected to the same power. Fig. III. Old culture upon blood-serum. Eye-piece IV., Beck ; Objective ^ ol. im. Leitz. potassium hydroxide. The organism grows best upon a culture- medium consisting of three parts of blood-serum and one part of a mixture of meat-infusion with one per cent; each of peptone and grape-sugar and one-half per cent, of sodium chloride. This is sterilized and at the same time solidified in test-tubes supported at an acute angle in a steam or hot-air sterilizer at a temperature a little below 100° C. The inoculation is made by means of a pledget of cotton wrapped on the end of a steel rod, and the culture-tube is kept in a thermostat at a temperature of about 37° C. In the course of from twelve to twenty-four hours, dense, white, opaque colonies develop, and examination of cover-glass preparations will disclose the presence of the characteristic bacil- lus. Bacilli resembling true diphtheria-bacilli in appearance and in culture, but wanting in virulence, have been described as pseudo- diphtheria-bacilli ; but "it is believed that these are merely a modi- fied form of diphtheria-bacilli. The disease begins usually as sore throat, with redness and swelling of the arches of the palate, and of the tonsils. There is slight stiffness of the neck, the cervical and submaxillary glands of the jaw are enlarged and tender, and the subcutaneous tissues may become involved in the swelling. Within a period varying from a few hours to a few days, an exudation takes place 526 MEDICAL DIAGNOSIS. on the tonsils, the uvula, and the soft palate. This exudation is more or less extensive, generally tough, and of a white or grayish hue. It may show but little tendency to spread ; or it may extend to the gums, and along the walls of the pharynx into the windpipe, sometimes even into the bronchial tubes and the lung structure. In some cases it passes upward into the nares, yet it may begin there or in the larynx simultaneously with its appear- ance in the throat. The false membrane in the throat, once formed, darkens, wastes from the circumference toward the centre, and gradually dis- appears. But sometimes the coat becomes for a time thicker and thicker by the constant addition of fresh layers. This happens particularly in the " croupous form" of diphtheria, in which the inflammation is more intense from the onset and the fibrinous exudations succeed one another rapidly until the dense thick coating of false membrane results. Under any circumstances, when artificially removed, the pseudo-membrane is soon re- developed. After the first week from its beginning, no further exudation is apt to take place, and the danger arising from the membrane may be generally looked upon as over, unless, as is not uncommon, a relapse of the malady occur. The specific bac- terium may, however, be present in the fauces and nasal passages for many days, even for weeks, after the disease has apparently come to an end.* It may be occasionally found in the absence of false memorane, and also, it is said, in the throats of healthy per- sons.f The Klebs-LoefBer bacillus has been also detected in in- stances presenting all the clinical features of follicular tonsillitis, and, however valuable it is as a sign, we are not justified, with pur present knowledge, in abandoning well-attested clinical experi- ences and making the presence or absence of the bacillus the only test of diphtheria. * Tobieson, Centralblatt fiir Bakteriologie und Parasitenkunde, Bd. xii., No. 17, p. 587; Park and Beebe, Medical Record, vol. xlvi., No. 1247, p. 1. Abel (Deutsche Mediciniscbe 'Wochenschrift, 1894, No. 35, p. 692) has re- corded a case in which virulent diphtheria-bacilli were found sixty-five days after the onset of the primary illness. t Feer, Correspondenz-Blatt fiir Schweizer Aerzte, 1893, No. 8, p. 295 ; Welch, American Journal of the Medical Sciences, Oct. ] 894, p. 427 et seq. ; Park and Beebe, Medical Eecord, vol. xlvi , No. 1247, p. 1. DISEASES OF THE MOUTH, PHARYNX, ETC. 527 The constitutional symptoms vary greatly. The pulse may be frequent, the skin hot, and there may be much pain in the head ; in fact, the symptoms are those of fever, with a temperature of 102° to 103°. Yet the temperature is exceedingly variable ; there is often, even in the worst cases, an almost normal temperature. A sense of weakness and prostration are prominent from the onset. Not rarely the urine contains albumin and casts, and there may be partial or complete suppression of the renal secretion. In some instances typhoid phenomena manifest themselves, especially when decomposition of the disintegrating exudation takes place, giving rise to the septic form of the malady ; in this the tempera- ture may be even below the normal. The nervous system be- comes much affected, and the tendon reflexes are lost.* In children exacerbations of pre-existing nervous symptoms may take place and give rise to a state resembling acute bulbar palsy.f In diphtheria the danger is twofold : it arises partly from the depressing effect of the poison, increased as this effect must be by the absorption of toxic matter from the throat, partly from the extension of the disease to the larynx and lungs. Again, at the height or even at the decline of the malady there is risk of heart- palsy or heart-clot and of peripheral embolism.J Nor is the termination of the acute disorder always the termination of the complaint. A chronic irritation of the throat, lasting weeks or months, and readily relapsing, on exposure to infection, into a diphtheritic sore throat, remains ; or albuminuria, which outlasts the acute manifestations ; or pleurisy, or bronchitis and pneumonia, — both of which may be delayed until after the exudation has dis- appeared from the throat, — increase the list of the complications of the affection, and protract or imperil the convalescence. Occa- sionally, too, inflammation of the joints is observed in the course of diphtheria, or as a sequel, and sometimes trophic changes in the periarticular structures are met with.§ * McDonnell, Medical News, Oct. 15, 1887. t Guthrie, Lancet, April 18, 25, 1891. X A case has been recorded in which embolic obstruction of the popliteal artery occurred during convalescence from an attack of diphtheria, and amputa- tion of the affected member became necessary. Eooney, Occidental Medical Times, vol. vii.. No. 4, p. 188. g Lyonnet, Lyon Medical, Jan. 4, 11, 1891. 528 MEDICAL DIAGNOSIS. Some morbid conditions there are which may be wholly looked upon as after-symptoms. A paralysis of the velum palati and of the pharyngeal arches, making itself apparent by a peculiar nasal intonation of the voice, and by proneness to regurgitation of fluids through the nostrils, is among the earliest of them; it manifests itself often, indeed, just at the termination of the acute malady. Later appear impairment of vision, gastrodynia, ulcers in various parts of the body, profound anaemia, and that gradual failing of muscular power with numbness which ordi- narily does not take place until after complete convalescence, and which winds up in almost total loss of muscular force with anaes- thesia, and absence of reflexes, constituting diphtheritic paralysis. In rare instances these symptoms occur early in the attack.* They are attributable to the development of a peripheral neuritis dependent upon the action of the toxic products of the disease. Hemiplegia has been observed in some cases as a result of rup- ture of a cerebral blood-vessel or its occlusion by a clot.f Other symptoms of profound nervous derangement have also been re- corded, such as peripheral neuritis, in which the sense of smell and the muscular sense were lost, and slight sensory irritation was not appreciated, while more profound impressions were re- ferred to corresponding points on the opposite side of the body,J with temporary absolute deafness, unsteadiness of gait, and paralysis of the palate.§ Furthermore, I have known aphasia to follow the depressing complaint. But to look at the differential diagnosis of the disorder. It varies widely from stomatitis, from tonsillitis, from pharyngitis, ^in truth, from all the ordinary local inflammations of these structures, — by the presence of a membrane, by the striking con- stitutional symptoms, and by the sequelae. The diagnosis becomes unequivocal if the characteristic bacilli are found on bacteriologic * As in two cases reported by Dabney, Medical News,. Jan. 16, 1892, in which they appeared on the first and second days respectively. t McPhedran, Canadian Practitioner, 1892, No. 19, p. 454 ; Allen A. Jones, Medical News, Oct. 22, 1892, p. 467 ; Edgren, Deutsche Medicinische Wochenschrift, 1893, No.' 36, p. 864; C. W. Sharpies, Medical News, Aug. 4, 1894, p. 124. J G-ay, Brain, part Ixiii., p. 431. J Tooth, British Medical Journal, 1893, No. 1680. DISEASES OF THE MOUTH, PHARYNX, ETC. 529 examination of some of tlie material taken from the throat or the nose. Yet there are certain sources of error against which it is neces- sary to guard. In simple pharyngitis, a mass of mucus, in part derived from the nares, is apt to collect on the inflamed mem- brane, and looks at first sight like the coating from an exudation ; but it may be easily removed, and a closer inspection proves its true nature. In follicular tonsillitis, liquid may ooze from the openings of the follicles on the surface of the swollen tonsils, or little yellowish or whitish points form there. But they are strictly confined to the gland, exhibit no tendency to spread or to coalesce, and are generally small white specks of roundish or oval shape. I desire particularly to call attention to the possibility of confound- ing these appearances with diphtheria, for I have known them to occasion more than one mistake. The error is most likely to happen in those mild cases of the disease in which the exudation is limited and the injection or superficial inflammation of the tonsils and back of the throat marked, which are sometimes de- scribed as the "catarrhal form" of diphtheria. What adds to the diSiculty is that follicular tonsillitis is contagious. Should, in an individual instance, the facts mentioned be insufficient to solve the doubt, the microscope can do so ; for it shows the white or yellowish masses to be largely composed of epithelium, and not, like the diphtheritic membrane, mainly of fibrillated fibrin, of granular corpuscles, and of leucocytes, besides epithelium in different degrees of development and retrograde change.* Fur- ther, if the case is one of follicular tonsillitis, streptococci and staphylococci are likely to be found, though, as already stated, the Klebs-Loeffler bacillus has been occasionally observed in instances presenting all the clinical features of follicular tonsillitis. Ulcerative stomatitis, the form of stomatitis most likely to be confounded with diphtheria, and especially with this malady when the exudation lines the gums, is discriminated by the iilceration or sloughing ; whereas the mucous membrane in the pseudomem- branous disease remains intact, save in the rarest instances. The same feature distinguishes diphtheria from gangrene of the mouth, for which, on account of the extreme fetor of the breath, it is some- * Senator, Klinisclie Vortriige, 1874. 530 MEDICAL DIAGNOSIS. times mistaken, and aids in distinguishing it also from other kinds of stomatitis, as from thrush. In the latter, too, the buccal mucous membrane, and not the throat, is chiefly aifected, and the abdom- inal symptoms, and the other constitutional phenomena, are dif- ferent. So are they in aphthse, in which, moreover, the superficial ulcerations, which bleed when touched, the unbroken vesicles or pustules in other parts, and the seat of the disorder — usually on the edge of the tongue, on the internal surface of the lips, and ou the gums and inside of the cheek — are points to be taken into account. Besides these affections, there are others which must be distin- guished from diphtheria. We occasionally find cases occurring in epidemics, and where the membrane is limited nearly altogether to the follicles, and chiefly to the tonsils. As the membrane passes away, ulcerations are obvious. Swelling of the glands of the neck, and fever, but not of acute type, attend this ulcero- membranous angina, which, moreover, shows a strong disposition to relapses. But, though kindred to diphtheria, and in isolated instances perhaps difficult to discriminate, it differs from it in its seat and in its want of tendency to spread, in the formation of superficial ulcers, in its less marked constitutional depression, and in its invariably favorable termination.* It is similar to herpes of the tonsils, described by Trousseau. Whether there be not also other kinds of membranous sore throat to be separated from true diphtheria, is a matter requiring further investigation. The pseudo-membranous inflammations of the throat attending scar- latina and measles and other of the exanthemata have been shown not to be diphtheritic, although they seem to predispose to inva- sion by the diphtheria-bacillus.f There is an acute disease of the throat to which Todd especially has called attention,^ and which presents also some strong points of similitude to diphtheria, — erysipelas of the fauces. Like diph- theria, it is a most dangerous ailment; as in diphtheria, the morbid process may extend to the larynx ; as happens often in * See a paper in which I have described an epidemic of the kind, in the Amer. Journ. Med. Sci., July, 1870. t Booker, Bulletin of the Johns Hopkins Hospital, vol. iii., No 26, p. 129 ; Park and Beehe, Medical Eecord, vol. xlvi.. No. 1247, p. 1. J Clinical Lectures on Acute Diseases. DISEASES OF THE MOUTH, PHARYNX, ETC. 531 diphtheria, the mucous membrane may exhibit a peculiar dusky- red color ; as in diphtheria, the poison paralyzes the muscles of the palate and pharynx, and liquids are apt to be rejected through the nostrils and mouth. But the difficulty in deglutition differs from that of diphtheria in being present from the onset, and is not attended with enlargement of the glands of the neck, or with the formation of a false membrane. In some instances, too, we find vivid redness of the throat, which may be associated with much swelling. If the erysipelatous inflammation extend to the larynx, there is local pain, with urgent dyspnoea and hoarseness ; and usually rapid exhaustion supervenes. In cases of this kind, the submucous tissues of the larynx are found extensively infil- trated with pUs. The cases may happen without erysipelas show- ing itself on any external part of the body ; on the other hand, erysipelas beginning in the fauces may spread to the face.* This erysipelas of the fauces is not a frequent disease ; and it must be stated that there are cases of diphtheria which simulate it very closely. I have seen a number of instances of the malady in which the whole mucous membrane was of a vivid or dusky hue ; in which there was much swelling, with an effusion of serum, especially in the submucous tissue of the uvula, causing it to look like a small transparent bag ; in which immense difficulty or even impossibility in deglutition existed, — yet in which no membrane appeared for days after the violent inflammation of the throat had set in, and was, when it showed itself, very slight in extent, and out of all proportion to the inflammation. But the constitutional symptoms and the sequelae were the same as those of ordinary diphtheria. In one of the cases of tlie kind referred to, suppu- ration of one of the tonsils took place in consequence of the inflammation ; a layer of deposit had coated parts of the tonsils and of the half-arches and uvula. How shall we separate diphtheria from membranous croup, a disease with which, indeed, it is by many regarded as identical ? Yet this seems taking a narrow view of the facts. In the first place, ordinary membranous croup lacks the peculiar constitutional symptoms, the early depression, and the sequelae of diphtheria. Secondly, an affection of the windpipe is not by any means an * Cases quoted in Schmidt's Jahrbiicher, 1869, No. 1. 532 MEDICAL DIAGNOSIS. essential element of diphtheria, for in the majority of cases the disease does not spread to the larynx. Thirdly, when, from the paroxysms of hoarse, irritative cough, the labored breathing, the attacks of suffocation, the huski.ness or extinction of voice, we may infer that the exudative process has reached the larynx, — when, in other words, the symptoms of croup arise, — we still recall that the first manifestations of the membranous affection were perceived in the throat, and not in the laiynx. Indeed, save in the rarest cases, the disease does not begin in the windpipe; though the beginning above it may not attract attention, and may be readily overlooked. Thus, laryngeal diphtheria affects primarily the throat, and may extend to the windpipe ; membra- nous croup affects j)rimarily the windpipe, and may extend to the tliroat. Fourthly, croup is not contagious, as diphtheria is. And, even granting that as regards the membrane and the symptoms we may not be able to distinguish individual cases of membranous croup from laryngeal diphtheria, the origin of the diphtheritic complaint, and its spreading to other members of the household, if not in a membranous form yet in the form of sore throat with singular constitutional depression, show its peculiar and special traits. Of course the finding of the specific bacillus in the false membrane establishes the diagnosis, though we must always remember that this may be absent in diphtheria. On one symptom we cannot lay as much stress as might be supposed. Albuminuria, the elaborate report of the committee of the Medico-Chirurgical Society has taught us,* is not always present in laryngeal diphtheria, owing to the early fatality of the malady ; again, in certain cases the mere dyspnoea of laryngitis may give rise to albumin in the urine. Yet when albuminuria is marked, and when it has happened where an affection of the fauces has preceded the laryngeal implication, it points to an infective cause, — to laryngeal diphtheria. Lastly, diphtheria may be confounded with scarlatina. When, indeed, we reflect on the similar appearance of the throat, on the occurrence of albuminuria in both maladies, and on the frequency * Medico-Chirurgical Transactions, vol. Ixii., 1879. Some of the anatomical points involved are also well discussed by Welgert in Virchow's Archiv, vols. Ixx. and Ixxi. DISEASES OF THE MOUTH, PHAEYNX, ETC. 533 with which both are found to prevail at the same time as epidemics in a community, it is not astonishing that one should be looked upon as but a modified form of the other. Allied they certainly are, but not identical ; for the poison of one leads to a thoroughly- defined rash, and leaves a protective influence against a second attack, and often also deafness, suppuration of the glands of the neck, and dropsy, — phenomena which are not encountered in the other. It is true that in very rare instances of diphtheria we en- counter a slight erythema of the neck and breast, but it is not like the vivid, difiused rash of scarlet fever. Moreover, the exudation in the throat is not exactly similar in the two diseases. In scar- latina it is pultaceous, and not coherent, and has no tendency to spread to the respiratory passages. Bacteriologic examination, further, may disclose the presence of streptococci and staphy- lococci, but not the bacillus peculiar to diphtheria. Then the albuminuria happens at a diiferent period. In scarlatina it is a sequel rather than a concomitant ; in diphtheria it is a concomi- tant rather than a sequel. Further, the gravity of the symptom is not the same. In the latter malady it is an indication of danger ; it has not so serious a meaning in the former. Diphtheria may be intercurrent in various maladies : in typhoid fever, in the exanthemata, in pneumonia. Nor is the exudation always restricted to the throat. It may show itself in a wound or on excoriated skin, on the nasal mucous membrane, the con- junctiva, the nipple, the uvula, or around the anus; it may be found coating the stomach, the intestines, and the ramifications of the bronchial tubes. Nasal diphtheria is a very grave form of the malady : it may either be present alone, or coexist with a deposit in the fauces and pharynx. It generally occurs with evidences of the septic form ; the symptoms are of a low type, and we recognize the affection by carefully inspecting the posterior pharynx and seeing that the membrane extends upward ; by noting the irritated, red- dened look of the nostril, even when no membrane can be dis- cerned in it ; and by the coryza, the sense of obstruction in the nose, and the acrid sanious discharge which comes from it. In cases in which the nasal duct and the laryngeal canal are stopped up by the false membrane, tears are constantly rolling down the cheeks. Epistaxis is a not uncommon symptom ; swelling of the 534 MEDICAL DIAGNOSIS. cervical glands may or may not be present. Recent bacteriologic investigation has shown that so-called membranous rhinitis is in reality often of diphtheritic origin.* And in the enlarged glands in any form of diphtheria the characteristic bacilli are found in the ojDaque, yellowish masses, consisting principally of fibrin, which they contain, f Mumps. — This, like diphtheria, is a general disease, and is only here described as a matter of clinical convenience. Parotitis is most commonly seen as an epidemic malady ; but we occasion- ally encounter a secondary parotitis following typhus fever, scarlet fever, smallpox, measles, and dysentery. In this form suppura- tion is much more common than in ordinary mumps. The dis- ease generally begins with pains at the angle of the jaw, which are soon followed by a marked swelling, first on one side, then on the other, which results in the head being kept rigid. The tumid glands are sore, and become more painful during attempts at swallowing and chewing, though there is really little, if any, difficulty in swallowing. If the patient be made to swallow slowly ten to thirty drops of undiluted vinegar, decided pain is produced in the affected glands, — an old and useful diagnostic test, to which Dr. Louis Starr called my attention. The mouth is generally filled with saliva, though it may be very dry ; and the hearing may be impaired, or, for the time being, entirely lost, and ringing in the ears is very common. The temperature generally ranges between 101° and 102°, but in cases of orchitis following mumps, or of metastasis, I have seen it 104° to 105°. The nervous system may become decidedly affected. Acute mania has been known to become associated with mumps ; so has periph- eral neuritis.J Parotitis is easily recognized. There is no swelling of the tonsils, hence it cannot readily be mistaken for tonsillitis. Laveran and Catrin have foimd a diplococcus in mumps, in the secretions of the parotid and other glands, as well as in the blood. § In cellulitis of the neck, angina Ludovici, the swelling may * Abbott, Medical News, May 13, 1893, p. 505. t Bulloch und Scbmorl, Beitr. zur Patbol. Anatomle, etc. , von Ziegler, B. xvi., H. 2; Centralblatt f. Innere Medicin, 1895, No. 6, p. 156. i Lancet, April 9, 1887. j Gaz. Med., June, 1893. 535 mislead, but it is uniform and not confined to the region of the parotids ; the constitutional symptoms are very severe, pointing to an infective malady. Ludwig's angina is met with as an idio- pathic affection, or in certain fevers, such as scarlet fever or diphtheria. Chronic Sore Throat. — Attacks of angina are prone to re- cur, and to lead to chronic inflammation of the structures. Now, an affection of this kind is liable, on any exposure, to be kin- dled into the acute complaint ; besides, it yields at all times some manifestations of a disorder of the throat. A thickening of the folds of membrane forming the half-arches, a tumefaction of the follicles at the upper part of the pharynx, a lengthening of the uvula, are the visible signs of the chronic malady ; a constant disposition to clear the throat, and a dry cough, are often the attending general symptoms. Owing to the habitual coughing, the patient may be suspected to be laboring under phthisis, and be treated accordingly, when the whole difficulty lies not in the lungs, but in the throat. Yet an error in the opposite direction is perhaps more frequently committed. Tonsils and uvulas are removed, with the view of curing a cough which is really kept up by a source of disturbance in the lungs, in forgetfulness of the fact that in scrofula and tuberculosis chronic enlargement of the tonsils and follicular pharyngitis are by no means unusual. A careful examination of the chest ought always to be made, even when inspection of the throat shows disease to be there present. On the other hand, we may find in the condition of the throat and of the nares the explanation of thoracic affections, for instance of asthma, a number of cases of which have their origin in irritation reflected from these parts. The follicular disease of the throat, or " clergyman's sore throat," is the most frequent of all the morbid conditions which produce a chronic sore throat. The abnormal condition of the follicles of the pharynx and fauces often extends to the larynx. There are constant hawking and attempts at clearing the tliroat, and not unfrequently roughness of voice or decided hoarseness. On in- specting the throat, the enlarged mucous follicles can be readily discerned ; those on the pharynx are very prominent. In cases of long standing, the follicles may ulcerate, and very commonly they pour out an acrid secretion. But, unless from coexisting 536 MEDICAL DIAGNOSIS. enlargement of the uvula, or an altered position of the epiglottis, or a laryngeal or bronchial complication, there is no decided cough. The follicular disease may occur in consequence of re- peated attacks of sore throat, or be an attendant upon gastric dis- order, or follow constant exercise and straining of the voice. Chronic rheumatic sore throat gives rise to pain which is often referred to the hyoid bone, is increased by pressure, and is also felt in the tonsils. Ingals * points out that the pain often entirely disappears while the patient is eating, but increases in cloudy and damp weather. There are signs of slight congestion in the throat, and generally in the larynx, yet mostly out of all proportion to the pain. The general health remains good, and we find no fever ; there is apt to be a history of a rheumatic diathesis. Ulcers are not often developed in the fauces during an attack of acute inflammation, except in the specific sore throat of scar- latina ; in chronic inflammation, especially if occurring in scrofu- lous persons, they are more common. The most profound ulcer- ations are those of constitutional syphilis, implicating, as they do, not only the tissues of the fauces, but also the parts in front, and destroying both the fleshy covering of the bones and the bones themselves. With regard to treatment and to prognosis, it is of the utmost importance to distinguish these syphilitic ulcers from those produced by other causes. A cutaneous eruption of a syphi- litic character, and enlarged lymphatic glands, or the history of antecedent syphilis, would lead us to a correct conclusion ; but an accurate history of a syphilitic infection cannot always be obtained. The ulcers themselves furnish some information by which we may suspect their origin. They are not superficial and stationary, like those resulting from ordinary inflammation ; on the contrary, they are deep and have a strong tendency to spread. They are rounded, or of a serpiginous form, with borders well defined and elevated, and surrounded by a distinct zone of redness ; and the inflamma- tion which precedes them is limited to spots, and is not so diffused, nor attended with so much swelling, as the inflammation which exists prior to simple ulceration. These ulcers must be distin- guished from the deep ulceration with spreading destruction of tissue that occurs in cancer of the fo?m&.f * Medical News, March, 1890. f See Newman, Amer. Journ. of Med. Sci., May, 1892 537 PHARYNX AND (ESOPHAGUS. In describing the affections of the fauces, those of that portion of the pharynx which is most usually the seat of disease have been at the same time described. Indeed, when we speak of acute or chronic pharyngitis, we generally meaa acute or chronic inflammation of the fauces, to which the upper pai-t of the pharynx belongs. Inflammation of the portion of the pharynx which is out of sight when the tongue is depressed, is rare. It may be presumed to exist if there be pain and an impediment in swallow- ing when the food arrives opposite the top of the larynx, while the respiration remains free and the voice unaffected. Abscesses sometimes form between the textures composing the pharynx, and between its posterior wall and the cervical vertebrae. These retro- pharyngeal abscesses mostly result from disease of the vertebrae. They occasion great diiSculty in deglutition and in breathing ; an altered voice ; dull pain and stiffness in the neck ; external swell- ing, which may or may not be cedematous ; and commonly a tume- faction at the back of the throat, which can be seen, or which at least can be felt with the finger pressed against the posterior wall of the pharynx. On account of the obstructed respiration and the changed voice, the disease is liable to be mistaken for croup. Its differences have been already enumerated. Retro-pharyngeal abscess is often confounded with coryza and with tonsillitis. It differs chiefly from tuberculosis of the retro-pharyngeal glands by the presence of tuberculous lesions of the deep lymphatic glands on the same side of the neck.* It may happen in infancy.f There is a peculiar form of pharyngeal disease due to the accumulation on the mucous membrane of a micro-organism gen- erally supposed to be the leptothrix, though HemenwayJ in his elaborate article pronounces it to be the bacillus fasciculatus. The deposits in this jpharyngo^myeosis take place largely in the follicles. The oesophagus is not often the seat of disease. We meet with * Sokoloff, Yratch, May, 1891. f See cases of Pollard, Lancet, Peb. 1892. X Journ. of Laryng., Feb. 1892. 538 MEDICAL DIAGNOSIS. acute inflammation produced by swallowing boiling water or cor- rosive poisons, especially nitric or sulphuric acid, or ammonia. The symptoms of acute oesophagitis are usually mixed up with those of inflammation of the pharynx, or of the stomach. We may, however, infer its presence if difficulty and pain in degluti- tion exist for which nothing in the throat accounts, and if these phenomena be associated with hiccough and with a burning sen- sation between the shoulders, in the course of the tube. CEsoph- agitis is sometimes encountered in infancy.* Of the chronic diseases of the oesophagus, stricture is the most common. The narrowing may take place at any part of the tube, and results from preceding inflammation or ulceration, from can- cerous degeneration of the walls, from polypoid growths project- ing from the mucous membrane, or from the pressure of a tumor, of an abscess, or of an aneurism ; sometimes it is congenital. The formidable malady manifests itself by impediment in swallowing : even liquid food cannot pass without great difficulty ; and if the stricture go on increasing, the patient perishes miserably by star- vation. In addition to the obstruction to the passage of food, we may find a peculiar pain occurring at a particular part of the tube, and that the patient raises, without cough or vomiting, clots of blood presenting the shape of the stricture. The matter ejected in the attempts at deglutition consists simply of masticated food together with more or less mucus, and, unlike what comes from the stomach, has an alkaline reaction. If long retained, the albuminous materials are macerated ; the starchy materials are in process of fermentation ; fungi are formed in great quantities, although never sarcinje.f Should there be doubt as to the seat of the obstruction, a bougie will clear up the doubt ; and thus we possess in this instrument the most valuable diag- nostic as well as therapeutic agent. But we must not immediately conclude, because the bougie. meets with resistance, that an organic stricture is present. The narrowing may be only spasmodic, yet give rise to the symptoms of organic constriction. But they are not permanent : at times nourishment is readily swallowed, and a full-sized bougie passes with ease. Spasmodic stricture occa- * Brush, New York Med. Eec, 1883, xxiii. t Ziemssen, " Diseases of the (Esophagus," in Ziemssen's Cyclopsedia. DISEASES OF THE MOUTH, PHAEYNX, ETC. 539 sionally accompanies ulceration of the larynx ; but it is chiefly met with in hypochondriacs and in hysterical women. The latter, indeed, sometimes fancy that they are incapable of swallowing, and reject the food they take without there being even a temporary spasm to prevent its passage. Spasmodic stricture is also ob- served in hydrophobia and as an attendant on cerebral disease. The distinction of the other causes of stricture is not always an easy matter. In tlie stenosis arising from syphilis, we lay great stress on the history. In the strictures due to compression, we discern the swelling that has occasioned them, and the oesoph- agus is apt to be pushed to one side. In strictures the result of dcatriees, we have the gradual development of the affection after an injury or the swallowing of some irritant poison, and the great resistance of the dense tissues to the sound is very signifi- cant. Cancerous narrowing occurs after forty years of age, pro- gresses steadily, and, as Ziemssen has pointed out, is frequently associated with paralysis of the recurrent laryngeal nerves. It may affect the whole middle part of the oesophagus.* Cancer of the oesophagus is most commonly epithelioma. Rupture of the oesophagus may be met with as the result of protracted vomiting. The accident is apt to occasion great pain. It leads to a rapidly fatal result.f Dilatation of the oesophagus above the seat of a stricture, or without a stricture existing, is, on the whole, a rare disease. Its chief symptoms, when extensive, are difficulty in swallowing, vomiting or regurgitation of food, a swelling in the neck coming on after eating and diminishing greatly after vomiting or by pressure, slowly-progressing inanition, and at times long spells of delusive improvement. The sound may penetrate through the neck of the sac with difficulty, or enter it ceadily, which largely depends upon whether the sac be empty or full ; once in tlie sac, the end of the tube can be generally moved about with ease. In all the diseases mentioned, the value of the sound as a means of diagnosis has been spoken of. A few more remarks about it may not be amiss. Great care should be always used in passing a sound. The patient's head should be well thrown back, * Moore, Lancet, London, 1883, i. 13. •f See for cases paper by Fitz, Amer. Journ. of Med. Sci. Jan. 1877. 34 540 MEDICAL DIAGNOSIS. and the instrument passed along the posterior wall of the pharynx with the utmost gentleness. There is a slight resistance as it goes past the cricoid cartilage. When an aneurism or an organic dis- ease of the heart exists, it should not be employed at all. When the sound on reaching a particular spot always occasions pain, we may infer the existence of inflammation or ulceration at this point, and, in the case of ulceration, some pus or blood is likely to be brought up on the instrument. Should any doubt exist whether the sound have passed into the oesophagus or into the larynx, let the patient be directed to speak ; he can make no noise if the tube be in the larynx. In cases remaining doubtful, a lighted candle may be placed before the end of the tube projecting from the mouth. If the instrument be in the windpipe, the flame will be wafted to and fro with the currents of air ; if in the oesophagus, this is not observed, except when the tube is in the intrathoracic portion. The diseases of the oesophagus may be studied by means of auscultation, listening while the patient swallows food or liquid ; and we owe to Hamburger an elaborate description of the sounds.* In health, the oesophageal sound is extremely distinct, but of very short duration ; the pharyngeal swallowing sound is generally a loud gurgle. In a moderately advanced stage of stricture of the oesophagus, a noise similar to emptying a bottle, "clucking," " gurgling," is perceived ; while in cases of dilatation we are apt to meet with a sound like that heard when rain driven by the wind impinges and is deflected. In cases of very marked stricture or of obstruction by an impacted foreign body, we find that the act of deglutition cannot be detected below a certain point, while it is distinct above. To auscult the oesophagus, the stethoscope should be placed [fi the vicinity of the hyoid bone, also to the left of the vertebral column from the upper dorsal vertebra downward. This method of exploration has not, however, proved itself of much value. The disorders of the pharynx and oesophagus have as a common symptom difficulty in swallowing. But we must not forget that other causes may produce dysphagia, such as paralysis of the mus- cles of the throat, diseases of the larynx or trachea, particularly ulcerative diseases, and aneurismal tumors within the chest. * Jahrbiicher der k. k. Gesellschaft dor Aerzte in Wien, Bd. xviii. CHAPTER VI. DISEASES OE THE ABDOMEN. The abdominal cavity contains viscera of very varied func- tions: some form, others break down organic constituents; while others, again, excrete the broken-down material. They all, how- ever, labor in one cause ; they all work toward preserving a nor- mal state of the blood, either by preparing fit matter for it or by removing such substances as would be hurtful if they were retained. Any serious derangement of any of these viscera, especially any serious chronic derangement of those which are not simply reservoirs, must therefore lead to a deterioration of the blood and to a defective nourishment of the body. But, in- dependently of the change in the blood and the falling off in the general nutrition, there are no vital symptoms that characterize abdominal diseases as a group ; and, as many causes may give rise to the same symptoms, they furnish but little information as to the particular organ at fault. This we learn to some extent by examining, where it can be done, the secretions or excretions ; to some extent by noticing the peculiar appearances of the skin which are produced by alteration of the blood; and by the ex- ploration of the organs through the parietes of the abdomen. It is, in truth, by means of the physical method of investigation that we often obtain the most valuable information not only as to the seat but even as to the nature of the morbid action ; and, although physical exploration of the abdomen does not yield as perfect re- sults as when this form of diagnosis is applied to the affections of the thorax, the senses of sight and touch still supply us with an amount of knowledge most valuable, and with which it would be difiicult to dispense. I speak only of the senses of sight and touch, because the sense of hearing, save in so far as it enables us to judge of the sounds elicited by percussion, or of murmurs in the vessels, is not very applicable to the study of diseases below 541 542 MEDICAL DIAGNOSIS. the diaphragm. Let us pass in review the different methods of physical diagnosis with reference to abdominal disorders. Methods and General Eesults of Physical Examination of the Abdomen. INSPECTION. By inspection we learn the size, shape, form, and movements of the abdomen. To inspect the abdomen satisfactorily, the patient should be placed in an easy attitude, either standing or sitting. The recumbent position is less eligible, though we are often obliged to examine sick persons in this posture. Whenever practicable, ocular inspection must be made not only from the front, but also from the sides and from the back. In appre- ciating the results thus obtained, it is necessary to bear in mind that the appearance of the abdominal walls is modified by certain physiological conditions. The abdomen is much larger, in com- parison to the size of the chest, in childhood than in adult age. It is more voluminous in females, especially such as have given birth to children. It increases in size with advancing years, par- ticularly when a tendency to obesity exists. Its shape is some- what altered by the pernicious habit of wearing tight stays. Its upper portion is distended after a copious meal. In disease we may observe either partial or general abdominal enlargement. The latter is caused by accumulations of air in the intestinal canal ; by liquid in the peritoneum ; by an cedematous condition of the abdominal walls ; or by large tumors which fill up the whole cavity. A partial enlargement is mainly produced by an increase in size of particular organs. It may also be brought about by swelling of the niesenteric glands, or by tumor, -^solid or hernial ; and it is sometimes due to diseases above the diaphragm. A pleuritic or a pericardial effusion, or emphysema of the lungs, may give rise to a marked fulness below the margin of the ribs. A retraction of the abdominal parietes is perceived in general emaciation, and is very obvious in that dependent upon a nar- rowing of the cardiac or the pyloric orifice of the stomach, or upon chronic diarrhoea or dysentery. It is also noticed in lead colic and in cephalic diseases, especially in tubercular meningitis. DISEASES OP THE ABDOMEN. 543 There are further changes in the appearance of certain external parts which tend to elucidate the state of the parts within. Thus, we learn from the distention of the superficial veins that an ob- struction to the flow of blood exists in the large veins of the abdomen, either in the portal system or in the vena cava. The lessening of the depression at the umbilicus, unless it be produced by pressure limited to the spot where the umbilicus lies, is a sign indicative of general abdominal enlargement. While inspecting the abdomen, we may see distinct movements. The act of breathing gives rise to a motion which is very slight when a tumor or any other impediment interferes with the free action of the diaphragm, and which is much exaggerated by dis- eases within the thoracic cavity. The rolling of the intestines is sometimes visible on the exterior ; so are at times those shift- ings of accumulations of gas which give rise to a series of jerking elevations ; so, too, are occasionally the spasmodic contractions and relaxations of the abdominal muscles. But none of these is as frequently encountered as a pulsation in the epigastric region, which is often mistaken for an aneurism. The inspection of internal organs, such as the stomach, will be considered in con- nection with those organs. PALPATION. We judge by the application of the hand of the size, JDOsition, and consistence of the viscera which are felt through the abdom- inal walls. We determine whether the parts are firmly attached or movable; whether they are smooth or nodulated; whether they possess a motion of their own; whether they are tender; and by tapping with the fingers of one hand, while those of the other are applied to another portion of the surface, we discover, by the peculiar feeling of fluctuation, the presence of fluid in the abdominal cavity. We satisfy ourselves further, by the sense of touch, of the state of the parietes, whether resistant or elastic, oedematous or not ; and we may detect a friction fremitus. In order to use palpation with most eifect, the abdominal mus- cles must be relaxed ; and to do this the patient should be placed on his back, and the thighs be flexed on the body. Occasionally it is essential to vary this position ; to turn him from side to side, or to examine him when erect. The amount of pressure, too, 544 MEDICAL DIAGNOSIS. should not always be the same. When we wish to examine deep parts, the pressure is increased. The character and the intensity of the pain which pressure calls forth often throw considerable light on the disease we are investigating. Thus, if it take deep pressure to produce pain, we are usually right in concluding that tlie mischief is not superficially seated. The pain of inflamma- tion of the serous membrane is commonly much augmented by pressure, and is of a very severe, cutting character. Pain due to inflammation of any part of the mucous membrane of the intes- tinal tract is duller. All neuralgic or nervous pain, such as that of colic, is, as a rule, relieved rather than augmented by pressure, and may be thus distinguished from inflammatory tenderness. But we shall not enter into any fuller particulars as to what palpation teaches us in individual diseases of the abdomen ; be- cause, as there is hardly one of any importance in which it is not of some service, we should say here what it would be necessary to dwell on repeatedly hereafter. There is, however, one point con- nected with the subject which may be briefly mentioned, — the attempt to use palpation as a means of diagnosis by the introduc- tion of the hand into the rectum. But the method is both dis- agreeable and not free from danger. Dilatation of the sphincter should be gradual, five minutes at least being allowed for its accomplishment. And, with all precautions, the information ob- tained may be indecisive. Strictures high up in the rectum or in the sigmoid flexure of the colon may be readily discerned, but a stricture below the descending colon may exist although the hand be unable to discover it. We might with palpation consider the results obtained by the use of bougies and of tubes, such as the stomach-tube. But these will be more appropriately considered when discussing the dis- eases of individual organs. PERCUSSION. Percussion is, in the study of abdominal affections, even more valuable than palpation. By it we can circumscribe the different organs with accuracy ; we can judge of the position of the stomach and intestines ; we can limit the distended bladder, and fix the borders of the liver and spleen. By its aid, further, we can tell DISEASES OF THE ABDOMEN. 545 whether a distention of the abdomen is produced by air, or by a solid tumor, or by liquid. But, without entering here into par- ticulars as to its use in individual disorders, we shall examine the results it yields when applied to the healthy abdomen. To render percussion a trustworthy interpreter of the state of the abdominal viscera, the patient should be placed in the same position as for palpation. The sounds are best elicited by mediate percussion. But to appreciate them fully we must be acquainted with the relations of the parts which the abdominal walls conceal from view, and take into account that during the digestive process the contents and position of these organs may vary sufficiently to modify the percussion sound. To begin with the airless viscera. The liver is one of the easiest organs to limit. We determine its upper boundary by striking with moderate force in a line from somewhat above the right nipple toward the lower part of the thorax, until marked resist- ance and dulness tell us that a solid organ has been reached. At this point we make a mark; then we again percuss downward from near the median line, and above the dulness just obtained ; then we percuss from the axilla downward ; then posteriorly from beneath the lower angle of the scapula ; and so on, until the line traced out reaches the vertebral column. The dulness thus elicited marks the upper boundary of the liver; at least of the portion more directly in contact with the ab- dominal walls. Anteriorly it extends from the lower extremity of the sternum to between the fifth and sixth ribs; at the side, the dulness is generally in the seventh intercostal space; neai the vertebral column, it is on a level with the tenth or the eleventh, more rarely with the ninth, interspace. The dulness of the left lobe reaches nearly two inches across the median line ) but the heart lies here so near to the liver that we cannot with accuracy distinguish the flat sound of the one from the flat sound of the other ; nor indeed is this, for practical purposes, of great consequence. After the upper border has been fairly traced out anteriorly, laterally, and, if thought necessary, posteriorly, we determine the inferior margin of the organ. This is readily effected by per- cussing downward from the already-ascertained line of dulness, and noting where the large intestine sends forth its distinct tym- 546 MEDICAL DIAGNOSIS. panitic sound. To determine tha lower border correctly, the plex- imeter must be pressed firmly on the integuments, and the stroke of the finger be slight ; for if it be strong, we obtain the sound of the surrounding hollow viscera through the thin layer of liver which covers them, and before we have arrived at its margin. This mode of procedure is dilFerent from the one pursued to de- termine the height to which the liver rises, because the position of the parts is different. Superiorly, the lung descends between the surface and that portion of the convex surface of the liver which fits into the diaphragm, and it requires strong percussion to bring out the dulness of the deep-seated solid organ. By forcible per- cussion, however, we detect a decided loss of the pulmonary reso- nance at about the fourth intercostal space. The inferior border of the liver will, anteriorly, be generally found to lie immediately at, or to project below, the last rib ; pos- teriorly, we cannot determine this border positively, for it becomes continuous with the dulness occasioned by the right kidney. The lower margin of the left lobe is commonly met with at the upper third of a line drawn from the ensiform cartilage to the umbilicus. A distended gall-bladder may cause a strictly-defined dulness lower than the dulness of the surrounding liver. The spleen is not so easily circumscribed as the liver. Indeed, if the stomach or the intestines be distended, it is difficult to detect the dull sound of the spleen. To find its limits, we must place the patient on his right side, with his legs flexed ; or let him stand erect, and then begin to strike with some force in a line from the axiUa to the crest of the ilium. At the ninth, or sometimes at the tenth, rib, the sound becomes dull, and there is much greater resistance to the finger. Here is the upper boundary of the spleen. We mark the spot, and continue to percuss in the same line until, at about the twelfth rib, we arrive at the lower boundary of the organ, as indicated by the distinct tympanitic sound of the intestines. After the vertical diameter has been thus ascertained, the hori- zontal is readily determined by percussing from the median line to a point between the lines which trace the superior and inferior margins, and by noticing where the sound of the stomach gives way to the dull sound of the solid viscus. When these three points have been decided upon, we have learned enough for prac- tical purposes. We may then, if we choose, percuss posteriorly ; DISEASES OF THE ABDOMEN. 547 but we cannot circumscribe the spleen with any accuracy behind, because its dulness becomes continuous with that of the left kidney. The average size of the spleen is four inches in length and three in width ; but it may in a diseased state increase to twice or three times that size. When the viscus eludes detection by percussion, we may infer it to be small ; provided the stomach and intestines be not much distended with gas. The kidneys cannot be limited with anything like accuracy, ex- cept at their inferior and outer borders, where the dull sound they occasion is surrounded by the intestinal resonance. This dulness extends somewhat lower during a full inspiration. To set limits to the stomach and intestines, by means of percus- sion, requires an ear accustomed to discriminate between shades of sound, since we have to judge more between sounds of diiFerent degree, but similar to one another, than between sounds of different character. Nor are the tones elicited always the same over the same spot ; they vary as the contents of the hollow viscera vary. "VVe can make use of this circumstance for purposes of diagnosis. In percussion of the stomach and of the intestines we may often with great advantage resort to auscultatory percussion. The stomach, when not unusually distended with gas or with food, renders a sound which is hollow, ringing, and tympanitic to a certain degree, yet which is not tympanitic as that of the intes- tine is. It is, in fact, a sound unlike any other, and experience soon enables us to .distinguish it from that of the surrounding viscera. Sometimes the sound is distinctly amphoric. To deter- mine the boundaries of the stomach, it is necessary to mark out first the lower margin of the liver, for it covers a portion of the stomach ; then the heart and the inner border of the spleen. The part which lies between these solid viscera yields the sound of the stomach, mixed at one point, namely, to the left of the apex of the heart, with the resonance of the lung. Near this spot, about opposite to the seventh rib, the cardiac extremity of the stomach is situated ; below it is the body of the organ ; the pylorus is on a level with the tip of the xiphoid cartilage, between the right edge of the sternum and a vertical line passing through the nipple. To ascertain the lower border of the stomach, we percuss gently in a downward direction, until the alteration in sound 548 MEDICAL DIAGNOSIS. shows that we are striking over the colon. The difference is at times very obvious, at times very slight. It is readily detected if the stomach contain either solid or liquid ingesta. Availing ourselves of this fact, we may sometimes with advantage let the patient swallow a glass of water. By placing him in the erect position, the fluid gravitates to the greater curvature, aud the line Fig. 53. KeanltJi of abdominal percnesion, as set forth in the text. The darlc shades indi- cate marlied dulness; the liglit shading exhibits a lessening of the clear or of the tympanitic character of the sound, — an approach to dulness, , of comparative dulness indicates the lower margin of the stomach, which is generally found near but above the umbilicus. In men the lower border of the stomach is a little higher than in women ; in working-women it is higher than in other women ; in children under fifteen years of age it very rarely extends to the umbilicus ; in persons of fifty it is not unusual for it to do so. In strong, DISEASES OF THE ABDOMEN. 549 healthy people the whole position of the stomach is more horizon- tal than in weak ones.* Deep percussion is used to limit the superior line, and light percussion the inferior line, of the stomach. Direct insufflation of the stomach is also valuable to determine its size and its distensibility. Another method to determine the limits of the organ, as well as whether the pylorus is still capable of self-closure in the direction of the duodenum, or is permanently patent, has been proposed by Epstein.f It consists in the distention of the stomach by means of carbonic acid, generated by first letting the patient swallow tartaric acid dissolved in lukewarm water and then rather more bicarbonate of sodium, about a full teaspoonful. The stomach becomes very much distended, and emits a deep tym- panitic note on percussion, unlike that over the intestines; but if the pylorus be incapable of closure, the intestines too become swollen, and their tympanitic note is changed. The colon yields, in all its parts, a sound of a pui'er tympanitic character than the stomach, the note of which is, indeed, in many respects more amphoric than tympanitic. When the tube contains faeces, the sound is modified ; and as these are prone to accumulate on the left side in the descending colon, and especially where this passes into the iliac fossa, it is usually not so resonant as the ascending colon. The small intestines, unless they are filled with fluid or solids, or distended with gas, render a sound of higher pitch and of smaller volume than the surrounding large intestine, and by the less deep-toned sound their position may be accurately determined. Artificial distention of the colon, by generating car- bonic acid in it by means the same as just mentioned passed into the lower bowel, has been advocated for diagnostic purposes by Ziemssen. J It enables us *to distinguish with ease the outline of the large intestine, and shows whether there is communication with adjacent organs, such as the stomach, the bladder, or the small intestine. Anomalies of position and form of the bowel give rise to differences in the results of abdominal percussion, as has been well shown in a careful clinical study by Curschmann.§ * Obrastzow, Deutsehes Arch. f. Klin. Med., Bd. xliii., 1888. t Klinische Vortrage, No. 155, 1878. J Deutsehes Arch. f. Klin. Med., Bd. xxxiii., June, 1883. g Ibid., Bd. liii., June, 1894. 550 MEDICAL DIAGNOSIS. The position of the viscera in the pelvis cannet be ascertained by means of percussion. It is only when the bladder is much distended, or the uterus augmented in size, that the outline of either can be traced on the walls of the abdomen. AUSCULTATIOlSr. Auscultation is serviceable in aiding in the detection of an abdominal aneurism ; and sometimes an enlarged spleen gives rise to a distinct blowing murmur ; or tlie rubbing of a roughened peritoneum may occasion a friction sound ; but, on the whole, the application of the stethoscope to the abdominal walls is rarely of much aid. In health, no constant sound is heard save that of the aorta ; for the rush of blood through the other arteries, or through the veins, produces no appreciable murmur. When the stomach is distended with air and contains liquid, sounds possess- ing a metallic character are perceived, which an inexperienced ob- server is apt to consider as originating in the lungs ; over which, in truth, they are often audible. The passage of gas through the intestines gives rise to those peculiar noises termed " borborygmi." In the pregnant state, auscultation is of value in detecting the pulsations of the fcetal heart and the utero-placental murmur. SECTION I. DISEASES OF THE STOMACH. As the disorders of the stomach are so common, and as a patient hardly ever gives a history of his ailment without thinking it obligatory to enter into a minute account of the state of his di- gestion, it would be reasonable to suppose that no affections are so well understood and so susceptible of clear description as those of this viscus. But in point of fact it is only within the last few years that any attempts have been made to bring to bear upon them modern means of research. Most of these attempts have DISEASES OF THE STOMACH. 551 had as their aim to ascertain the exact anatomical changes and the modifications in the secretions which give rise to the symptoms commonly referred to perverted function ; and to a decided degree they have been successful. The stomach is examined partly by physical exploration by the methods just detailed, and partly by paying attention to the chem- ical changes which attend the digestive acts. With reference to the physical examination, there are some special means that may be employed with advantage. To deter- mine the relative sensitiveness over the epigastrium. Boas * meas- ures the pressure by an algesimeter. The normal tolerance is from eighteen to twenty pounds. In cases of gastric ulcer, pain is com- plained of at a pressure of from two to four pounds. The direct application of electrioity to the coats of the stomach as a test of their motility has been also made use of; but, valuable as this agent has proved itself therapeutically, it has not shown itself valuable diagnostically. Ingenious instruments have been devised for illuminating and inspecting the interior of the stomach. By means of the gastro- diaphane of Einhorn,t which consists of a soft rubber tube through which pass wires connected with a source of electricity and pro- vided with an incandescent lamp enclosed securely in glass, the size and outlines of the stomach, as well as the density of its Avail, can be made out. The patient is, on an empty stomach, first made to swallow, or there are introduced through a tube, one or two pints of water ; the tube is passed into the stomach in the cus- tomary manner, and the appearance of the light is observed in a dark room. A reddish luminous zone upon the abdomen indi- cates the outline and the position of the stomach ; and dark spots may enable us to judge accurately of the size, shape, and position of tumors. The gastroscope of Mikulicz is a more complicated instrument, by means of which it is possible to inspect directly limited portions of the interior of the stomach. A revolving sound, the gyromele, has been invented by F. B. Turck.J The revolutions can be felt upon the abdominal wall. * Miinch. Med. Wochensch., Sept. 1893. t New York Medical Journal, Deo. 1892. X Joum. Amer. Med. Assoc, March, 1895. 552 MEDICAL DIAGNOSIS. and the various parts of the stomach, especially the greater curva- ture, accurately located ; we can also, by the use of different cables, measure the distensibility of the stomach. If the movements of the sound are distinctly felt on the parietes, tumors of the anterior wall and of the fundus can be excluded. The instrument is also valuable for obtaining materials from the wall of the stomach for microscopical and bacteriological investigation. It is always impoi-tant to study the activity of the movements of the stomach, and this is generally done partly by noting how long it will take a trial meal to digest completely, partly by chemical means to be presently detailed. But the object has been also sought to be attained by instrumental aid. With this view, F. B. Turck * has introduced a gastrie motormeter, which consists of a collapsed rubber bag with a fine rubber tube attached that' is connected with a manometer ; thus both degree and force of movement are registered. The bag is inflated with air after being passed into the stomach. The instrument records not only the peristaltic, or active, movement of the stomach, but also the respiratory movement and the aortic movement. Another way of determining the mechanical action of the stomach, as well as of recording its movements, is by the gastro- graph, the invention of Einhorn.f It is likely to prove of use in several pathological conditions of the organ, and will be valu- able in obtaining tracings for comparison. The accurate chemical study of the secretions and of the con- tents of the stomach is leading to great advances in the investiga- tion of its affections, as has been proved especially by the labors of Leube,J of Ewald,§ of Boas,|| and of others. We get the contents of the stomach for examination from two to four hours after a full or " trial meal," given as a mid-day dinner, and con- sisting of four hundred grammes of soup, sixty grammes of scraped meat, and fifty grammes of white bread ; of this, if the act of diges- tion have been normally carried on and the chyme have passed on into the small intestine, nothing remains after the lapse of six or * Proceed. Amer. Med. Assoc, May, 1895. t New York Medical Journal, Sept. 1894. X Deutsches Arch. f. Klin. Med., Bd. xxxiii., 1883; also Sohreiber, ii. ^ Klinilt der Verdauungskrankheiten, Berlin, 1889. II Diagnostik und Therapie der Magenkrankheiten, 3d ed., 1894-95. DISEASES OF THE STOMACH. 553 seven hours but a clear liquid. The material for examination is obtained by means of an elastic tube, preferably of soft rubber, about seventy- five centimetres long by six centimetres in diameter, and provided with an opening at its conical extremity and others at the side. The liquid is removed from the stomach by pressure over the epigastrium, or by aspiration by means of a hand-ball apparatus. Ewald has substituted a light breakfast trial meal, a small amount of dry bread or of toast, from thirty-five to sev- enty grammes, and a third of a litre, about eleven fluidounces, of warm water or weak tea, which, given on an empty stomach, allows the gastric contents to be tested in an hour, a matter often of great convenience. The results of these trial meals should be filtered for accurate examination. The next points to determine are the composition of the gastric juice and its digestive power. We first have to ascertain if the liquid obtained be acid, how acid it is, and what its acid nature is owing to. In from ten to fifteen minutes after the trial breakfast acid salts and a free acid are found ; the free acid is lactic acid. This disappears within the hour, hydrochloric acid gradually taking its place, and at the end of an hour only hydro- chloric acid is found in the normal stomach contents.* In the ordinary full mid-day trial meal, hydrochloric acid is not likely to be found for an hour or two after the ingestion. It is true that the acid phosphates in the ingesta determine somewhat the acid character of the gastric juice, but the hydrochloric acid is alone, for practical purposes, of importance. To determine the pi'esence of free acid in the gastric contents, the most delicate reagent is Congo red, which may be employed in solution or in the form of paper impregnated therewith. Free acid causes an azure-blue color; acid salts have no effect. A solution of methyl-violet may also be employed, which is turned into a deep blue ; or tropseolin, which in a saturated watery solu- tion is a dark yellowish-red liquid that on contact with any free acid becomes dark brown, while with acid salts it assumes a straw-colored tint. To ascertain the presence of hydrochloric acid the best test is Giinzburg's phloroglucin-vanillin solution. It consists of two grammes of phloroglucin and one gramme of * Ewald, op. dt, p. 21. 554 MEDICAL DIAGNOSIS. vanillin, with thirty grammes of absolute alcohol. A few drops of this solution, which is of a yellowish color, added to a similar quantity of a liquid containing hydrochloric acid, when gently heated, turn it at once a bright-red hue; while the reagent re- mains unchanged by organic acids, such as lactic or acetic acid. Boas * recommends a solution containing resublimated resorcin five grammes, white sugar three grammes, dilute alcohol sufficient to make one hundred grammes. Of this, three or four drops are added to five or six drops of the gastric contents, and the whole is gently heated to dryness ; a bright-red hue results if free hydro- chloric acid is present. To determine the presence of lactic acid, a matter often of very great value for diagnostic purposes, a solution is prepared of ten cubic centimetres of a four-per-cent. solution of carbolic acid, twenty cubic centimetres of water, and one or two drops of a solution of ferric chloride. This has an amethyst-blue color, which in the presence of la,ctic acid becomes lemon-yellow or canary-yellow. The degree of acidity of the gastric juice is more difficult to determine than the presence of tiie acids. Ewald recommends, as a ready way, to titrate with a one-tenth normal sodium hydroxide solution, ascertaining the saturation point with litmus paper or with phenolphtalein. Wolfff puts one cubic centimetre of the filtered gastric juice into a graduated cylinder, and dilutes it repeatedly until there is no more reaction with the standard methyl-violet solution. The quantitative determination of the hydrochloric acid present is made by titrating with a decinormal sodium hydroxide solution until there is no further response with Giinzburg's solution. We may test the solvent power of the gastric juice by taking a piece of hard-boiled egg albumen and adding the gastric juice in a test-tube. Heated in a culture oven, the egg albumen, if the gastric juice be normal, will be dissolved in about an hour. Propeptone and peptone are determined by the biuret reaction. The presence of the lab-ferment or rennet- ferment is shown by the coagulation of neutralized boiled milk by an equal quantity of neutralized gastric contents in ten or * Diagnostik u. Therapie der Magenkrankheiten, 3. Aufl., I. Theil, 1894, p. 149. t Trans. Phila. Co. Med. Soc, Oct. 1889. DISEASES OF THE STOMACH. 555 j&fteen minutes in an incubator. After an hour from the time Ewald's trial-breakfast has been taken there should be no reaction for starch found by Lugol's solution in the filtered liquid of digestion. The absorptive activity of the gastric mucous membrane is shown by the rapidity with which iodine appears in the saliva after the ingestion of one and one-half grains of potassium iodide carefully enclosed in a gelatin capsule. In health the charac- teristic blue coloration is, as a rule, obtained with starch-paper in the course of ten or fifteen minutes. The motor activity of the stomach is determined by the de- velopment of a violet color on the addition of a drop or two of a neutral solution of ferric chloride to two or three drops of the urine placed upon bibulous paper, after the ingestion of fifteen grains of salol in gelatin capsules at the height of digestion. The violet color shows the presence of salicyluric acid, which is in the majority of persons observed in the course of from sixty to seventy-five minutes. But there are still many clinicians who prefer the older method of examining the contents of the stomach after trial meals, with a view to determine the gastric motility. Leube's method consists in removing the contents of the organ six or seven hours after a trial dinner, or they may be examined an hour after Ewald's trial breakfast. In either case, the stomach should then contain nothing but the liquid of digestion; two hours after the trial breakfast it should be empty. If more than forty cubic centimetres are obtained an hour after Ewald's trial breakfast, it shows insufficient motor activity. The symptoms which are constantly met with in derangements of the stomach, whether organic or functional, are loss of appetite, nausea and vomiting, acidity, flatulency, and pain. Loss of Appetite. — This manifests itself in various ways. It may amount to absolute repugnance to taking any kind of food, or may be merely an inability to partake of certain articles. What the loss of appetite depends on, we do not know. That nervous influence has something to do with the anorexia, is shown by the sudden deprivation of all desire to eat when any strong impression is made on the nervous system, — such as that caused by the unexpected receipt of unwelcome news. The collection of epithelium on the mucous membrane is also connected with a 35 556 MEDICAL DIAGNOSIS. marked diminution of the appetite ; for with a tongue much coated, absolute disgust at the mere thought of taking food often exists, which yields to relish for food as soon as the tongue begins to clear. Attending lost appetite, we meet sometimes with great emacia- tion and with signs as if even the small quantity of food taken were not absorbed into, or utterly failed to nourish, the system. There is apt to be sensitiveness over the abdomen, and spots of particular sensitiveness exist which correspond to the situation of the mesenteric glands. We find, however, no evidence of organic disease, either in the abdomen or in the lungs; nor does this pseudo tabes mesenterioa, if I may so call it, occur, like the dis- ease it simulates, in scrofulous or tubercular patients. I have met with a number of cases, chiefly in young women with low- ered vital force, fond of excitement, and living indolent lives. Some were hysterical, others not. But in all the complaint seemed to be due to deficient nerve-power, with impaired func- tion of the stomach, and very possibly of the abdominal glands. This disorder is probably the same as that described by Gull as hysteric apepsia,* and kindred to the affection delineated by Lasagne as hysteric anorexia, f Instead of the appetite being lost, it may be capricious, or even ravenous. A craving after food is not often combined with a structural lesion. Yet we occasionally meet with it in persons affected with gastric ulcer. It is common to find it in those who suffer from neuralgia of the stomach. And sometimes in cases of mere nervous gastric disturbance, with or without pain, there is an extraordinary exaggeration of the appetite, a bulimia: the patient eats largely eight or even fifteen times a day, digests his food, yet is constantly hungry. The feeling of thirst does not lessen when the desire for food does. On the contrary, it usually increases when the latter diminishes. Excessive Acidity of the Stomach. — Excessive acidity occurs from various causes. The gastric juice may be secreted in great quantities, or it may contain an abnormal amount of acid. But excessive acidity is far more frequently due to the decom- * Transactions of the Clinical Society, vol. vii., 1874. t Arch. Gen. de M^d., April, 1873. DISEASES OF THE STOMACH. 557 position of food and to a process of fermentation dependent rather upon an insufficient amount or altered state of the gastric solvent. It then manifests itself only after meals. When the mucous membrane is covered with a tenacious mucus or with thick layers of epithelium, slow digestion and acidity from fer- mentation result ; because, although the gastric juice is sufficient, it cannot mix as readily with the aliment. The acids formed in the stomach are, besides the hydrochloric acid of the gastric juice, lactic acid, acetic acid, carbonic acid, butyric acid, and oxalic acid. Some articles of food produce these different acids in considerable quantities. Thus, sugar generates large amounts of lactic acid. The mode of detecting these acids, and of establishing whether the extreme acidity is due to excess of hydrochloric acid in the gastric juice or to other acids, as tested after a trial meal, has been above explained. In examining for acids, the two acids of greatest value to determine are hydro- chloric acid and lactic acid. The acids which are created in the stomach may give rise to vari- ous disorders. When much acid is present it occasions a sensation of heat which extends along the oesophagus. This " heart-burn" is apt to happen in paroxysms, and is attended with a feeling of constriction or with actual pain at the epigastrium. As a symp- tom it has no special diagnostic value, for it is met with both in functional and in organic diseases of the stomach. It simply de- notes great acidity ; it is common in gouty persons. It probably arises from the action of the acid contents of the organ on the sensitive nerves of the cardia and of the cesophagus, and the acid is mostl)' owing to fermentative changes. When the acidity is due to increase of hydrochloric acid, from excessive acidity or quantity of the gastric juice, it is the result of a gastric neurosis ; there may be acid vomiting coming on irrespective of food, and happening in the night or during the early morning hours. What has been called gastroxynsis by Rossbach is a gastric neurosis ap- pearing at intervals mostly after some psychical or mental dis- turbance, and marked by extremely acid vomiting and headache, like that of migraine. Flatulency. — The gas in the intestinal canal may be merely air which is swallowed ; or it may be generated from imperfectly- digested food ; or it may be a secretion from the blood-vessels of 658 MEDICAL DIAGNOSIS. the part. In those who suffer from indigestion, it is produced in the last two ways, and the patient complains greatly of the annoyance it occasions. It causes a disgust for eating, a feeling of distention, and sometimes actual pain. By interfering with the downward movements of the diaphragm, it induces a sensa- tion of constriction in the chest, shortened breathing, palpitation of the heart, and the sleep is broken by uneasy dreams. An expulsion of the gaseous contents of the stomach by the mouth gives rise to eructation, or belching. The belching which follows the decomposition of food has sometimes the taste and the odor of rotten eggs, owing to the gas evolved consisting of sulphuretted hydrogen. At other times the eructation is odorless, because the gases formed are carbonic acid, or hydrogen or nitro- gen, or some of their compounds. When the gas results from fermentation or decomposition of food, it frequently coexists with acidity occurring only after meals. When it is a secretion from the blood-vessels, it happens in an empty state of the stomach, and is often relieved by avoiding too long intervals between the meals. As a cause of flatulence and eructation which it is im- portant not to overlook may be mentioned thoracic aneurism.* Marked flatulency is often only a form of gastric neurosis. It is common in nervous dyspepsia and in hysteria. Xausea and Vomiting. — These are often combined. But sometimes there is persistent nausea without vomiting ; sometimes vomiting occurs without any or with but slight nausea. Yet they are both occasioned in much the same way : what gives rise to one will generally give rise to the other. Vomiting is a complex act. But its causes, although various, may all be arranged under four heads. It either arises from an irritation of the peripheral extremities of the nerves which sup- ply the parts more directly concerned in the act itself, such as the stomach, the diaphragm, and the oesophagus ; or the irritation originates in the centres from which these nerves spring, and is referred to their peripheries ; or there is a mechanical obstruction in the stomach or intestines ; or the vomiting is purely sympa- thetic. Under the first head belongs the vomiting observed in acute or chronic inflammation of the stomach, in ulcer, or in can- * Walter P. Atlee, Amer. Journ. of Med. Sci., July, 1869. DISEASES OF THE STOMACH. 559 cer ; also that following a debauch, or the introduction of irri- tating substances into the viscus. Under the second head may be ranged the vomiting which occurs in diseases of the brain ; per- haps, also, that which arises in morbid states of the blood, as in uraemia. Under the third head we may class the vomiting in narrowing of the oesophagus and of the pyloric or cardiac ex- tremity of the stomach, and in obstructions of the intestine. The fourth group is exemplified by the vomiting in pregnancy, in wounds of the extremities, in inflammation of the peritoneum, of the intestines, and of the liver, in renal calculus, and in irrita- tion of the fauces. Connected thus with so many various conditions, the act of vomiting, taken by itself, is of little diagnostic value. It pre- supposes a certain amount of irritation existing in the stomach, or reflected to it; but nothing more. It is, of course, a frequent symptom in disorders of the stomach, especially in those which are organic ; yet the error of considering it as having reference only to derangements of that viscus ought to be strenuously guarded against. As it is allied to moi'bid states too numerous to be here examined in detail, I shall content myself with making general statements regarding the indications to be drawn from it. When vomiting is observed in a person previously in good health, we may suspect either the invasion of some acute malady, or that some poisonous substance has been swallowed. Again, it may come on suddenly from violent mental emotion. When everything that is taken is immediately expelled, the difficulty lies in the oesophagus, or at the cardiac orifice of the stomach, or in an extreme irritability of the viscus ; and this irritability, attended as it often is with unceasing nausea, experience teaches to be more frequently due to sympathetic excitement of the organ than to structural gastric disease. But speedy vomiting, generally without preceding nausea, it must be remembered, is also among the symptoms of visceral hysteria, and is indeed, by some, regarded as the most frequent symptom.* I have known it associated or alternating with extraordinary flatulency. Nervous vomiting occurs where there is no lesion in the stomach or irritation of food as the cause. It is mostly due to reflected * Denian, L'Hysterie gastrique, Paris, 1883. 560 MEDICAL DIAGNOSIS. irritatioH of the nerve-centres controlling the act of vomiting, and is often found in disorders of the uterus ; or arises from direct irritation of the nerve centres in affections of the brain and cord. It is common in hysterical subjects. It is not associated with nausea, and may be of long duration. It is sometimes a pri- mary gastric neurosis, and as such is seen, particularly in neuras- thenics, in association with the condition described by Kussmaul as " peristaltic unrest." This is a very annoying symptom, in which there are loud borborygmi and gurgling, especially after eating. As regards the vomiting which is brought about by gastric disorders, it is of much consequence to note the period at which it happens, whether before meals or. after meals, and how long afterward. In some diseases, such as ulcer and cancer, it rarely occurs except when food has been taken. The act of vomiting then affords relief from the pain. In narrowing of the pylorus, it takes place some hours after digestion has begun. But, as vomiting will be described hereafter in its relations to the indi- vidual diseases of the stomach, we shall not dwell on what will be more fitly discussed elsewhere. Yet a few words on the characteristics of the ejected matter can hardly be omitted. The nature and the quantity of the vomit are, of course, most various. The foUowino; are its most common kinds : Food or liquid, mixed with saliva and some mucus, is expelled when the stomach is very irritable, or if an obstruction exist which renders the entrance into the organ difficult or impossible. Half digested food, in a state of acetous fermentation and with a strongly-acid reaction, is cast out when there is deficiency of hydrochloric acid, or when the food has been detained for a long time in the stomach. In the ejected matter the particles of food may be recognized ; but when the food has been kept for a pro- longed period in the stomach, or when it has passed on into the duodenum and is returned, it is changed into an apparently ho- mogeneous mass. Examined under the microscope, the structures of the animal or vegetable substances partaken of can even then be detected. Mixed with muscular fibre, elastic tissue, starch- corpuscles, and vegetable cells, is found usually a quantity of oil-drops and fat-crystals. The starch -corpuscles are turned blue by a solution of iodine and iodide of potassium. DISEASES OF THE STOMACH. 561 Sarcinas and yeast fungi are sometimes discovered, by means of the microscope, in the vomit. These organisms, first described by John Goodsir, are the result of a process of fermentation, and are generally associated with copious vomiting. They are small square or slightly oblong bodies, divided into similar smaller portions by cross-lines, and each portion thus formed is again subdivided ; but the markings of the smaller squares are not so distinct as those of the larger. The illustration shows a mass of sarcinse found in the vomit of a ... 1 nn -t n , • i Sarcinse ventriculi. patient who suttered irom gastric ulcer. Vomit containing sarcinse is always indicative of structural change in the stomach. It is sometimes found in chronic gastritis of long standing ; or in connection with ulcer, and yet oftener with cancer, and especially in those cases in which the narrowing at the pyloric extremity has led to distention of the organ ; indeed, any form of dilatation or a condition preventing the stomach from completely emptying itself pre-eminently gives rise to it. Sarcina vomit has an acid smell and reaction, and often a pecu- liar brownish appearance. After standing, it becomes covered with a dirty, frothy matter, like yeast. A solution of iodine and iodide of 'potassium turns the sarcinse mahogany brown or a violet hue ; but it is by the microscope that their presence can be recog- nized with greatest certainty. The process of fermentation at- tending the development of the sarcinse occasions heart-burn and extreme flatulency, and the copious vomiting is a source of relief. Mums is occasionally ejected in large quantities, both mixed with food and pure. In chronic gastritis, and in the milder forms of acute gastritis, the mucous membrane is covered with a tena- cious secretion, and a considerable amount of a glairy or stringy matter is expelled by the act of vomiting. As a general rule, indeed, it may be stated that, when much mucus is evacuated, a catarrhal state of the stomach is present. A thin, watery fluid, looking much like saliva, is discharged in some cases of organic disease of the stomach, as well as in func- tional derangement of the organ brought on by eating coarse food. Now and then it is met with in pregnancy. This variety of vomiting is known as pyrosis; popularly, as "water-brash." 562 MEDICAL DIAGNOSIS. ' It may be attended with a burning sensation extending to the fauces, and with pain running back to the spine. The fluid is commonly alkaline ; sometimes, owing to its intimate admixture with the gastric contents, it is acid. Frerichs found that it pos- sessed the power of converting starch into sugar. It is mostly regarded as being formed by the glands at the lower part of the oesophagus as well as of the stomach. Bile may find its way into the stomach, and be expelled by the mouth, imparting to the vomit a greenish or yellowish color and a very bitter taste. The occurrence of bilious vomiting is commonly held to indicate a disease of the liver, or that the pa- tient is extremely " bilious." It is not a proof of either. It is observed when there is much retching, and when the act of vomiting is protracted and frequently repeated, and is chiefly met with in the various forms of acute gastritis, and at the inva- sion of some acute malady which gives rise to sympathetic gastric disturbance. Faeoal vomiting never depends upon a disease of the stomach. It may be possibly owing to a fistulous opening between the colon and the stomach ; but such cases are extremely rare. Generally it is due to a mechanical obstruction to the passage of fseces. Occasionally it happens in fevers of a low type, or in peritonitis, and is then, perhaps, the result of paralysis of a por- tion of the intestinal tube, which acts, to some extent, as a me- chanical obstruction. The matter that is ejected has the odor of fseces ; but it is commonly of less firm consistence, and of lighter color, because it is the contents rather of the small than of the large intestine. Sometimes it is perfectly fluid. In fsecal vomit a considerable number of large comma-like bacilli have been noticed.* Pus in small amount is sometimes found mixed with the vomit in cases of large ulcers in the stomach, simple or cancerous. When in quantities, it is owing to an abscess in the neighbor- hood of the viscus having poured its contents into it. Still, pus is rarely met with in the matters expelled. And the same can be said of other substances that may find their way into the stomach, like echinococcus sacs and worms, and masses of false membrane. *Jaksch, Klinisohe Diagnostik. DISEASES OF THE STOMACH. 563 Blood, on the other hand, is not infrequently vomited. Having described the appearance of the blood when it comes from the stomach, in treating of the diagnosis of hemorrhage from the lungs, I shall, before examining into the circumstances which cause a hsematemesis, merely here recall the fact that it is pre- ceded by nausea and followed by black stools, and that the fluid ejected is generally black, and presents an acid reaction. The quantity of blood lost varies greatly; but the amount vomited is by no means a proof of the amount effused. The larger portion may pass off by the bowels, giving rise to peculiar tarry stools. Nay, the whole may be voided with the stools. Chocolate-colored material discharged by stool, and due to alka- line fluids acting on the blood after the effect of acids, is held to be a distinguishing trait between the blood passing by the intes- tines after a gastric hemorrhage and bleeding from the bowel.* Hemorrhage from the stomach is variously caused. It may spring from injury to the organ, or from disease of its coat ; it may be vicarious ; it may be the consequence of disorder else- where than in the stomach, as of a mechanical obstruction in the portal system ; it may depend upon an altei'ed state of the blood. In the hemorrhage that follows blows or kicks on the stomach, an active hypersemia of the mucous surface is occasioned, which leads to the extravasation of blood. An active arterial hypersemia also precedes the hemorrhage that sometimes follows the swal- lowing of irritant poisons ; and it is probably the cause of the hsematemesis in several of the organic affections of the stomach. Of these, only cancer and ulcer are apt to pi'esent hemorrhage as a prominent symptom ; and of these, again, it is much more fre- quent in the latter than in the former. The blood effused may be so slight in amount as to escape detection ; and this is especially likely to happen when it is intimately admixed with food or with bile. Yet, by means of the microscope, the existence of blood- corpuscles in the ejected matter can be always demonstrated. The fulness of the vessels may be associated with degeneration of their coats, as, for instance, in amyloid degeneration of the stomach. When blood has been detained for some time in the stomach, and has become intimately mingled with the acid contents of the * Bartholow, Practice of Medicine. 564 MEDICAL DIAGNOSIS. organ, it loses entirely its natural appearance. What is termed " coffee-ground vomit" is blood thoroughly intermixed with other substances. It is the result of a comparatively small or gradual hemorrhage; and, as this is the kind apt to happen in gastric cancer, it is common in this affection, though by no means limited to it. Vicarious hemorrhage from the stomach is not infrequent, and especially frequent is that which takes the place of the menses. It is not dangerous. The blood escapes at the time of the normal discharge, and while the bleeding lasts the stomach is slightly tender, and the digestion impaired. But during the intervals there are no signs of disturbance of the functions of the organ, and no pain ; both of which are points of importance in distinguishing between loss of blood caused by suppressed menstruation and loss of blood caused by disease of the stomach. Gastric hemorrhage, dependent upon a state of passive congestion brought on by an obstruction to the flow of venous blood, is occa- sionally seen in organic affections of the heart. But it is much more common as the result of embarrassment of the portal cir- culation, from tumors, or from affections of the liver and spleen. It frequently attends, therefore, cirrhosis and enlargement of the spleen, and is often joined to intestinal hemorrhage. In gastric hemorrhage resulting from changes in the blood the vessels themselves are toneless, and rupture easily or offer no resist- ance to their altered contents escaping. This kind of hemorrhage is met with in scurvy, in typhus fever, and in yellow fever. We see thus that blood is vomited from various causes, and that merely from the occurrence of hsematemesis we can deter- mine nothing definite as to its origin. Yet the symptom — for a symptom it always is — is of serious import, and when taken in connection with others is of great service in diagnosis. We ought, in chronic cases, first to suspect the hemorrhage to be due to some organic disease of the stomach ; when there is no other proof of a structural affection of this organ, we turn to the liver, spleen, or heart for its explanation, or examine carefully every part of the abdominal cavity, to see whether or not a tumor is the source of the disorder. If occasioned by none of these con- ditions, its cause lies probably in altered blood, or in suppressed discharges. The history of the case is indispensable to any DISEASES OP THE STOMACH. 565 induction. Thus, in low fevers there is no doubt as to what has brought about the hemorrhage. There is, however, one difficulty present in all instances ; and that is, to tell whether the ejected blood has found its way into the stomach and has been subsequently expelled, or whether the hemorrhage is really gastric. The only method to avoid being deceived is to scrutinize closely the history and the attending phenomena. Blood may be introduced into the stomach by the bursting of an aneurism, or from an ulcerating pancreas ; or it may have been swallowed during an attack of epistaxis or of haemoptysis, or wilfully, to excite sympathy or to escape pun- ishment. A strange result of gastric hemorrhage, first noticed by Graefe, is double-sided incurable amaurosis. So much for vomiting of blood, and for the different characters presented by the vomit. In describing them we have been led away from the indications they furnish in diseases of the stomach. But it was more convenient here to consider vomiting connectedly and somewhat in detail, than to be obliged to treat of it in various chapters. To return now to the more special symptoms of a deranged stomach. Merycism, or Rumination. — In this condition food that has been swallowed is brought up into the mouth, sometimes by an impulse of the will, but more commonly involuntarily, and remasticated and again swallowed. Rumination is recognized to be purely a neurosis, and may or may not be associated with other gastric disorder. Regurgitation of fluid or partly digested food may take place in connection with a relaxed condition of the cardiac orifice of the stomach, and, if obstinate, may lead to pronounced derangement of nutrition. This phenomenon is to be distinguished from a similar occurrence that takes place when the (esophagus is the seat of a pouch or diverticulum that empties itself from time to time. Fain. — Pain occurs in gastric disorders in every conceivable form. It is sometimes slight, at other times violent. It is often more a feeling of soreness than actual pain. It may or may not be increased by pressure, and may be either augmented or relieved by the taking of food. If persistent or severe, and accompanied by tenderness at the epigastrium, it is almost always linked to a morbid state of the tissues of the viscus. Mere uneasy sensa- 566 MEDICAL DIAGNOSIS. tions, on the other hand, also happen in functional derangement of the organ while the food is being digested, and may even be attended with slight tenderness at the epigastrium. Now, as both pain and soreness to the touch may be present as well in functional disturbance as in organic change, how can we tell with which they are associated ? As a rule, pain and soreness dependent on organic disease may be distinguished from pain and soreness that result from functional disorder by noticing the time at which they take place. If they are more severe soon after meals, or when the stomach is full, and worse after a heavy meal than after a light one, especially of a bland substance like milk, they point to a structural affection. If they occur only when the stomach is empty, and are relieved by food, they are indica- tive of a functional derangement. Occasionally the stomach is the seat of violent paroxysms of pain. These are at times linked to a chronic organic affection ; at others they are apparently connected with a perfectly sound state of the viscus, and coexist with a tendency to neuralgic pains all over the body, or with hysteria or neurasthenia; or they may appear as the gastric crises of locomotor ataxia ; at others they are brought about by some article of food which the stomacli does not tolerate or is unable to digest. The disorder is variously described under the name of gastrodynia or gastralgia. The pain is supposed to be associated with, or due to, a cramp of the stom- ach ; but whether it is so or is a pure neuralgia is uncertain. When the predisposition to it exists, exposure to cold and damp, a draught of cold water drunk when heated, sudden and violent emotions, or a collection of wind in the alimentary canal, will bring it on. The predisposition is met with in gouty and rlieu- matic persons, and in those who are debilitated, — in women who are ansemic, and in men who have been exposed to exhausting influences. Then we also find the gastralgia interchanged with other neuralgic or spasmodic affections, giving way to asthma or to angina pectoris, or, on the other hand, occurring in their place. The pain varies much in intensity : it is usually severe and agonizing ; but it is not permanent ; intervals of rest and comfort succeed to the paroxysms of distress. During a violent attack, the skin is cold, the pulse slow, there are frequently nausea, vomiting, sometimes fainting, and often sensations of utter prostration and DISEASES OF THE STOMACH. 567 impending dissolution. The seat of the pain is in the epigastrium, immediately beneath the ensiform cartilage. The patient feels as if the coats of the stomach were being violently drawn together, or rent asunder, or rapidly pierced by a sharp instrument. Thence the pain extends toward the umbilicus and the hypochondria. It is sometimes relieved by the recumbent position and by external pressure. But relief depends much on the condition with which the pain is associated. If it be connected with a chronic gastritis or an ulceration, external pressure aggravates rather than allevi- ates it. This is certainly true as a rule; yet we cannot positively announce that pain with tenderness at the epigastrium is proof of an organic lesion. There is sometimes sensitiveness to the touch in purely nervous gastralgia ; or slight pressure may augment the pain, but firmly compressing the pit of the stomach will diminish it. In a practical point of view, it is very important to discrimi- nate between the cases of gastralgia that may be viewed as pure neuroses and those in which the paroxysms of pain are combined with a chronic lesion. We infer that we have to deal with in- stances of the former, when the attacks occur in those whose im- poverished blood or enfeebled health predisposes to neuralgia, and especially if they happen in women laboring und^er disorders of the uterus or of menstruation, or in persons who suffer from neuralgic pains in other parts of the body. But the broadest line of distinction is drawn by the state of the digestive' appa- ratus during the intervals. The disordered digestion, the pain after eating, the tenderness at the epigastrium, the nausea and vomiting, and the other symptoms common in morbid altera- tions of the coats of the stomach, are not seen in pure neuralgic gastrodynia. Too much stress, it has been already stated, ought not to be laid on the influence of pressure on the paroxysmal pain during the paroxysm. A sign more trustworthy is the alleviation following the taking of food, for which, in truth, there may be a craving ; and occasionally cases of gastralgia are met with in which the pain occurs only early in the mornings, and is very distressing, but is almost immediately eased by a hearty breakfast. Gastralgia is common where there is an excess of hydrochloric acid in the gastric juice. The form of gastralgia which is pro- duced by some article of food that disagrees with the individual 568 MEDICAL DIAGNOSIS. is readily distinguished from the other varieties by observing it to be transient, and by noting its cause. The indigestible sub- stance undergoes fermentation in the stomach, and acidity, flatu- lent distention, and nausea attend the pain, which ceases when the oiFending matter is ejected and the gas expelled. The remarks just made apply also, in the main, to other manifestations of perverted innervation of the stomach, such as hyperesthesia, with or without persistent vomitings, — forms happening usually in weak or hysterical persons, or where men- struation is disordered, — but which in the present state of our knowledge are still conveniently classed with gastralgia as forms of gastric neuroses. The nervous filaments, the irritation of which occasions pain in the stomach whether paroxysmal or not, belong to the vagus ; sometimes, perhaps, the distress originates in the branches of the sympathetic that supply the organ. But we must be careful not to ascribe the seat of every pain which is felt between the umbili- cus and sternum, or referred there, to the stomach. Diseases of the pleura, of the heart and its covering, affections of the inter- costal nerves, abscess of the liver, intestinal disorders, rheumatism of the abdominal muscles, may give rise to pain in the epigastric region. And, again, spasmodic pain like that of gastralgia may. be caused by colic, by disorganization of the tissue of the kidney and of the pancreas, and by the passage of gall-stones or of renal calculi. The great safeguard against error is to bear in mind that painful complaints of the stomach may be mistaken for those enumerated, and to ascertain carefully, in cases of epigastric dis- tress, that there is no cause beyond the stomach to account for it. The nearer, in many instances, the pain is to the median line, or, should it occupy this, the more fixed and confined to a small spot, the greater is the probability of its being dependent upon gastric disease ; and pain of the character alluded to is generally indica- tive of serious malady. Pain is the last of the symptoms directly referable to the de- rangement of the viscus itself to which we shall advert. But when the great organ of assimilation is disordered, other organs suffer, either through sympathy, or because the irritation is trans- mitted to them, or because a similar state of their mucous surface is induced. The bowels are usually in a sluggish condition ; it is DISEASES OF THE STOMACH. 569 commonly only when the gastric acidity is extreme that they are relaxed. The viscera within the chest are frequently disturbed. The patient is annoyed by palpitation and shortness of breath after meals ; and as he feels the agitation of his heart, and finds that always, after he has eaten, his face is flushed, the palms of his hands are hot, and his temporal arteries throbbing, he is apt to overlook the derangement of the stomach, and to fancy himself laboring under an incurable cardiac affection. A dry cough, also, is a not unusual concomitant ; but a cough may be the result of coexisting catarrh of the bronchial mucous membrane, or of dis- ease of the lung-structure ; and sometimes the affection of the lungs precedes that of the stomach. Again, we may have an organic disease of the heart determining the gastric symptoms. So, too, with the kidneys. They may be irritated by the crude material which has made its way into the blood, and which they are called upon to excrete. The urine often contains various ab- normal constituents, especially urates ; yet not seldom a morbid state of the urine is found previous to the derangement of the stomach, and the indigestion is the secondary rather than the primary ailment. Indeed, we must never be too hasty in con- cluding, wlien a disordered stomach is associated with diseases of other viscera, that it is their cause ; it may exist as their conse- quence. Diseases of the liver and intestines are especially prone to induce a gastric affection. One of the worst results of a disordered digestion is the state of mind it produces. It occasions listlessness and a disposition to look at all events in a gloomy light, and sometimes brings on inveterate hypochondriasis. Aretseus ascribed to the stomach as its primary power that it acted as the president of pleasure and of disgust, " being, from the sympathy of the soul, an important neighbor to the heart for imparting good or bad spirits." Now, although no one at present would agree with this physiology, who will deny that there is in the remark a germ of truth ? But here, again, we must be careful not to confound cause with effect ; for want of activity or a distressed state of mind may seriously impair the appetite and subvert the normal action of the viscus. When the nervous symptoms are marked, the disorder is often called nervous dyspepsia. In this, while the gastric symptoms are slight, we may also have the gastric neurasthenia leading to 570 MEDICAL DIAGNOSIS. extreme acidity of the gastric juice, to eructations, to flatulency. ' There may be sensations of distress and uneasiness during the digestive act, but the gastric motility is not impaired. There is not always increased acidity of the gastric juice. The hydro- chloric acid may be normal or diminished in amount. In all forms there are uneasy feelings after meals and great nervous- ness. Nervous dyspepsia is common in neurasthenics and in hys- terics. The exact state of the stomach that coexists can be de- termined only by chemical investigation of the gastric secretion. In the rough sketch just finished of the symptoms encountered in gastric disorders, no attempt has been made to separate strictly the signs which belong particularly to alteration of its coats from those which occur in mere derangement of its functions ; in other words, I have not tiled to dissociate the symptoms of so-called "dyspepsia" fiom those of actual lesions. And this for two reasons : in the first place, the most palpable indications of or- ganic disease of the stomach are those of disordered function ; and secondly, there are no symptoms which belong exclusively to functional indigestion. Nor is it possible to present anything like a complete picture of merely functional, or, as it is still called by some, atonic dys- pepsia ; the combinations are too infinitely varied. The great difficulty is that the faulty performance of the act of digestion is too often regarded as the whole ailment. The time must come when the term dyspepsia will be banished. It is true that in an organ like the stomach it is particularly difficult to tell where disturbed function ceases and anatomical change begins. Yet that this can be done to a greater extent than is usually done, cannot be gainsaid. Moreover, there are many affections which have probably connected with them definite anatomical lesions and constant modifications of the gastric juice and of the secre- tions of the mucous follicles of the stomach, which we are as yet obliged to embrace under the name of dyspepsia, because we are unacquainted with their clinical expression. But we may fairly expect that, through those admirable clinical and pathological researches that have of late begun to illuminate the subject, the limits of purely functional indigestion will be much reduced ; so that what the physician of the present day is still compelled to class under the term functional indigestion will be recognized DISEASES OF THE STOMACH. 571 by the physician of the twentieth centnry as several distinct affec- tions, each with its characteristic fine structural change or its recognized chemical or motor variations, — much in the same way that the physician of the eighteenth century was obliged to regard and to treat dyspnoea as au individual disaase, while now we have learned to separate it into different varieties, in conformity with its prominent anatomical causes, and to treat it in accordance with its source. Diseases of the Stomaoli in whicli Pain and Soreness at the Epigastrium, and Vomiting, occur. After what has been premised, it is obvious that the structural diseases of the stomach present but few symptoms that can be regarded as at all characteristic. Indeed, the only ones which can lay any claim to be so considered — and we have already seen that this claim is not always valid — are pain and soreness at the epigastrium, and vomiting. We may, then, take these symptoms as a starting-point in diagnosis, and describe the individual organic affections in which they chiefly occur, speaking first of the acute. ., Acute Gastritis. — This malady is pronounced to be exceed- ingly rare, save as the result of irritant poisons. Undoubtedly, inflammation of an intense kind, involving more than the mucous membrane, originating spontaneously, and not from the introduc- tion of any highly acrid or corrosive substance, is very seldom met with. But it is no less certain that inflammation of a less active character, limited to the most important part of the stomach, to the mucous membrane, and especially to its surface, the so-called gastric catarrh, is far from being a rare disease, and, whether as a concomitant of fevers or as a separate malady, is a disorder to which the physician's attention is constantly drawn. Thus, then, acute inflammation of all the coats of the stomach, or even of the entire mucous membrane, is uncommon; acute inflammation of its surface is common. Yet it is the doctrine of the day not to regard any case as acute gastritis unless serious changes have been wrought by the inflammation in the tissues of the organ, so serious as almost to preclude recovery. But I think that, irrespective of the oidinary catarrhal cases, there are instances in which much more severe and deepsr in- flammation happens, and that a diseass exists fully entitled to 572 MEDICAL DIAGNOSIS. be called acute idiopathic gastritis. I am sure that I have seen cases which differed in nothing from the typical and graphically- described cases of Andral,* save in the fatal termination and in lacking the symptoms which immediately precede that termina- tion. I shall detail one which was striking. A robust woman, the mother of several children, whom she was obliged to support by hard labor, was suddenly seized with a pain in the epigastric region, and vomiting. There was no apparent cause for the at- tack : she had certainly not swallowed any irritating substance. Although at one time a sufferer from indigestion, her digestive organs had not been markedly disordered for weeks prior to the appearance of the pain and the irritability of the stomach. The former seemed to come on before the latter. It was of a dull character, increased by swallowing either solids or liquids, and associated with the greatest tenderness. Nausea was constant, and vomiting very frequent. Large quantities of a greenish fluid were ejected, as well as nearly everything she swallowed. The tongue was deeply coated ; its edges and tip were red. The bowels were constipated, but not painful on pressure. There was fever, — not, however, of an active type ; it rose toward evening ; the pulse was quick and small ; the breathing was hurried, and the patient exceedingly restless and prostrated. She complained most of the distress in her head, and of violent thirst. The treatment pursued consisted mainly in opening the bowels by enemata, and in administering ice and repeated doses of calomel, some of which she retained. After the symptoms had lasted for about ten days, they gradually disappeai-ed, and she slowly recovered. The pain ^on swallowing and the soreness at the epigastrium were the last to leave. Indeed, when she passed from under my care they had mot ceased entirely. Now, here is a case which presented all the symptoms of a severe inflammation of the stomach, similar to that produced when an irritant poison has been received into the organ. In all such instances there are the same nausea and vomiting, and pain ; the same restlessness and headache ; the same form of fever and small or feeble pulse; the same unquenchable thirst. Sometimes the * Clinique Medicale, tome ii. DISEASES OP THE STOMACH. 573 pain is of a burning kind ; and in those cases which prove fatal — and many do prove fatal, as much perhaps from the destructive effect of the irritant on the tissues as in consequence of the inflam- mation—there is hiccough, the skin becomes cold, the features col- lapse, and the sufferer dies prostrated, yet frequently preserving his mental faculties to the last. From these severe cases of acute gastritis, however caused, there exists every grade of inflammation, down to an active congestion of the mucous membrane, and to a mere reddening of its surface. Of course, there will not be in the milder forms the same intensity in the symptoms. But the outline is the same, although the filling in be in far less vivid hues. There is in all the same tendency to nausea and to vomiting, with more or less epigastric pain and uneasy sensations, and more or less tenderness at the pit of the stomach, and headache. A mild gastritis is very commonly brought on by a debauch or by the introduction of irritating articles of diet into the stomach. These cases are classed as ax:ute gastric catarrh, and are popu- larly known as severe attacks of indigestion : that they are owing to an inflammatory state of the mucous membrane was proved by the ocular demonstration Beaumont had of the process in the person of Alexis St. Martin. The symptoms that inflammatory change, when it was marked, produced, were some tenderness at the epigastrium ; nausea ; vomiting ; constipation, or sometimes diarrhcea ; a coated tongue, and headache, — in fact, just the symp- toms of which patients complain when they are suffering from an acute attack of indigestion. Another common and kindred kind of mild inflammation of the stomach or acute gastric catarrh is that usually called a " bilious attack." The French designate it expressively as em- barras gastrique. It is a catarrhal affection, and often associated with catarrh of other mucous membranes. It may come on from indigestible food, or after cold and exposure ; it sometimes occurs in epidemics. The symptoms are those already detailed. There is nausea, and frequently bile is vomited. We do not usually observe much pain in the epigastrium ; but rather a feeling of uneasiness, and a slight soreness to the touch. The urine is dark, and deposits urates ; the tongue is much coated ; there is thirst, with generally a moderate or slight fever, vhich exacerbates at 574 MEDICAL DIAGNOSIS, night, and is of remittent type, and there may be a yellowish tinge of the conjunctivse. In children acute gastric catarrh may become complicated with convulsions, or with symptoms simu- lating those of meningitis. Secondary acute inflammation of the mucous membrane of the stomach is found in association with various disorders. It is met with in remittent fever, in typhus, in the exanthemata, in rheumatism, and oftener in gout, and partakes somewhat of the specific character of the malady with which it happens to be com- bined. Indeed, instead of being a secondary inflammation, it is oftener, to speak correctly, a local expression of a constitutional state. Several writers describe a form of gastritis which occurs in very young children and leads to softening of the mucous lining of the stomach, a gastromalada. This softening is most likely a post-mortem change due to the action of the gastric juice, and especially met with in the subjects of acute gastric catarrh. Kundrat has called attention to the occurrence of gastric soften- ing with vomiting of blood in the brain affections of children, especially in tubercular meningitis. Sometimes a suppurative inflammatory process takes place in the submucous and muscular coats of the stomach. This may be primary, arising through local infection, or secondary or meta- static. It is characterized by intense epigastric pain, which may set in suddenly or be preceded by vague symptoms of digestive derangement. In addition there are a sense of burning, intense thirst, dryness of the tongue, and complete anorexia. The general depression is profound, and the temperature is usually high. The vomited matter maj- contain pus. Death may be preceded by general restlessness, delirium, and coma. Chronic Diseases attef)ided with Pain, Epigastric Tenderness, and Vomiting. The chronic diseases of the stomach may, like the acute, be considered in accordance with the pain, the soreness at the epigas- trium, and the vomiting that attend them. At all events, these are the symptoms common to the chronic diseases which are sus- ceptible of diagnosis. . Besides these, there are some chronic dis- DISEASES OF THE STOMACH. 575 orders with the morbid anatomy of which recent careful researches have made us familiar, — such as destruction of the tubular struc- tures; hypertrophy of the solitary glands; interstitial growths leading to glaudular wasting, and to a gradual fibroid thickening of the entire mucous or submucous coat ; fatty degeneration of the atrophied masses,- — but which we are as yet unable to dis- tinguish with any certainty at the bedside, notwithstanding much recent valuable work. - Contrasting the chronic diseases with which we are clinically acquainted with the acute, vomiting is found to be a symptom of greater diagnostic value, — not the act itself, but the appearances of the ejected matter. And, further, the phenomena of dyspepsia stand forth much more conspicuously. Chronic Gastritis. — In chronic inflammation of the mucous membrane, or chronie gastric catarrh, the symptoms of indiges- tion are persistent and manifold. They vary somewhat according to the extent of the mucous surface involved and the amount of mucus and epithelium which accumulates on it, and probably also according to the healthy or wasted state of the gastric glands. Generally there is a sensation of discomfort, of weight, and of soreness at the pit of the stomach, aggravated by food ; the part is also tender to the touch. Sometimes, even when the stomach is empty, a burning at the epigastrium and an inward fever are complained of. The appetite is impaired or capricious. Fer- mentation, heart-burn, and flatulency frequently attend the slow digestion of the food ; the tongue is usually heavily coated ; it may, however, be clean. The bowels are constipated. The urine contains an excess of phosphates or of urates, or exhibits crystals of oxalate of lime. The patient's circulation is languid ; he suffers from chilliness ; his spirits are depressed. Not unfrequently he is annoyed by thirst, and by vomiting, after meals, the half-digested food mixed with strings of mucus. But the vomiting may also take place when the stomach is empty, and the ejected matter is then fluid and colorless. Drunkards who suffer from chronic gastritis often throw up a quantity of glairy fluid on rising in the morning. A colorless vomit, joined to symptoms of long- continued indigestion, is very characteristic of chronic gastritis. The gastric contents removed after a trial meal show a diminu- tion in the amount of hydrochloric acid present, usually in the 576 MEDICAL DIAGNOSIS. total acidity also, and in the activity of the digestive ferments ; still, hydrochloric acid is generally present. When atrophy of the gastric tubules has taken pla^e there is complete absence of hydrochloric acid and of the digestive ferments. The fasting stomach is usually found to be empty. Thus, then, the results of chemical examination of the removed gastric contents, the character of the vomit occasionally, more fre- quently the coated tongue, the distress after eating, the soreness at the epigastrium, and the persistency of the symptoms, distin- guish the dyspepsia of chronic inflammation of the stomach from that which is purely functional. The causes of the malady are at times obscure. It certainly cannot be traced often to an antecedent acute attack, although those who suifer from the chronic disorder are particularly prone to acute exacerbations. It is more common in persons over than in those under forty years of age. It is especially common in gourmands and drunkards, and in those who live on coarse food or who eat irregularly. It is often found conjoined with chronic bronchitis, and sometimes with Bright's disease, with tubercular disease of the lungs, with gout, and with diabetes. Passive congestion undoubtedly acts as a predisposing element. The inflammation is seen to arise from this cause in the course of chronic affections of the heart or of the liver, and of obstructions to the portal circulation, whether complicated with a lesion of the liver or not. Chronic gastritis is frequently associated with ulcers in the organ or with cancer, and many of the symptoms of these disorders are clearly attributable to it. Let us inquire whether there are any special symptoms to Inform us that something more dangerous than chronic inflammation of the mucous membrane of the stom- ach exists. Gastric Ulcer. — Ulcer of the stomach is a disease compara- tively rare in this country ; but it is not so in some parts of the Continent of Europe and in England. The aifection is essentially dependent upon disturbance of the normal relation between the gastric secretion and the circulating blood, in that the one is unduly active or the other is deteriorated in quality. It is more common in females than in males, and between twenty and forty years of age than at any other period. It is generally associated DISEASES OF THE STOMACH. 577 with anaemia, or follows chronic gastric catarrh, or embolic plug- ging of small arterial twigs, or other disturbances of the circu- lation in the gastric mucous membrane. Amyloid degeneration of the finer vessels, too, occasions these perforating ulcers. The acid gastric juice acts readily and destructively on the weakened tissues. Rarely, gastric ulceration is due to tuberculosis and to syphilis. The ulcer or ulcers, for there are sometimes several present, are seated usually on the posterior wall of the stomach, in or near the lesser curvature and toward the pyloric extremity. The great danger arises from perforation of the coats and subse- quent peritonitis. But the ulceration may prove fatal by opening a large blood-vessel. Again, the formation of a gastro colic or a gastro-pulmonary fistula may lead to death ; or the protracted sufifering and excessive vomiting may gradually exhaust the vital energies. On the other hand, the ulcers may heal by cicatriza- tion ; and this, William Brinton tells us, takes place in about half the instances. Perforation, Welch states, happens in about six and a half per cent, of all cases. Recurrence of the gas- tric ulcer is not uncommon. In cases which may be regarded as typical, the malady is an- nounced by symptoms exactly like those witnessed in chronic gastritis, — the same uneasiness and pain at the epigastrium, and occasional nausea and vomiting of food, or of a watery fluid. Perforation may at this early stage of the disease most unex- pectedly cut short the patient's life. Should perforation not take place, hemorrhage from the stomach, with emaciation and anaemia, next appears. In this way the disease usually continues for months or years, the symptoms remitting from time to time, and showing singular variations in their severity. Welch * states the average duration of gastric ulcer to be from three to five years. The majority of the cases recover. Of the symptoms, pain and vomiting are the most character- istic. Pain is rarely absent ; never, perhaps, except in cases which run a rapid course. It is generally a continuous dull feeling; sometimes a burning, at other times a gnawing sensation. As a * Pepper's System of Practical Medicine, article " Simple Ulcer of the Stomach." 578 MEDIOALDIAGXOSIS. rule, it is rendered more acute within a quarter of an hour after eating, and remains so as long as food occupies the stomach. Its situation is commonly in the middle of the epigastric region, and there it continues strictly limited. At that point, too, thei-e is localized soreness, or even great tenderness to the touch. Some- times the pain is seated behind the ensiform cartilage, or is referred to the right or to the left hypochondrium. It is often associated with a gnawing pain in the lower dorsal vertebrae, which may shoot between the scapulae or down the spine ; but the dorsal pain, like the epigastric, is, on the whole, very fixed, radiates but little, and is most severe when the ulcer is on the posterior surface. Besides this continued feeling of distress, there occur violent paroxysms of pain, which may last for several hours ; nay, with trifling intermissions, for days. They sometimes come on suddenly when the viscus is empty, but are aggravated by pressure or by food ; and, in fact, they are often thus induced. The patient refers the sufl^ring chiefly to the pit of the stomach, or to the dorsal vertebrae. He is apt to seek the recumbent posture for its relief. Yet it is remarkable that there are at times long intervals during which all pain, whether paroxysmal or not, ceases, and during which food can be taken without inconvenience. The acidity of the urine is diminished ; the reaction may even be alkaline ; the chlorides are diminished or absent. The peculiarities the pain exhibits form, on the whole, the most distinctive symptom of gastric ulceration. The paroxysms just spoken of might be mistaken for a purely nervous gastralgia. Indeed, when it is considered that both disorders are specially apt to occur in anaemic women, and in those whose menstrual func- tions are deranged, it becomes apparent how easily this mistake may be committed. The soreness at the epigastrium; the per- sistent symjjtoms of indigestion ; the excess of hydrochloric acid in the gastric juice ; the increase of pain after meals, — constitute, in a diagnostic point of view, the safeguard against error. To these might be added the vomiting of blood, were it not that vicarious hemorrhages are not at all unlikely to take place in young women who are troubled with amenorrhoea. This is, in truth, a matter having a close connection with the diagnosis of gastric ulceration. Persons who suffer from disturbance of the menstrual function are prone to be hysterical ; and it may happen DISEASES OF THE STOSfACH. 579 that one of the most marked traits of the hysterical disorder is that it manifests itself by tenderness in the epigastric region, and by pain in the stomach. We thus may have the most significant signs of gastric ulcer, occurring, as so many cases of amenorrhcea do, in chlorotic young women ; therefore happening in the class among whom ulceration of the stomach is most frequent. Nay, the very history may point to the probability of gastric ulcer.* Yet generally, by close atten- tion to all the phenomena of the.case, we can arrive at a correct Conclusion. The tenderness, as in all local hysterical affections, is great on the slightest touch ; and there is no severe pain pos- teriorly corresponding to the spot of soreness in the epigastric region. Pressure upon a spinous process may cause pain, but it is not the peculiar dorsal pain of gastric ulceration. Then, in the hysterical complaint there is often hypersesthesia of the skin in various portions of the body, and the apparent gastric distress bears no relation to the taking of food or to the circumstance of its being of an irritating character or otherwise. The epigastric surface temperature is elevated in gastric ulcer, and may even exceed the temperature in the axilla, f But to return to the vomiting of blood. When this is not traceable to a suppression of a natural discharge, and when it does not befall a person who suffers from disease of the heart, or livei", or spleen, or oesophagus, it acquires great significance. It is the only kind of vomit at all distinctive of a gastric ulcer ; for the substances ejected present otherwise appearances not different from what they do in chronic gastritis. The blood may be pure and red, but it is more frequently blackened by the gastric juice ; and large quantities are sometimes passed by stool. Now, hem- orrhage does not take place in chronic inflammation of the mucous membrane of the stomach, except perhaps in drunkards. In those instances in which erosions exist on the surface, the vomited mucus may be a little streaked with blood; yet anything like a profuse hemorrhage never happens. Hence its occurrence in a ease with the symptoms of chronic gastritis, cancer being excluded, renders the presence of an ulcer probable. Yet there is a source * Case under my care, Philadelphia Hospital ; Med. and Surg. Kep. , Feb. 1863. f Hayem, Bevuo des Sciences Medioales, Oct. 15, 1888. 580 MEDICAL. DIAGNOSIS. of fallacy, as I know by having met with such an instance, due to removal of the ovaries in an hysterical woman with marked gastric symptoms, in whose case subsequent hsematemesis re- peatedly occurred. It must also be borne in mind that we may have gastric ulceration without hsematemesis.* The vomiting of the matters taken into the stomach may be immediate or not for some time after the food has been swallowed. Usually it happens speedily, and in some instances so speedily that there seems to be rather regurgitation than vomiting. But this is rare, and in the rarity is a safeguard against confounding gastric ulcer with the vomiting of cerebral disease, especially tumor; which I have known to happen in a young woman in whom, moreover, vomiting of blood had occurred. In the re- gurgitation, then, in the frequently absent nausea, in the clean tongue, — though coating may also be absent in ulcer, — in the want of oppression and weight at the epigastrium, and in the headache, altered vision, and other nervous phenomena, we have the distin- guishing traits between gastric and cerebral vomiting on which to lay stress in the diagnosis between disease of the brain and gastric ulcer, or indeed any other serious stomach affection. The attacks of gastralgia that occur in the gastric crises of locomotor ataxia may be misleading. But the absence of knee-jerks and the eye phenomena explain their meaning. Perforating gastric ulcer may lead to abscess beneath the diaphragm, and be mis- taken for pneumothorax. Indeed, this pyopneumothorax sub- phrenicus, as Leyden f called it, may show physical signs like those of pneumothorax. But they do not extend to the summit of the chest, and there is but little displacement of the heart. More- over, the history points to long-existing gastric derangement. Pain in the front of the chest or in the abdomen, as the cases of Penrose and Dickinson J prove, is an early symptom, and is soon followed by the physical signs of pneumothorax or of pneumonia. In concluding this sketch of gastric ulceration, two questions arise which require solution : Does an ulcer always produce the peculiar train of symptoms mentioned ? May not the same phe- nomena be met with in other disorders ? The first question must * See a case reported by Walker, Lancet, No. 3691, p. 1301. fZeitschr. f. Klin. Med., Bd i. p. 320. J Clinical Society's Transact., vol. xxvi., 1893. DISEASES OP THE STOMACH. 581 be answered in the negative. Ulceration of the stomach may occasion nothing but the symptoms of chronic gastritis ; and even these may not be marked. The second question is to be answered in the affirmative. There is a disorder with symptoms almost identical with those of gastric ulcer, the corrosive ulcer of the duodenum. Now, this affection, were it more frequent, would be a constant source of error. It may run an acute, or at least an apparently acute, or a chronic course. In either case it is scarcely distinguishable from gastric ulceration. Trier,* from an analysis of twenty six cases, mentions, among the most important grounds for a differential diagnosis, a sensitive tumor in the epigastrium, proceeding from adhesion with the pancreas, and jaundice or other hepatic phenomena. But these symptoms are far from constant; and, in accordance with his own showing, in acute cases, and in those chronic cases which run a latent course, the diagnosis is impossible. It may be added that the perforating ulcer of the duodenum is much more apt than ulcer of the stomach to remain latent and to lead rapidly to a fatal termina- tion. The most certain signs of duodenal ulcer are the sudden and apparently causeless occurrence of intestinal hemorrhage, which may recur and be associated with gastric hemorrhage; violent attacks of pain referred to the epigastrium ; and pain in the right hypochondriac region happening two or three hours after meals. Duodenal ulcer is thought by some to be almost invariably due to the action of a highly-acid gastric juice, and to furnish the best illustration of the so called "peptic ulcer." It is most common between thirty and forty years of age, and, as Krauss proves, is ten times more common in men than in women. * Quoted in British and Foreign Medico-Chirurgical Review, Feb. 1864. See, also, the excellent monograph by Krauss, "Das perforirende Gesohwiir im Duodenum," 1865, and remarks on it in Niemeyer's work on Practical Medicine ; Wadham and Barclay, London Lancet, Feb. and March, 1871 ; G. Ollive, Gaz. Med. de Nantes, 1885-86, iv. 31 ; W. Osier, Canada Med. and Surg. Journ., Montreal, 1886-87, xv. ; Bucquoy, Arch. Gen. de Med., Dec. 1887; "W-.H. Allchin, Transact. Pathol. Soc. Lond., 1887, xxxviii. ; Schrotter, Aerztlicher Bericht des k. k. Allgemeinen Krankenhauses zu Wien (1886), 1888, 27 ; J. M. Emmert, Weekly Med. Eev., St. Louis, 1888, xvill. ; W. "W. Johnston, Amer. Journ. Med. Sci., 1888, N. 8., xcvi. ; McPhedran, Canadian Practitioner, Toronto, Dec. 1890 ; Crozer Griffith, Transact, of College of Physicians of Phila., 1895. 582 MEDICAL DIAGNOSIS. There is yet another affection with symptoms like those of ulcer, an affection still more serious and destructive, — cancer. Gastric Cancer. — Cancer is found more frequently in the stomach than in any other organ except the uterus. Of nine thousand one hundred and eighteen cases of cancer which occurred in Paris from 1837 to 1840, two thousand three hundred and three were in the stomach.* The disease is generally primary. It is most often seated at the pylorus ; next in frequency stands the cardiac orifice ; most rarely does it involve the whole viscus. We find all the varieties of cancer affecting the stomach ; but none is so common as scirrhus. Indeed, what is called cancer of the stomach means, in the large majority of cases, scirrhus ; and, more- over, scirrhus at the pyloric extremity, deposited primarily in the textures which intervene between the mucous and the serous coat. It would be out of place to enter here into a minute description of the appearances of a gastric scirrhus. I shall only state that I have usually found it to present cell-growths less marked than those of scirrhus of any other part of the body. As found by an analysis of two thousand and thirty-eight cases of gastric cancer, three-fourths occur between forty and seventy years of age.f The symptoms of cancer of the stomach are the same as those of chronic gastritis, — pain, tenderness in the epigastrium, disor- dered digestion, vomiting. In a more advanced state of the can- cerous malady they may be those of gastric ulcer, hemorrhage being added to the list above given. There is only one symptom distinctive of cancer, — namely, the existence of a tumor ; and this is so only when it is joined to digestive disorder and to increasing anorexia, debility, emaciation, and cachexia. But let us see if there be anything in the pain and vomiting, or in the circumstances of the case, by which, even when a tumor cannot be discovered, the presence of a cancer may be suspected. Pain is a very constant symptom ; quite as constant as in gastric ulcer. But the pain is, as a rule, more continued, much less in- fluenced by the taking of food, and more radiating, being often referred to the right or the left hypochondrium. Its character is very varying. It may be dull, or gnawing, or it may be lanci- * Walshe on Cancer. f Welch, Pepper's System of Practical Medicine. DISEASES OF THE STOMACH. 58'3 nating. It may be slight, or it may amount to excruciating agony. It is often of the latter kind. But it is a mistake to suppose that a cancer of the stomach necessarily causes severe. or lancinating pain. Again, it should be borne in mind that the part diseased may ulcerate, and then the pain is exactly like that of an ordinary gastric ulcer, and is affected in the same way by food. The most marked seat of the pain is sometimes under the shoulder-blade. Vomiting is not an invariable result of cancer; yet it is a frequent one. The seat of the morbid growth determines, to a great extent, the occurrence of vomiting and the period at which it will happen. When the body of the stomach is attacked, and the orifices are not obstructed, it may not take place at all; or, if it take place, it is within a brief time after meals. When the disease has narrowed the cardiac extremity, vomiting supervenes almost immediately ; the food has hardly been swallowed before it is brought up again. But when, as is much more common^ the pylorus is constricted, the food is not thrown off until it attempts to pass through into the intestine ; therefore not until a considerable time after meals. With respect to the character of the substances ejected, this too depends on the seat of the cancer, and the time at which the vomit- ing arises. If it ensue several hours after meals, the cast-off matter consists of food partly digested, partly in a state of highly-acetous fermentation. An enormous quantity of acid material, the accu- mulation of several meals, is sometimes brought up during one act of emesis. The ejected matter may be intermingled with blood, and have a blackish or reddish-brown, "coffee-ground" appearance ; or the mucus which is thrown up may be tinged with black flakes : in either case we find reduced hsematin. Earely is any considerable amount of unmixed blood vomited. Free hydrochloric acid is, as discovered by von den Velden,* often absent from the vomited contents of the stomach or from the " trial meal." But we must not forget that it is also absent in amyloid degeneration, in atrophy of the gastric tubules, in many fevers, and occasionally in chronic gastritis. Its presence, * Doutsches Arch. f. Klin. Med , Bd. xiii. 584 MEDICAL DIAGNOSIS. however, renders the existence of careiuoma improbable. The test is best made in the manner already described. In many cases of carcinoma of the stomach lactic acid is to be found in the gastric contents after the administration of a special trial meal, free from lactic acid and lactates, and consisting of oatmeal gruel (a tablespoonful of oatmeal to a quart of water) with a little salt.* This phenomenon is rare under other conditions, and, confirmed as it has been by the observations of Cohnheim f and of Stewart, J promises to be a most valuable test, particularly of the early stages of gastric carcinoma. Microscopic examination may disclose the presence in the gastric contents of characteristic " concentrically arranged conglomerations of cells." § A close study of the pain and vomiting may furnish evidence by which the existence of a gastric cancer may be suspected. There are a few other circumstances which would strengthen this suspicion : one of these is the acidity of the stomach, with the sour eructations ; another, the extreme flatulency ; another, the fetid breath, for, although fetor of the breath may result from putrefactive changes in the food in almost any form of gastric disorder, it is never perhaps so permanent as in cancer. A fourth is the obstinate constipation ; a fifth, the progressive loss of flesh and the cachectic appearance of the patient, who is pale and tired- looking, or has a complexion slightly jaundiced, or whose face is of a color which seems to have arisen from a combination of the hue of chlorosis and that of jaundice. The supposed characteristic straw color of cancer is not often met with. The temperature is generally below the norm ; but there are exceptional cases in which a moderate amount of irritative fever accompanies the gradual wasting, — ^gradual, because the duration of the malady averages more than a year. Qj^dema of the ankles is a frequent symptom of the advancing disease. In some instances coma happens similar to diabetic coma, or tetany, as Kussmaul pointed out. There is an aseptic form, in which rapid enlargement of the liver, some fever, and erythematous eruptions occur. || * Boas, Miincliener Medicin. Woohenschr., 1893, No. 43, p. 805. j- Deutsch. Med. Wochenschr. , May, 1894. t Med. News, Feb. 16, 1895. ^ Ewald, Klinik der Verdauungskrankheiten, 3. Aufl., II. Band, p 342. II Hanot, Archives Gen. de Med., Sept. 1892. DISEASES OF THE STOMACH. 585 Now, should all these symptoms be met with in a person who is steadily becoming feebler, whose age is above forty, in whose family cancer is hereditary ; should cancerous tumors develop themselves in any other part of the body, — ^the suspicion enter- tained would be converted into almost a certainty. But it is not often that a perfectly typical case, presenting a combination of all the symptoms enumerated, is met with. And, I repeat, the most distinctive sign is a tumor : when this is not detected, consider- able uncertainty hangs over any diagnosis of gastric cancer. To contrast, then, cancer of the stomach with chronic gastritis and gastric ulcer : Chronic Gastritis. Pain at the epigastrium some- what augmented by food ; also soreness. Buth con- stant, although compara- tively slight. Tongue usually heavily coated ; may be clean. Acid eructations. Symptoms of indigestion marked. Sometimes vomiting; especially morning vomiting in alco- holic cases. No hemorrhage, or but trifling hemorrhage; at most, blood- streaks in vomited matter. Bowels constipated. No fever. Not much emaciation ; no ca- chectic appearance. Not confined to any age. More common in middle-aged or elderly people. Gastric Ulcer. Pain at the epigastrium much augmented by food ; subsides whPM this is digested ; parox- 3'8ms of pain, but not lanci- nating; a strictly-localized soreness to the touch in the epigastric region, sometimes a painful spot over the lower dorsal vertebrse. Intermis- sions in the pain of consider- able length are frequent. Tongue dry, red, streaked in middle; or smooth and moist or slightly coated. Eructations occur, are not acid. Symptoms of indigestion some- times very slight. Vomiting usually immediately or soon after taking food; often an early symptom. Abundant hemorrhage the stomach common. from Bowels may or may not be con- stipated; usually are. No fever. Frequently extreme pallor and debility. May occur In middle-aged per- sons ; but is most frequently seen in young adults, espe- cially in young women. Gastric Cancrr. Pain frequently of a radiating kind, often paroxysmal, nut unusually severe and lanci- nating, but not of necessity associated with soreness. Lit- tle or not at all affected by food. Pain rarely remits ; never intermits for any con- siderable time. Tongue pale and thickly coated. Fetid eructations. Symptoms of indigestion marked. Anorexia ; ex- tremely sour stomach. Vomiting a very frequent symptom; occurs sometimes On an empty stomach ; usually preceded by other symptoms. Hemorrhage not very abun- dant, but occasioning fre- quen tly cofFee-ground-Iook- ing vomit. Bowels obstinately constipated. Intercurrent attacks of slight fever may occur; but temper- ature often subnormal. Gradual and progressive loss of flesh, and debility ; and at times with the cEichexla hy- pertrophy of the peripheral lymphatic glands, especially above the clavicles. Most common in elderly peo- ple ; rarely occurs in persona under forty years of age. 586 MEDICAL DIAGNOSIS. Chkonic Gasteitis. Gasteic Ulcer. ' Gasteic Cancee. Disease may be relieved or Duration uncertain; may get Average duration one year; cured ; is often of very long well, may run on rapidly to may be shorter, but seldum duration, perforation; on the other longer; very rarely reaches hand, may last for years. two years. No tumor. No tumor. Geuerally a tumor. Contents of stomach contain Hydrochloric acid in excess in As a rule, no hydrochloric nrid almost always free hydro- contents of stonutch. in contents of stomach; often chloric acid. lactic acid present. No dropsy. No dropsy. (Edema of ankles often met with. The diiFerences laid down in the table are derived from an analysis of well-marked cases. In the early stages of the cancer- ous malady, a differential diagnosis is impossible. Subsequently, as already stated, the detection of a tumor plays an important part in any deduction. But this remark does not apply to cases of cancer of the cardiac orifice, which are rare, and in which a tumor, from its deep situation, almost always eludes discovery. Such cases are, however, discriminated by their presenting the same signs as a stricture of the oesophagus low down ; indeed, they are very constantly combined with a narrowing of the tube, produced by the cancer spreading to it. Cancer at other parts of the organ occasions a perceptible tumor in about three-fourths of all the instances ; its situation is, of course, not always the same. Where no tumor can be discerned, and particularly if, as may happen, portions of the stomach remain healthy and the digestive disturbances are slight, the existence of cancer may not reveal itself by any symptoms, and the case run a latent course.* A cancer of the anterior wall produces^ as a rule, fulness, re- sistance, and percussion dulness in the epigastric region. A can- cer involving the greater curvature gives rise to a swelling near the umbilicus, or to one extending toward either hypochondrium. The tumor formed by cancer of the pylorus is commonly felt plainly a little to the right of the median line, and one to two inches below the cai-tilages of the ribs. In women its position is apt to be even lower than this ; and, indeed, in both sexes the situation of the indurated pylorus is very variable. It may be pushed down to near the umbilicus ; nay, it has been discerned near the anterior superior spinous process of the ilium.f It is * See report of case under ray care at the Pennsylvania Hospital, published in Amer. Joiirn. of Med. Sci., vol. lii., 1866. f See Lebert's cases, in Traite pratique des Maladies cancereuses. DISEASES OF THE STOMACH. 587 rarely found in the left hypochondrium, but not unfrequently in the right. Then it may form adhesions to the liver, which viscus at times so completely covers the tumor as to render this impossible of detection. The reason why the swelling, in not a few instances, shows itself much lower than the normal seat of the pylorus, is obvious. During meal after meal the organ seeks to overcome the resistance offered by the narrowed pyloric orifice, and does so with great and increasing difficulty. The constantly-repeated and long- continued struggle leads to hypertrophy of the muscular coat and to distention of the hollow viscus. The tumor may or may not be movable, — ^generally is not; its surface may be either smooth or nodulated. It may be large and distinct, or small and requiring a careful examination to distinguish it from the surrounding and more yielding textures. Percussing over it elicits a dull sound, usually mixed with a tympanitic note. The tumor is much more perceptible on some days than it is on others. Its existence, as has been already insisted on, furnishes the most conclusive evidence in favor of a cancer. But is a swelling in the region of the stomach strictly pathog- nomonic of gastric cancer ? No ; not even when the swelling has been ascertained to belong to that viscus. At times the cicatrix marking a previous ulcer, or even the indurated and thickened margins of an existing ulcer, may be palpable through the ab- dominal walls and raise the question of a new growth. A mere fibroid thickening of the pylorus will occasion a tumor, and, moreover, produce symptoms which resemble so closely those of malignant disease at the orifice that I much doubt the possibility of distinguishing during life, with any certainty, between the two affections. Let us take this case, which I saw with Dr. Moss,* as an example. A woman, aged forty, complained much of pain at the pit of the stomach, and of a heavy sensation throughout the abdomen. For some months she had been suffering from indigestion, and had been steadily losing flesh. Her countenance had a tired look, and she was very despondent. She had a slight cough ; and on per- * Published in full in Proceed, of Pathol. Soc. of Phila., vol. i. 37 588 MEDICAL DIAGNOSIS. cussing the lungs, impaired resonance was detected at the apices. The bowels were obstinately constipated, the tongue was smooth and red, the pulse feeble. She vomited shortly after meals, yet never anything but the ingesta. There was no pain on press- ure over the pylorus : but a greater resistance to the finger than usual was detected. The ftirther progress of the complaint was marked by incessant vomiting, only, however, after meals. Once, and once only, did it cease for several days ; and then without apparent cause. As the case drew toward its fatal termination, the patient was much troubled with acid eructations, and had occasionally slight febrile attacks. The distress in the epigastrium increased in severity. About three weeks before her death she was seized with lancinating pains under both patellae, which were neither relieved nor aggravated by pressure or motion. They were accompanied by pricking sensations and numbness in the legs, and an inability to walk. The pains gradually ceased, but the numb- ness and loss of motion increased from day to day. She died, utterly exhausted by the abdominal pains and the incessant vomit- ing, about three months after she began to reject her food. On post-mortem examination, tubercular deposits were found at the apices of the lungs. The abdominal viscera were healthy, except the stomach ; and this, too, was healthy, save at its pyloric orifice, which was so narrowed that the tip of the little finger could hardly be forced into it. The mucous lining lay in folds, but on dis- section was found to be perfectly normal. At the pylorus, but only there, the submucous and the muscular coat were uniformly thickened. Examined microscopically, they contained nothing but areolar tissue, spindle-shaped fibre-cells, and very distinct organic muscular fibres. Now, here is a case which was not cancer ; yet it had the symp- toms of cancer. It is true that the absence of blood and of glairy mucus in the matter vomited, and the indistinctness of the swell- ing, in spite of the great emaciation, were against the supposition of cancer of the pylorus. Still, no inference based on these data alone could be strictly trusted, since eTOry cancer is not associated with the vomit of coffee-ground material or of glairy mucus, or with a palpable tumor. The disease was combined with tuber- cular deposits in the lung. Nor is this the only example of the combination which has come under my notice. And when a DISEASES OP THE STOMACH. 589 tubercular state of the lung has been fairly made out, and there exist at the same time signs of pyloric obstruction, I should make a diagnosis that this is not of a cancerous nature, but consists simply of an increased development of the submucous coat, with probably subsequent hypertrophy of the muscular tunic. The fbroid thickening may extend throughout the whole stom- ach. Such cases differ from cancer by their long duration ; the absence of hemorrhage, of vomiting, and of severe pain ; and the more uniform gastric swelling. The affection is sometimes ob- served in spirit-drinkers. Its discrimination from cancer is never a certainty, but merely a matter of conjecture. I am not aware of any extended chemical examination of the contents of the stomach having been made. In a case reported by Cornell,* which was complicated with tuberculous peritonitis, loss of digestive power was indicated by unbroken starch grains in the vomit. The ab- sorptive activity of the stomach tested by iodine was normal. Boas t states that in these non-malignant cases with pyloric ste- nosis, though there are fermentative processes, lactic acid is absent. There are other diseases than those of the stomach which may occasion a tumor in its region and are thus liable to be mistaken for gastric cancer. Prominent am,ong these are enlargement of the liver projecting into the epigastrium, tumors of the omentum, and diseases of the pancreas and of the kidney. Of course, the stomach symptoms proper are not so marked in these affections, and in some they may be wholly wanting ; examination of the gastric contents and of the urine, and due regard to the history of the case, will show us the truth about many ; and, after all, the best way of preventing ourselves from falling into error is to seek in any case of supposed gastric cancer for these other diseases, and to see if their chief symptoms are present. Resting with this general statement, I shall not take up the differential diagnosis of all the many affections mentioned ; es- pecially as some are referred to when treating of partial abdominal enlargements and of cancer of the liver. But there are two which may be here specially looked at : one is omental cancer, the other kidney affection attended with marked swelling, such as occurs * Montreal Med. Journ., Aug. 1892. t Miinch. Med. Wochenschr., Oct. 1893. 590 MEDICAL DIAGNOSIS. in hydronephrosis, pyonephrosis, abscess, hydatids, and morbid growths. In oTnenUxl cancer there is far less dyspepsia, hemorrhage and coffee-ground vomit are absent, the tumor appears to occupy chiefly the site of the greater curvature, the swelling is, or soon becomes, more generally diffuse, and hydrochloric acid and the digestive ferments are present in the gastric contents. In the kidney affections referred to, the history is of great importance, and we include in this history the passage of renal calculi as bearing on some forms of kidney enlargement, especially abscess from impaction of stones ; the limits of the mass, though this may project into the epigastrium, will scarcely be those of a gastric cancer. But the most certain safeguard against error is careful and repeated examination of the urine and of the gastric contents. And as regards the urine, the observations of Rommelaere * seem to show that its analysis may be of value even in the diag- nosis of the different forms of gastric disease. Thus, a cancerous ulceration of the stomach is attended with decrease in the amount of urea, and the acidity and the chlorides are diminished. In simple gastric ulcer these are in normal quantity or in excess ; so is the urea. In spreading gastric ulcer the chlorides in the urine are decreased, but there is normal or increased amount of urea and urates. Dilatation of the Stomach. — This happens frequently in connection with obstruction of the pylorus, whether cancerous or fibroid, but it is also met with independently of this structural lesion. The latter form occurs from weakening of the muscular coats produced by malnutrition or impaired innervation, and has been noticed as an attendant upon ansemia or hysteria, or following fevers, or obstruction of the upper part of the bowel, or compres- sion of the pylorus by an enormous gall-stone,t or, as Bamberger mentions, dislocation of the stomach by omental hernias. Edinger has proved that it may be associated with amyloid degeneration of the vessels or of the muscular coat of the stomach. The chief signs of a dilated stomach in either form are the rejection of food, * Journal de Medeoine de Bruxelles, 1883 ; quoted in the Lancet, Sept. 1 and Oct. 27, 1883. f Minkowski, quoted by Ewald. DISEASES OP THE STOMACH. 591 mostly in large quantities and retained for days ; fermented and vomited matter containing often torulse and sarcinee; extension of the tympanitic note of the gastric region, detected by percus- sion, to much below the umbilicus ; a splashing sound when the patient moves, particularly after drinking, and gurgling on sudden pressure ; the low line of dulness occasioned by fluids in the dis- tended organ, and the change of the dulness with the position of the patient; and slowly-progressing emaciation. The character of the gastric secretion and that of the contents of the stomach after a trial meal vary with the nature of the causative condition. As a rule, there are increased acidity and diminished absorptive and motor activity. The general nutrition suffers as assimila- tion is more and more interfered with. In doubtful cases the organ may be examined and its limits traced by distending it with ordinary air, or with carbonic acid, generated by swallowing iirst bicarbonate of sodium and then tartaric acid. Displacement of the right kidney has been observed in a number of cases. The sounds of the heart heard over the dilated stomach often have a metallic ring, but, irrespective of this, peculiar gurgling sounds, systolic in rhythm and evoked by the action of the heart, have been met with by Franck and other observers. Dilatation of the stomach may occasion nervous symptoms ; even tetany has been noticed.* The dilatation occasionally happens in an acute manner, and occurs in children f as well as in adults. As a rule, the muscular coat is not hypertrophied, but in the cases in which an obstruction at the pylorus exists, this is frequent at first, ulti- mately giving place to atrophy. The stomach may be unduly large without giving rise to any symptoms. This condition of raegalogastria is to be distinguished from gastrectasia by the absence of the symptoms of the latter, as well as of derangement of secretion, absorption, and propulsion. To tell the atonic cases from those due to narrowing at the pylorus is generally not difficult : we can detect a hard swelling, or find the resistance with a stomach sound. In cancerous ob- struction the gastric juice, as a rule, contains no hydrochloric acid, but we obtain lactic acid. In other forms of stomach dila- * Bulletins et Memoires des Hopitaux de Paris, t. xx., 1884. f Arch. G-en. de Med., August, 1884. 592 MEDICAL DIAGNOSIS. tation, particularly in the atonic form,* we find hydrochloric acid, as well as the acids of decomposition and fei-mentation, acetic acid, and butyric acid. Enlargement of the stomach is to be distinguished from dis- placement of the organ, — gastroptosis or GUnard's disease. The latter is seen in persons with pendulous abdomen. The condi- tion is due to relaxation of the ligamentous attachments of the stomach, and is often associated with a similar displacement of other abdominal viscera, — splanchnoptosis or enteroptosis. There are present, in addition to symptoms of digestive derangement and the obvious evidences of the dislocation of the viscera, mani- festations of functional nervous disturbance. Among the first are impaired or perverted appetite, epigastric fulness and disten- tion, eructation, acid taste and dryness of the mouth, burning or tearing pains at the pit of the stomach after eating, and constipa- tion alternating with seeming diarrhoea. The nervous symptoms include a feeling of weakness, general irritability, mental de- pression, headache or a sense of fulness in the head, vertigo, heaviness of the lower extremities, coldness of hands and feet, palpitation of the heart, heavy sleep, and frequently sacral pains. Emaciation takes place, with impoverishment of the blood, pallor of the surface, changes in the skin, and falling out of the hair. A certain number of cases are associated with dilatation of the stomach. This is also seen, as Reichmann has proved, in some persons who are much emaciated and in whom supersecretion of the gastric juice exists. Dilatation of the stomach may be confounded with dilatation of the large intestine. But the gastric symptoms of the former malady are of great significance. Moreover, we may make use of the salol test in the discrimination. Salol is not acted upon by the acid gastric juice, but is changed into salicylic acid by the alkaline intestinal secretion. The salicylic acid manifests itself in the urine of healthy persons in from half an hour to an hour, as shown by the addition of a drop of tincture of chloride of iron to the urine giving it a violet color. In dilatation of the stomach salicylic acid does not appear for two or three hours after salol has been taken. * Germain See, Bull, de I'Acad. de Jled., May, 1888. DISEASES OF THE IXTESTIiSES AND PEKITONJEJUM. 593 SECTION II. DISEASES OF THE INTESTINES AND OF THE PERITONEUM. In considering the diseases of the intestines, we meet with symptoms the import of which we have examined in connection with affections of the stomach. We encounter nausea, vomiting, and impaired digestion. These disturbances are sympathetic or dependent upon coexisting gastric disorder ; they do not serve, therefore, as trustworthy guides in intestinal maladies. The signs upon which we rely more implicitly are pain and the faecal dis- charges. As regards the former, we draw the truest inferences from its kind rather than from its mere occurrence. The study of the faecal discharges tells us in a more direct manner what is going on. , Alvine Discharges. — To examine briefly their appearances : Watery stools are observed whenever a large quantity of the serum of the blood finds its way through the intestinal coats. They are met with after the administration of saline purgatives, in serous diarrhoea, and in cholera. Their hue varies: they may be almost colorless, or tinged with yellow. Sometimes, although very thin and watery, they are decidedly yellow ; again they are rendered turbid by the dissemination of whitish flocculi of cast-off" epithelium, or by mucus. Whether they be yellow or colorless depends on the existence or non-existence in them of faecal matter and of bile. In a prognostic point of view, the most colorless evacuations are the most dangerous. The presence of an excessive quantity of mucus renders the dis- charges less consistent than natural ; yet, unless they contain more or less serum, they are not of necessity liquid. The appearance they present is similar to that of the white of an egg; or the whitish masses of mucus surround the lamps of faeces, or are intermingled with the fluid alvine discharges. Pus in large amount and unmixed with fteces is discharged only when an abscess has ruptured into some part of the intestine. Stools composed of faeces and pus are encountered in chronic in- flammation and in ulceration of the bowels ; and whitish, creamy streaks indicate the presence of the foreign substance. Yet the 594 MEDICAL DIAGNOSIS. pus may be so intimately blended with the faeces, or with masses of mucus, as to require the microscope for its detection. Stools consisting entirely of bile are rarely met with. More generally there are other elements joined to the voided secretion of the liver. An excess of bile in the alvine discharges gives rise to evacuations of a yellowish-brown or yellow hue, which darken on exposure to the air. When the alimentary tube is highly acid, the resulting color is green. Both these kinds of stools are commonly called "bilious;" but the latter is less absolutely so than the former. A deficiency of bile manifests itself by clayey, sometimes even by almost white, stools. The normal color of fseces is due to urobilin. It is the changed bili- rubin from the bile. Bile-pigment is not found in healthy stools. BlacJc stools result from eating certain articles of food, such as blackberries ; from the action of medicines, as iron, bifmuth, manganese ; from a vitiated condition of the bile and intestinal secretions ; or from the effusion of blood into the alimentary canal. At all events, when the hemorrhage proceeds from the stomach or the upper part of the canal, the stools have a black, tarry appearance ; when from the lower section of the tube, pure blood is passed, or, if it be small in quantity, a blood-streaked mucus. Should any doubt exist as to whether the dark discharges be dependent upon the presence of blood, let them be diluted with water; they will assume a reddish tinge if this be the cause of the abnormal color. The odor of the evacuations is extremely offensive in fevers of a low type, and when the intestinal secretions are vitiated. So, too, at times in smallpox and in cholera. Acidity of the intes- tinal canal, as in the intestinal catarrh of children and of adults,* or in rheumatism or gout, imparts to the stools a sour smell and an acid reaction. The reaction in health is mostly alkaline. In cases of constipation it may be important to notice the shape of the passages, because this may show whether aii impediment in the gut has flattened or otherwise altered them. In fevers, as well as in affections of the intestinal mucous membrane, whether inflammatory or not, we often derive information from studying the form of the voided matter. Figured stools succeeding to fluid * Jaksch, op. cit. DISEASES OF THE INTESTINES AND PERITONEUM. 595 passages are always of favorable omen. We also note whether the stools contain masses of undigested matter, and its kind. Chemical and microscopical examinations of the fseces are not often made; yet chemistry and the microscope may be frequently of great service. They enable us, for instance, to recognize with certainty that the yellowish lumps contained in the evacuation, or the greasy film which collects upon its surface, consist of fat. The microscope, too, detects masses of muscular fibre, of elastic tissue, of starch-corpuscles, of fat, coagulated albumen, crystals of cholesterin, red corpuscles, leucocytes, and various fungoid growths, micro-organisms, and parasites. Among the animal parasites, besides various infusoria and worms, — the main variety of which will be discussed farther on with the parasites, — we find the amoeba coli, now known to be the chief cause of tropical dysentery. It is one of the rhizopods, varying in size from 0.012 to 0.035 millimetre, and when active has a characteristic move- ment. This will be best seen if the stage of the microscope be kept warm. The microscope exhibits, in the faecal discharges of all diseases in which the stools readily decompose, masses of crystals of the triple phosphates ; in acrid stools, yeast fungi ; in typhoid fever, shreds of slough from the enteric ulcers, and bacilli ; in tubercular ulceration of the bowel, tubercle-bacilli ; and under many vary- ing conditions both in the fseces and in different organs, as well as in peritoneal exudates and in appendicitis, the bacillus coli communis. This is, as a rule, a sluggishly-moving bacillus which grows readily on gelatin plates, the surface colonies being large and spherical and of a dull white. They are stained by aniline dyes, but are decolorized when treated by Gram's method. The main normal ingredient of faecal matter is mucin.* Peptone occurs only in disea-scf One drawback to the use of chemical research for clinical purposes is the uncertain composition of the fseces, owing to the number of elements derived from the food. The study of the alvine discharges is of service not merely in intestinal complaints, but equally in the many maladies in which * Hoppe-Seyler, Handbuch. t Jaksch, op. cit See also on this and other points Nothnagel's researches, Beitriige zur Physiologie und Pathologie des Darms, Berlin, 1884. 596 MEDICAL DIAGNOSIS. the alimentary tube sympathizes or becomes involved. But to- return to the uncomplicated intestinal diseases, grouping them as they may be recognized by pain and peculiarity in the faecal dis- charges, and describing with them, for the sake of convenience, the aii'ections of the peritoneum. Diseases attended with Paroxysms of Pain referred chiefly to the Middle or Lower Part of the Abdomen, and not asso- ciated with marked Tenderness or with Fever. The type of these is colic. GoliCi — This is. an intestinal pain, paroxysmal in its charac- ter, and usually combined with constipation, but unattended with febrile symptoms. The pain is of a severe griping or twisting kind, and is commonly referred to the neighborhood of the um- bilicus. It is generally relieved by pressure. Sometimes there is soreness with the pain, and, indeed, a slight soreness not un- frequently remains after the paroxysm has passed off. While the pain lasts, the countenance wears an anxious, frightened ex- pression ; the skin is cold ; the pulse is depressed. Occasionally there is vomiting, and in severe cases the abdominal walls are tense or raised in hard knots by the spasmodic contraction of the muscles. An attack may last only a few minutes, or, with trifling remissions, for several hours. Some persons are very liable to attacks of colic. Those who suffer from indigestion, or are enfeebled by exhausting maladies, are predisposed to them ; so also are hysterical, gouty, and rheu- matic individuals. As to the exciting causes, they are various ; and somewhat according to its different causes, colic presents dif- ferent forms. Let us indicate the more prominent. Colic, simple and wiconneded with a disease of the bowel. — Now, in these cases, which are generally called spasmodic colic, the par- oxysmal pain may have a diverse origin. It may be the result of direct excitation of the peripheral intestinal nerves by the presence of irritating substances in the alimentary canal, such as indigest- ible food, cold or acid drinks, hardened fseces, gases, morbid secre- tions, ptomaines, worms, medicines, or poisons. It may proceed from an irritation of the central nervous system reflected to the DISEASES OF THE INTESTINES AND PERITONEUM. 597 intestinal nerves. It may be sympathetic, and produced by a morbid state of the adjacent abdominal viscera. 1. Colic owing to food difficult of digestion is very common, especially at the time of year when fruit is beginning to ripen. It may be caused by food taken in quantities greater than the digestive organs can assimilate. Hence it is frequent in children at the breast who are ovcrnourished, and in persons in delicate health with enfeebled digestive powers. The form of colic under discussion is often attended with vomiting and diarrhoea; it may be of only a few hours' duration, or it may last for several days. Colic arising from distention of the intestines with flatus, or " flatulent colic," is the result of the decomposition of food in the alimentary canal ; sometimes, however, the gases are extricated from morbid secretions, or are exhaled directly from the blood- vessels. The abdomen is very tympanitic and greatly distended, and the flatus is from time to time discharged, with evident relief. Hysterical persons are very subject to this form of colic. Colic from accumulation of hardened fseces is preceded by obstinate constipation, and is usually a tedious disorder. The accessions of pain are easily enough remedied by emptying the bowels ; but they constantly recur. Colic from the presence of morbid secretions in the intestinal canal is not so often encountered as that from indigestible food or retained fsecal masses. Yet it is occasionally met with in cases of diarrhoea attended with a disordered state of the intestinal functions ; even in the so-termed bilious colic the intestinal pain is not purely sympathetic, but is owing to the irritating character of the bile discharged into the intestine. This " bilious colic" is often preceded by nausea, loss of appe- tite, and a coated tonguc. The paroxysms of pain frequently go hand in hand with vomiting, — first of the contents of the stomach, then of bile. They are in general accompanied or soon followed by a yellowish tinge of the conjunctiva, by tenderness in the region of the liver, and by a desire to go to stool. The bowels are, however, apt to be obstinately constipated. Bilious colic is common in malarious districts ; it occurs especially during the summer and autumnal months, and frequently follows exposure.. It sometimes begins with a chill, and, unlike the other forms of 598 MEDICAL DIAGNOSIS. colic, it has as companions febrile excitement, and a full, frequent pulse. Malarial colic may occur in an epidemic form.* 2. In the second class of cases to which allusion has been made, colic is dependent upon some abnormal condition affecting pri- marily the great centres of innervation. The colic arising from fright, from anger ; that happening in nervous females and hypo- chondriac males ; perhaps that proceeding from sudden exposure to cold ; the form which is sometimes seen coexisting with neu- ralgic pains in other parts of the body, — in short, all those cases which are spoken of as nervous colic, might here be mentioned. The attack is sudden, and not commonly of long duration ; but it is very apt to be repeated. The " metallic colics" are further instances of colic produced through agents which act primarily on the nervous system. This is at any rate true of lead colic. Copper colic exhibits paroxysms of severe pain like those caused by the poisonous influence of lead ; but it is attended with nausea, vomiting, diarrhcea, tenes- mus, an abdomen distended and tender to the touch ; in other words, it is rather an inflammation of the intestine with colicky pain, than uncomplicated colic. Lead colic, on the other hand, is a pure colic. The distinguishing marks of lead colic are the bluish-gray line along the gums ; the contracted abdomen ; the obstinate constipation ; the great relief usually afforded to the pain by pressure ; the duration of the pain ; its marked and agonizing exacerbations ; and the history of the case. The signs of the lead poisoning also manifest themselves in other parts of the body. 3. Affections of various organs may give rise to colic, by sym- pathy, and generally through the intervention of the nervous system, to which the irritation is first transferred, and from which it is then reflected. Thus, colic is a not uncommon attendant on morbid states of the kidneys, liver, bladder, testicles, uterus, or ovaries, and on disordered menstruation. Yet we must not forget that the pain, although spoken of as colic, is often not strictly intestinal, but is merely a pain radiating from the affected organs themselves. Again, how far it is due to neuritis is a matter to be taken into account. * American Journal of the Medical Sciences, April, 1872. DISEASES OF THE INTESTINES AND PERITONEUM. 599 Colic arising in consequence of some abnormal state of the bowel. — In the preceding illustrations of colic the disorder was viewed as occurring in a healthy bowel. But colic may have only the significance of a symptom, and be combined with an altered structure or a changed position of the intestine. We meet, indeed, with colicky pains, undistinguishable from those of pure colic, linked to an organic disease of the bowel, and under circumstances some of which forbid the idea of a spasm. They are encountered in dysentery; enteritis; hernia; ulceration; intussusception; stran- gulation; twisting; strictures; distention, — in fact, in the most various morbid states of the intestine. And colic as a symptom can be discriminated, as far as the pain is concerned, from colic as an idiopathic disorder, only by a careful study of the history and the concomitant phenomena of the case. In several of the maladies cited, however, the more transitory nature of the pain, — or gripings, as they are termed, — in others, the presence of fever and of tenderness, serve as guides in diagnosis. Fever and soreness to the touch are also met with in that form of inflammation of the bowel which happens after exposure or after the retrocession of rheumatism from some external part, and which is commonly known as rheumatic or inflammatory colic. Having thus indicated the various forms of colic, and having mentioned the relation they bear to structural diseases of the intestines and to affections of adjacent viscera, I shall only here again insist on the necessity of tracing out in every case, as far as possible, the cause of the painful malady, so as to know if any serious mischief lie at the bottom of it ; and shall add but a few words with reference to the disorders with which uncomplicated colic, or that which is held to be purely spasmodic, may be con- founded. They are : Gastralgia ; Perforation op the Intestine; Strangulated Hernia; Passage of Gall-Stones ; Nephralgia ; Spasm of the Bladder; Uterine Colic; Neuralgia op the Dorsal and Lumbar Nerves; 600 medical diagnosis. Abdominal Aneurism and Tumors; Diseases of the Spine ; Enteritis and Peritonitis. Gastralgia. — In gastralgia the pain is seated in the epigastric region ; whereas in colic, or entei'algia, as it is called by some, the pain is either in the neighborhood of the umbilicus, or rapidly shifts its position from that point to different parts of the abdo- men, and is often connected with a spasmodic contraction of the abdominal muscles. Again, the history in cases of gastralgia; the fact that the attacks happen most frequently after meals ; their association with signs of a disordered stomach, — indicate the organ in which the pain arises. And much the same general signs, in addition to the marked constipation and the visible movements, enable us to distinguish those instances of peristaltic disturbance of the stomach to which Kussmaul * has called attention, and in which the drawing pain is apt to be referred to the intestine ; indeed, the peristaltic dis- order may spread to it. Perforation of the Intestine. — When paroxysms of pain have their origin in perforation of the intestine, the extreme prostra- tion and collapse show that they are not produced by a harm- less disorder like colic. Further, the abdominal distress is in such cases preceded by symptoms of a diseased state of the stomach or the intestines ; and if the patient live sufficiently long after the accident, the pain is followed by great distention of the abdomen and extreme tenderness, — in fact, by the signs of peritonitis. However, the differential diagnosis is occasionally very difficult. Especially is it so in typhoid fever ; for in this affection colic is readily induced, or perforation of the intestine may be brought on by very slight exciting causes ; and, moreover, peritonitis may occur without perforation. A valuable sign of perforation and of air in the peritoneum is the obliteration of the dulness on per- cussion over the hepatic region, pointed out by Alonzo Clark. Strangulated Hernia. — All mechanical obstructions of the in- testine will lead to paroxysms of intestinal pain. They are met with in cases of intussusception and of ileus ; they are equally frequent in cases of strangulated hernia. In all, the obstinate * Sammlung Klinlscher Vortriige, No. 181, June, 1880. DISEASES OF THE INTESTINES AND PERITONEUM. 601 constipation must arouse suspicion regarding the true nature of the complaint. To detect a hernia a local examination is re- quired ; and, therefore, a careful search at the usual seats of this affection ought to be made in every instance of severe or pro- tracted colic. Lives have been lost in consequence of the neglect of this simple precaution against disastrous error. Passage of Gall-stones. — The passage of a gall-stone is gener- ally attended with paroxysms of intense pain which are readily mistaken for colic. There is, as a rule, the same absence of fever and of tenderness ; yet fever of short duration does happen. Pressure is often resorted to in order to mitigate the suffering, and thus the resemblance to colic is heightened. The points of distinction from colic are, the position of the pain in the epigastric region ; its sudden beginning and sudden termination ; the severe nausea and vomiting attending the attack ; the jaundice ; and the voiding of gall-stones with the stools. The latter sign, though a positive one, assists less in the discrimination of the disorder than would appear at first sight ; partly because it does not serve as a means of indicating the nature of the affection until its close, partly because the stone often escapes detection in the faeces.* 'J he other circumstances have, therefore, a more available diag- nostic value. Yet even they do not enable us to distinguish positively between the transit of a biliary concretion from the gall-bladder to the intestine, and the bilious colic that is joined to derangement of the function of the liver. The repetition of the attack is always a strong reason for suspecting it to be owing to a discharge of calculi from the gall-bladder ; and so are severe retching and vomiting, the sudden supervention of jaundice, and the localized epigastric pain. But these phenomena, too, are produced by hepatic neuralgia, which in rare cases is believed to happen without there being gall-stones or inspissated bile. There is nothing by which we can discriminate this malady — the very existence of which is, indeed, denied — except its recurrence after certain intervals, the alternations with other affections of the nervous system, and the slightest touching of the part inducing * The best way to find the stone is to pass the evacuation through a sieve : this is more certain than covering the discharge with water. The stone may not come from the bowels for some days after the attack of colic. 602 MEDICAL DIAGNOSIS. at times the acute pains.* There is said to be an increase of tem- perature over the gall-bladder during an attack of gall- stones, f Sometimes gall-stones are closely simulated by impacted faeces, which occasion colicky pains, and even jaundice, by pressure. The pain is at once removed by morphia given hypodermically, and a dose of oil brings away the hardened faeces. The attack^ may recur, and are always relieved in the same manner. The swelling in the right side may be sometimes readily detected. Among the rarer symptoms attending or following the passage of gall-stones, temporary dilatation of the heart and tricuspid re- gurgitation have been noticed, J just as temporary mitral insuffi- ciency has been observed in jaundice. Where the gall-stones are lai'ge and have become impacted in their course toward the intestine, they give rise to inflammation which may lead to ulceration and to the discharge of the concre- tion — generally then very large — into the intestine or stomach. Subsequently an obliteration of the duct may happen ; or the in- flammation and ulceration of the duct may result in perforation into the peritoneum. In some cases the gall-stones are voided through the abdominal walls, in consequence of their having caused inflammation of the gall-bladder and subsequent adhe- sions to the abdominal parietes. The fistulous passages discharge pus and bile, and occasionally fresh concretions : they may last for years ; but in time they generally heal. As regards the other forms of fistulous communications alluded to, they very rarely present symptoms so peculiar as to warrant anything like a cer- tain diagnosis.! Nephralgia. — Paroxysms of pain with intervals of comparative ease and unassociated with fever occur in nephralgia, or pain of the kidney, and are, therefore, often mistaken for colic. Now, nephralgia is generally, although not invariably, caused by the passage of a calculus through the ureter. Its symptoms, besides the pain, are numbness of the thigh, nausea and vomiting, a con- stant desire to make water, and aching and drawing up of the * See the cases of JBudd. on Diseases of the Liver; of Andral, Clinique Medicale, tome ii. ; and of Prerichs, Diseases of the Liver, f Jules Cyr, Traite sur I'Affeetion calculeuse, Paris, 1884. X Potain, quoted by See, Maladies du Coeur, Paris, 1883. J See a collection of cases by Murchison, Edinb. Med. Journ., July, 1857. DISEASES OP THE INTESTIXES AND PERITONEUM. fi03 testicle. The patient, as in colic, is restless, and seeks relief by frequently changing his position. The pain comes on suddenly, and is excruciating. It is felt in the loins, usually on one side, and shoots along the track of the ureter to the corresponding hip and thigh. It sometimes extends to the pelvis or toward the umbilicus, and is often attended with tenderness in the course of the ureter. Occasionally it is almost exclusively felt at the hip. When the stone reaches the bladder, the pain ceases as abruptly as it began ; though sometimes there is still discomfort produced by the stone interfering with the act of micturition. During the attack the urine is passed in small quantities at a time. It is high-colored ; sometimes it contains a little blood. If it be col- lected, and, after all pain has disappeared, be carefully examined, a small, hard body or a sandy deposit is generally detected, and reveals the cause of the past anguish. It is from the presence of the sandy deposit that the complaint has received popularly the name of a fit of " the gravel." From the description given, it will be seen that in several respects the disorder is like intestinal colic. The seat of the pain is a point of distinction ; yet in neither complaint is the seat en- tirely characteristic. It is not always strictly umbilical in colic ; it is not always exactly in the region of the ureter or kidney in nephralgia. Of more importance is the state of the urinary functions, which are comparatively undisturbed in colic. Again, the numbness of the thigh and the retraction of the testicle are valuable diagnostic marks; they would be absolutely decisive, were they constantly present in nephralgia. Spasm of the Bladder. — The bladder is sometimes the site of paroxysms of violent pain, supposed to attend upon a spasm of the viscus. There is an intense desire to urinate, which the pass- ing of water does not allay. The pain is not steady ; it is accompa- nied by a sense of constriction at or near the pelvis, and sometimes by tenesmus, and may extend to the kidneys, to the thighs, and to , the sacrum ; or the irritation may be communicated to the penis, and cause erections. If the sphincters be involved, the urine can- not be voided. The bladder distends ; there is intense anxiety, with restlessness ; the pulse is feeble ; the skin is cold, and covered with clammy perspiration. A spasm of the bladder may be caused by the presence of a stone 38 604 MEDICAL DIAGNOSIS. or of irritating urine. It is also encountered in gout and hysteria, and as the result of stimulating diuretics. Violent fright, too, may- occasion it. It sometimes proceeds from a disorder of adjacent structures, such as of the rectum, or of the uterus. Now and then, as Sir Benjamin Brodie pointed out, it is associated with inflam- mation or suppuration of the kidney, and the vesical pain is so intense that it withdraws attention from the organ most affected. To distinguish it from colic is not difficult ; the position of the pain and the disturbed condition of the urinary functions serve as guides. It resembles more closely nephralgia ; as in nephralgia, too, after the fit is relieved, the important indication is to prevent its repetition by endeavoring to remove its source. Uterine Colic. — The painful sensations experienced by some women at their menstrual periods may come on in paroxysms similar to those of colic. In truth, the pain is often spoken of as uterine colic, and at times continues for many days, persisting during the whole menstrual period, or even longer. In some of these cases the complaint is localized in the uterus ; in others, more especially in the ovaries, which are then tender to the touch. Similar attacks of pain, also accompanied by congestion or even by inflammation of the ovaries, are occasionally met with as the result of falls or of blows on the hypogastric region. Now, with reference to the disorder first alluded to, or ordinary dysmenorrhcea, it may be generally easily discriminated from colic by its occurrence with the setting in of the menstrual flow ; by the pain remitting rather than intermitting ; by the seat of the pain in the pelvis, or the lower part of the abdomen ; by its not uncommon association with sickness, nausea, and vomiting ; and by the fact that all the signs of disordered menstruation have .happened over and over again at the menstrual periods. Where the ovaries are very much congested or inflamed, whether or not the affection exist in connection with dysmenorrhcea, or occur in consequence of other causes, among which gonorrhoea may be one, the pain, tenderness, and swelling in the hypogastric region ; the not unusual numbness and flexed position of one or both thighs ; the febrile irritation, and the hysterical symptoms ; the retention of the urine ; the violence of the paroxysms of pain, and the duration of the malady, — form a group of phenomena very dissimilar to those of ordinary cases of colic. . DISEASES OF THE INTESTINES A.ND PERITONEUM. 605 Neuralgia of the Dorsal and Lumbar Nerves; Abdominal Nev^ ralgia. — The dorsal and lumbar nerves are subject to neuralgic affections, which exhibit, like colic, paroxysms of pain unac- companied by fever. But Valleix has taught us to look for spots painful to the touch in the course of the aching nerves, and has shown that the disturbance of the nerves supplying the ab- dominal parietes manifests itself on one side of the body only, whereas an irritation of the intestinal nerves obeys no such law. In neuralgia of the lumbar nerves, or lumbo-abdominal neural- gia, the pain is commonly felt in the hypogastric region, a little to one side of the median line. In this situation, too, there is localized soreness on pressure ; the other tender spots are, gener- ally, one a little to the outside of the first or second lumbar ver- tebra, and one immediately above the middle of the crest of the ilium. In women, who are by far the greatest sufferers from the disease, there is sometimes also a painful place about the middle of the Fallopian tube, or on the neck of the uterus ; in men, a point on the scrotum here and there is found sore to the touch. These spots of tenderness serve as characteristic signs ; and they enable us to separate neuralgia not only from colic, but also from lumbago, and from rheumatism of the abdominal walls. Besides these forms of neuralgia, we find other kinds of ab- dominal neuralgia, which may be mistaken for colic. They are attacks of pain affecting especially the mesenteric plexus or the solar plexus, happening in paroxysms of great severity, and at- tended with a sense of faintness and annihilation. The disorder is unconnected with lead poisoning or any of the causes that pro- duce colic, is often excited by exertion, and is associated with de- bility and relieved by an antineuralgic treatment. In some cases it is clearly of malarial origin ; and in every instance we must lay stress on the frequent recurrence of the pain and on the his- tory to enable us to discriminate between the neuralgic complaint and colic. The distinction from gastralgia can be made only by the more marked gastric symptoms, and by the absence of, or the less decided, prostration and sense of fainting in this malady.* * A number of cases of abdominal neuralgia are reported by Handfield Jones in his Treatise on Functional Nervous Diseases ; and by Porcher in Amer. Journ. of Med. Sci., July, 1869. 606 MEDICAL DIAGNOSIS. Abdominal Aneurism and Tumors; Diseases of the Spine. — In all of these we may find violent pain of a paroxysmal kind re^ ferred to various portions of the abdomen, and unaccompanied by fever. We judge that the pain is not colic, by its frequent repetition ; by its want of association with intestinal or gastric disturbance; by its being, although liable to exacerbations, so steadily present at some part either of the spine or of the abdo- men ; and by the attending symptoms and signs occasioned by an abdominal tumor, or by a disease of the lower dorsal or of the lumbar vertebras. Enteritis and Peritonitis. — Inflammations of the intestines and of the peritoneum also give rise to severe abdominal pain. But it is more constant, and is linked to great tenderness, and, in acute cases, to symptoms of high febrile excitement. Thus enteritis and peritonitis belong to a different group of diseases, — a group of in- flammatory affections, which I shall describe somewhat at length, before contrasting the symptoms of inflammation of the intestines or of the peritoneum with those of colic. Diseases attended with Pain and marked Tenderness in tlie Umbilical Eegion or difiused over the Abdomen. Acute Enteritis. — Enteritis means, by common consent, in- flammation of the small intestine, especially of the portion that lies between the duodenum and the colon. The morbid process may extend to the colon ; if, however, it involves a iai'ge portion of the latter, it is colitis or dysentery. There are two forms of enteritis : one in which the mucous membrane of the bowel is alone affected ; muco-enteritis or intestinal catarrh. In the second, more than the mucous tunic is implicated ; there is also inflam- mation of the submucous and muscular coats, or even of the serous investment of the bowel. To this variety of the complaint the term enteritis is by several writers restricted ; and it is to this rare form of the malady, a phlegmonous enteritis, occurring acutely, that the description about to be given more particularly applies. The symptoms of an acute attack of enteritis are those of colic, attended with fever and tenderness. The disorder may begin with the symptoms of colic, or it may set in with chill and fever. DISEASES OF THE INTESTINES AND PERITONEUM. 607 When the disease is fully established, the fever runs high ; the pulse, tense and full at the onset, becomes small and wiry. There are nausea and vomiting, and sometimes distressing fits of retch- ing. The tongue is covered with a white coat, or is red and dry. The bowels are constipated ; sometimes there is diarrhoea, or con- stipation alternating with diarrhoea. The stools may contain a small quantity of blood, but they very rarely contain pus. The appetite is lost, the thirst great. The pain, as in colic, is parox- ysmal. It begins near the umbilicus, and thence may shift to various parts of the abdomen, but not to the epigastrium ; it does not cease as in colic, but rather exacerbates, and then changes to a dull feeling of distress. It is greatly increased by pressure, and the patient seeks relief, as in peritonitis, by lying on his back with his thighs flexed, so as to relax the abdominal muscles. Toward the right of the umbilicus it is not uncommon to find a marked pulsation, as if from throbbing of the abdominal aorta or of its large branches, — a sign to which Stokes* directed atten- tion. This pulsation may be very annoying. In looking over the notes of. my cases on which the description of the symptoms of enteritis just given is based, I find one in which neither the thirst, nor the pain, nor the nausea and vomiting occasioned as much distress as the violent throbbing in the abdomen. In those instances of the malady that advance to a fatal termi- nation, the pulse becomes quick and irregular and loses its tense- ness ; hiccough appears ; the abdomen swells ; the features are haggard ; and the patient's strength becomes gradually exhausted. The worst and most hopeless cases of the disease are those de- pendent on mechanical obstruction of the bowel, whether it pro- ceed from organized bands in which a loop of intestine is caught, or from invagination, or from accumulation of hardened faeces, or from a hernial strangulation. The disease may lead to puru- lent infiltration of the submucous tissue and to abscess-formation. Among the symptoms of enteritis mentioned, the pain is one of the most important for diagnosis. It is never absent, save in rare instances in which the inflammation is very intense at the onset.f Still more important is the great tenderness. This en- * Article " Enteritis," in Cyelopffidia of Practical Medicine. •j- Andral, Pathologie interne, tome i. p. 47. 608 MEDICAL DIAGNOSIS. ables us to say that the case, in spite of the colicky pains, is not colic. It tells us, when it succeeds to ordinary colic, that inflam- mation of the bowel has supervened. It admonishes us not to administer strong cathartics to overcome the constipation that ap- pears in consequence of the severe inflammation. The disease in its violent form just described bears a close re- semblance to peritonitis : we shall presently see what are its dis- tinguishing marks. But there is, as above stated, another variety of the disease, a mild variety, or muco-enteritis, in which the dis- turbance is limited to the mucous membrane. The main features of this intestinal catarrh are the same, but they stand out in less bold relief. There are griping pains, a slight soreness to the touch, general uneasiness, loss of appetite, thirst, nausea, and sometimes vomiting. But we find only slight fever ; and the febrile excite- ment remits in the morning. Diarrhcea is present, and the stools are sometimes very offensive. This form of the disease may ter- minate, as the severer inflammation generally does, in less than a week ; yet it may persist for several weeks, and thus gradually lapse into a chronic complaint. It is common in children, espe- cially during dentition. It is also observed when irritating food or secretions occupy the alimentary canal for any length of time, or after exposure to cold and damp, particularly when the skin is perspiring freely, and as an attendant upon the exanthemata. It resembles typhoid fever. Indeed, it is sometimes difficult, espe- cially in children, or in the intestinal catarrh of catarrhal fever, to know whether we are dealing with a case of simple intestinal catarrh, or with the intestinal symptoms of enteric fever. The state of the cerebral functions, the pain and gurgling in the iliac fossa, and the high temperature of the latter malady, may clear up the doubt ; yet in some cases nothing but the eruption and the course of the symptoms will do so. The symptoms just described belong to catarrh of the ileum, or of the ileum and the ascending colon. In catarrhal inflammation of the duodenum there is often constipation in place of diarrhoea. Pain between two and three hours after the taking of food, loss of appetite, coated tongue, fetid breath, marked digestive disorder, flatulency, and jaundice are prominent among the symptoms. The pain is apt to come on in paroxysms like gastralgia, although re- ferred somewhat lower than the stomach ; these seizures last several DISEASES OF THE INTESTINES AND PERITONEUM. 609 hours, and slowly subside. We frequently find a certain amount of soreness developed by deep pressure in the right hypochondrium and the upper part of the umbilical region. There is weakness, with much despondency, and slight elevation of temperature. An acute attack lasts two or three weeks. In the chronic form the duration may be as many months. Another affection which is liable to be mistaken both for en- teritis and for typhoid fever has been described by Klob.* The chief symptoms are violent pains in the hypogastric region, with vomiting, thready, frequent pulse, high temperature, and the rapid supervention of somnolence and coma. In some instances hemor- rhages happen. Hemorrhagic erosions are found in the stomach, and bloody infiltrations in the jejunum ; the parenchyma of the mesenteric glands, their lymphatics, and the thoracic duct are in- filtrated with blood ; the spleen is enlarged. The disorder shows then a striking hemorrhagic tendency, and is supposed to be a blood-affection similar to pseudo-leuksemia. A croupous or diphtheritic enteritis is not seen except as a secondary process, if we except the instances in which it follows poisoning by mercury, by arsenic, or by lead. It is more gen- erally encountered as a secondary affection in some infectious dis- eases, as in pneumonia, or in pyaemia, or in typhoid fever, or in cancer, Bright's disease, or cirrhosis of the liver. Its symp- toms may be latent, but generally there are diarrhoea and pain without tenesmus. Acute Peritonitis. — As in acute enteritis, so in acute peri- tonitis, pain and tenderness are the most significant symptoms. To these are joined fever, distention of the abdomen, and, fre- quently, cold sweats, nausea, vomiting, and obstinate constipation. The disease begins with chilly sensations or protracted rigor. To these succeed fever, and abdominal pain and distention. The fever runs high at the onset ; it exhibits a dry, burning skin, an axillary temperature of 103° and upwards, a pulse frequent, but, as in acute inflammations of the mucous and serous membranes below the diaphragm, small and wiry. However, both the char- acter of the pulse and that of the skin change as the malady progresses. The pulse will be less tense and more developed as * Wien. Med. Zeitung, quoted in Lond. Med. Kecord, Feb. 1875. 610 MEDICAL DIAGNOSIS. the inflammation subsides, or feeble and flickering if the disor- der proceed toward a fatal termination. The skin is frequently covered with cold sweats. The temperature is irregular, and may sink below the normal. The features are sharpened and wear the look of death, even in cases which ultimately recover. The pain is constant and severe. It may exacerbate, but it never intermits. At first the pain is confined to a particular point; but as the inflammation extends, so it extends over the whole abdomen. It is increased by the slightest pressure, be that pressure exerted by the hand or by movements of any kind. To obviate the pressure, the patient lies on his back with his thighs flexed, and, however tired of retaining the same position, he does not change it. The descent of the diaphragm augments the pain : instinctively, therefore, he refrains from drawing long breaths, and his respiration is short and frequent and purely thoracic. The abdominal distention is in part owing to meteorism, in part to the liquid effused into the peritoneum. Percussion tells us in individual cases how far each factor acts as a cause of the enlarge- ment, by the tympanitic or the dull sound elicited. Palpation, too, reveals the presence of liquid. Yet percussion or palpation ought to be employed only with the greatest care, on account of the pain they occasion. The fluid does not gravitate as invariably as in ascites to the lower portion of the belly. It is often caught in sacs formed by the membrane adhering in sj)ots ; and thus circumscribed dulness may be found at one or several parts of the abdomen. Sometimes the roughening of the_ membrane gives rise to a distinct friction sound. Independently of the abdominal pain and swelling, we meet, in acute peritonitis, with constipation, nausea and vomiting, headache, a suppression of the urinary discharge, and in rare instances with priapism ; of these symptoms, constipation is the most constant. The bowels are never relaxed, except in the puerperal form of the malady. The constipation is caused by the paralyzed state of the intestine, to portions of which the inflammation may spread ; or by the lymph gluing together the coils of the bowels. Death in acute peritonitis is commonly preceded by enormous tumefaction of the belly, cold sweats, a pinched countenance, and a rapid, flickering pulse. When recovery takes place — unfortu- nately a rarer issue of the malady than its fatal termination — it is DISEASES OF THE INTESTINES AND PERITONEUM. 611 commonly very slow and gi-adual : the symptoms diminish one by one ; they do not cease suddenly; and often morbid conditions remain which prolong greatly the patient's illness and may lead in themselves to a disastrous result. It is, therefore, impossible to foretell the duration either of the acute disease or of its con- sequences. Andral fixes the average length of an acute attack at between six and nine days, and of a subacute attack at from twenty to thirty days. But the nature of the malady is such that many cases last a longer, many a much shorter period. The presence of gas in the peritoneal cavity is always a very valuable sign of perforative peritonitis. Tympanitic resonance over the hepatic region is thus occasioned. On the other hand, when the hepatic dulness is found, the inference is a fair one against perforation of stomach or intestine as a cause of a peri- tonitis that is detected. Acute peritonitis arises only very occasionally idiopathically from exposure to cold and wet ; much oftener in consequence of injuries to the abdomen, such as blows, stabs, or kicks ; or from perforation or laceration of some of the abdominal organs, such as perforative ulcer of the stomach, intestine, or gall-bladder, and discharge of their contents into the peritoneal cavity, or from a ruptured tubal pregnancy. Uterine injections passing into the peritoneal cavity may cause peritonitis. It also results from rheumatism,* or from a poisoned state of the blood, as, for example, the peritonitis of childbed fever, or from acute tuber- culosis, or from Bright's disease. It sometimes originates from an inflammation of the abdominal viscera, especially of the spleen, intestines, or uterus and its appendages, spreading to their serous covering, and thence extending more or less rapidly. Again, other morbid states of the abdominal organs, such as cysts of the ovaries, intestinal intussusception, or strangulated hernia, may compress or irritate the membrane, and lead to inflammatory action. Owing to these diverse sources, peritonitis presents varieties which exhibit points of difference that require special notice. The inflammation produced by extravasation into the peritoneal sac is characterized by its sudden development. The matters ex- * Schmidt's Jahrbiicher, No. 9, 1873. 612 MEDICAL DIAGNOSIS. travasated may be blood, or bile, or urine, or the contents of the stomach. Most frequently perforation of the stomach or intestine lies at the bottom of the mischief. Whatever its cause, the per- foration is immediately followed by collapse ; and tenderness and distention of the abdomen soon make their appearance. Yet peritonitis may set in rapidly in cases in which there has been no rupture ; and, on the other hand, in rare, very rare, instances, the contents of the alimentary canal may be discharged into the sac without giving rise to inflammation.* The peritonitis of childbed fever, or puerperal peritonitis, is principally distinguished by its occurring during the puerperal state. Its symptoms are, so far as the peritoneal inflammation is concerned, those of any other kind of peritonitis, except that diarrhoea, instead of constipation, is often present. The disease is generally ushered in by chills. The temperature rises speedily to a considerable height, to 104° or 105°, and continues high with irregular remissions. The uterus or the uterine appendages are generally first attacked ; and it is in these regions that pain and tenderness are first felt. The infiammation spreads to their serous investment, or it may be primarily seated in that invest- ment : in either case it soon involves the entire membrane. But, independently of the symptoms of the local d.isorder, there are phenomena which clearly belong to the diseased state of which the inflammation of the peritoneum is but a local expression ; there are evidences of a poisoned state of the blood, of a septi- caemia. We find delirium, black vomit, exudation into the peri- cardium and pleura, features of disease not met with in the purely local malady, and showing that, while childbed fever occasions peritonitis, peritonitis does not constitute childbed fever. Fortunately, the diagnosis is one we are now less and less often called upon to consider, for antisepsis has almost put a stop to the disease. Partial or looal' peritonitis is almost invariably owing to a pre- existing morbid condition of some abdominal viscus. Sometimes the circumscribed inflammation is protective rather than calculated to work mischief. It arrests a destructive perforation of the mem- * Cases reported by Bardeleben and Siebert, quoted in Henoch's Clinic of Abdominal Diseases. Instances of rapid peritonitis without perforation are given by Thirial, L'Union Medicale, 1853. DISEASES OF THE INTESTINES AND PERITONEUM. 613 brane, or it limits the matter discharged to a certain spot ; it may at least do so for a time, for general peritonitis is very apt ulti- mately to follow. Partial peritonitis often pursues a subacute rather than an acute course. It may end in adhesions or lapse into a chronic state. Its symptoms are much the same as those of a more general inflam- mation, — the same fever and constipation, the same pain and ten- derness. The fever does not, however, run so high, and the pain and the great tenderness are much more localized. The abdomen, also, is not so swollen or so tympanitic. But perhaps even more frequently than in general peritonitis are found accurately-limited spots of dulness on percussion corresponding to circumscribed col- lections of pus in the peritoneal cavity. Partial peritonitis is more liable than the general disease to be confounded with other disorders. Yet error can hardly arise, or, should it arise, it is not of much consequence, provided we bear in mind that it is precisely with the morbid states of the viscera which lie below the peritoneum that the circumscribed inflamma- tion of the serous membrane is usually connected, and that local jjeritonitis, therefore, frequently attends the very disorders from which it is sought to be distinguished. Let us, however, examine into some of the complaints with which peritonitis, whether local or general, may be confounded. They are — leaving for considera- tion elsewhere obstruction of the bowel, appendicitis, and peri- typhlitis — Acute Gastritis ; Acute Enteritis; Acute Pancreatitis; Metritis ; Cystitis and Distention of the Bladder; Rheumatism of the Abdominal Walls; Abdominal Hysteria; Colic. Acute Gastritis. — Acute inflammation of the stomach can scarcely be mistaken for inflammation of the peritoneum, pro- vided attention be paid to the history of the case and to the seat of the pain. The former disorder begins with vomiting, and this continues a prominent symptom throughout ; whereas vomiting is not so constant, nor does it occur so early, in peritonitis. The 614 MEDICAL DIAGNOSIS. pain and tenderness are limited to the region of the stomach in gastritis; they are diffused and accompanied by general ab- dominal enlargement in peritonitis. They may, it is true, be localized when the peritonitis is partial. But acute inflamma- tion of the gastric peritoneum is hardly encountered, save as an attendant on severe inflammation of the stomach, or on a destruc- tion of its coats, — the form of gastritis which results from irritant poisons. Acute Enteritis. — Enteritis differs from general peritonitis by the less extended tenderness ; by the seat of the pain near the um- bilicus, and its more paroxysmal character ; by the comparative absence of tympanites and abdominal tumefaction ; and by the greater prominence of nausea and vomiting. It is, moreover, a disease far less violent and dangerous than acute peritonitis ; yet it cannot be distinguished with certainty from the partial form of this disorder, to which, in truth, some of its symptoms are clearly owing. Aeute Pancreatitis. — This is a cause of peritonitis which may be easily overlooked. The pancreatic inflammation mostly arises in consequence of the extension of a gastro-duodenal inflamma- tion along the pancreatic duct ; or it may follow hemorrhage into the pancreas. In the former case we find sudden pain, deep- seated, constant, or paroxysmal, tenderness, and tympany in the epigastrium in the region of the pancreas, with nausea and vomit- ing. This is gradually followed by peritonitis at the same place, and by a low fever. Constipation is frequent, arid, with the other symptoms, has led to the diagnosis of acute intestinal obstruction and to laparotomy. In hemorrhagic pancreatitis the symptoms run a rapid course. The disease, occurs in persons over thirty years of age. The attack begins with violent pain in the abdo- men ; nausea, vomiting, and tympanitic distention soon follow, and signs of collapse appear. There is usually constipation. The temperature, as we know from Fitz's * comprehensive study, may remain normal. The disease is most likely to be confounded with acute perforative peritonitis. It usually proves fatal in from two to four days. The hemorrhage may lead to gangrene ; in either case the signs of peritonitis are marked. Hemorrhage may occa- * Middleton-Goldsmith Lecture for 1889. DISEASES OF THE INTESTINES AND PERITONEUM. 615 sion sudden death.* Abscess of the pancreas has much the same symptoms ; but it does not run so acute a course, — is, indeed, often chronic ; the pain is much less ; there is apt to be irregular fever. Metritis. — Inflammation of the womb is not likely to be mis- taken for general peritonitis ; the pain on pressure, which they have in common, is confined in the former disease to the uterus and its annexes, and there is little or no tympanites. It is thus only that the acute metritis of childbed fever may be distinguished from the acute general peritonitis of the same malady. When the puerperal malady attacks the uterus as well as the whole peri- toneal surface, the signs of inflammation of the serous membrane mask those of inflammation of the womb. A local inflammation of the peritoneum occurs still more constantly as an attendant on inflammation of the womb and its appendages, whether the disorder of the sexual organs be or be not puerperal. It frequently leads to collections of pus, which can be readily felt through the parietcs of the abdomen or through the rectum and the vagina, and which sometimes discharge into the bowel or vagina after a lingering sickness. The proofs that the uterus is involved in these cases of partial peritonitis, are the signs of its disordered functions and the excessive pain occasioned by pressing on the cervix during an examination per vaginam. Cystitis and Distention of the Bladder. — Both inflammation and distention of the bladder are occasionally mistaken for general acute peritonitis. An acute inflammation of the bladder gives rise to frequent calls to pass urine : yet the act is performed with great difficulty, and in severe cases may become impossible ; the bladder distends ; a sense of uneasiness is felt in the perineum ; the region above the pubes becomes tender, and sounds dull on percussion ; the unhappy sufferer is restless and distressed ; he has the excited pulse and the hot skin of fever ; at times vomiting and hiccough supervene; and death is preceded by gradually- deepening coma. Such cases resemble those of peritonitis with suppression of the urinary discharge and with strangury. But the urine voided in peritonitis is simply high-colored, like that of any febrile state. In cystitis it contains large quantities of mucus and pus, and often blood and crystals of phosphates. * Draper, Transact. Assoc. Arner. Physicians, 1886. 616 MEDICAL DIAGNOSIS. Again, the abdominal tenderness is localized, and is frequently accompanied by a smarting in the course of the urethra. Neither of these signs is encountered in peritoneal inflammation, and, as a rule, the temperature in this is higher. The disturbance of the urinary organs which not unfrequently takes place in the latter disorder is atti'ibuted to inflammation of the part of the perito- neum covering the bladder or its immediate neighborhood. An overdistention of the bladder, not the result of inflamma- tion of its coats, may produce a local tenderness spread over a considerable portion of the lower part of the abdomen. But the outline of the dulness, which is coextensive with that of the ten- derness, the fact that the patient has generally not passed urine in any quantity for a considerable time, the almost normal tem- perature, and the sudden cessation of the supposed peritonitis on passing a catheter, show the true nature of the malady.* Inflammation and Abscess in the Abdominal Muscles. — When the abdominal walls become inflamed, symptoms are occasioned that are not always easily distinguished from those of acute peri- tonitis. The disease is attended with some fever, with pain in- creased by movement, by the act of coughing, and by pressure, and sometimes with excessive tenderness. The seat of the inflam- mation is generally the rectus muscle and the surrounding cellular tissue. The parts on one side of the umbilicus are most commonly attacked, and it is there that a hard swelling is perceived, over which the skin is rather hot and sometimes red. The tumefaction gradually disappears by resolutif)n, or else fluctuation becomes from day to day more distinct, showing that suppuration is taking place ; and the pus being discharged, immediate relief follows, and the pain and febrile symptoms instantly cease. Now, the disease rarely runs a very acute course ; it lasts at least a week or two, and often much longer. Where much of the muscle is involved, the complaint simulates peritonitis, — more, however, the partial than the general kind. Where the inflam- mation of the muscle is not extended, the resemblance to inflam- matory affections of the organs lying underneath the point of tenderness is even greater than to inflammation of the peritoneum. * A case of this kind, occurring after delivery, is given by Lever, Guy's Hospital Reports, 2d Series, vol. viii. p. 41. DISEASES OF THE INTESTINES AND PERITONEUM. 617 Hepatitis, splenitis, and gastritis have been mistaken for the affec- tion of the abdominal parietes. These errors can be avoided only by taking into account the absence of disturbed function of the suspected viscus ; often, too, the peculiar swelling furnishes a clue to the real nature of the case. But as regards signs of disturbed function, we must bear in mind that these are produced occasion- ally by disorder of adjoining viscera. Thus, we have jaundice in abscesses seated in the walls in the right hypochondrium.* Abscesses in the abdominal walls are sometimes symptomatic of a more distant lesion, as of caries of a rib.f Can we distinguish, with anything like certainty, between ab- scesses in the abdominal walls and instances of partial peritonitis leading to collections of pus in the peritoneal cavity ? I believe not ; for in both there is a tumefaction ; in both the general symptoms are much the same ; and, as happens sometimes in peritoneal abscesses, the pus presses its way through the parietes of the abdomen. How, then, are we to know where was the seat of its formation ? Whenever we iind a swelling which has come on gradually, or has followed a blow or a kick on the abdomen, or a swelling which is very hard before fluctuation appears ; whenever the softening of the tumor is immediately preceded by distinct chills, and the skin covering it is tense, and heated, or reddish ; wherever there is nothing pointing to the occurrence of partial peritonitis, as an attendant on visceral disease, or as a consequence of an attack of general peritonitis, — we may infer, from the history and the signs, that the affection lies in the ab- dominal walls. But the skin is not always discolored or hot, and the beginning of the swelling is sometimes veiled in obscurity. In some instances I have seen, in which there was great doubt, the aspirator drew off a very offensive pus and broken-down material ; and I looked upon this — as the sequence proved, cor- rectly — as indicating abscess in the abdominal walls. Abscesses within the abdomen seated at the upper part, if not caused by abscess of the liver, are, as Bristowe accurately points out,J largely due to pei-foration of one of the hollow viscera with circumscribed peritoneal suppuration. * As mentioned by Habershon, Diseases of the Abdomen, 1878. t Oppolzer, Wien. Med. Woobensch., 1862. J Lancet, Sept. 1883. 618 MEDICAL DIAGNOSIS. But it is not every case of abscess in the walls which is attended with symptoms that render it likely to be mistaken for the results of inflammation. Sometimes the preceding tumefaction is so hard, or it is so long before the process of suppuration sets in, that the aifection is more liable to be confounded with abdominal tumors. The most trustworthy points of difference are furnished by a study of the history of the case, and of the mode of inva- sion ; by the slow growth of the tumor on the one hand, and its far more rapid growth on the other ; and by the absence, or at all events the comparative absence, of signs denoting serious dis- turbance in one or several of the abdominal viscera. Tiien, in doubtful cases, the aspirator or the exploring needle will be of use. The fluid thus obtained shows, under the microscope, shreds of broken-down muscle and of areolar tissue, mixed, if suppu- ration have commenced, with pus. Again, stress may be laid on the occurrence of chills preceding the softening of the mass. In some patients the inflammation is unaccompanied by any appre- ciable signs ; it leads to gradual changes in the muscular fibres, which do not reveal themselves until the disorganized muscle gives way. The fibres undergo softening or a true fatty meta- morphosis, and the slightest force suffices to produce a rupture. Not a few cases have been reported in which one of the recti mus- cles has been torn asunder during a fit of coughing. The seat of laceration is generally about midway between the umbilicus and the pubes, a little to one side of the median line; the rent fills with blood, occasioning a circumscribed swelling and rigidity of the abdomen. Thei-e is sometimes pain, with nausea, vomiting, and obstinate constipation. Nay, the symptoms have mimicked so closely a strangulated ventral hernia as to have led to the performance of an operation.* Rheumatism of the Abdominal Walls. — Occasionally rheumatism * Richardson's case, American Journal of the Medical Sciences, Jan. 1857. Further instances of this accident are given by Virchow, in the "Wiirzburg. Verhandl., Band vii. The description of abscesses in the abdominal parietes I have drawn from cases coming under my own notice, from manuscript notes taken by Dr. J. K. Kane at the Philadelphia Hospital, and from the cases collected in the Dictionnaire des Dictionnaires de Medecine, art. " Abdomen." See also Paul Deriencourt, These de Paris, 1886, No. 153; Marsigny, Arch. Med. Beiges, Bruxelles, 1886, 3e ser., xxix. ; Weisz, British Med. Journ., April, 1891 ; Moran, Physician and Surgeon, Ann Arbor, Mich.", Aug. 1893. DISEASES OF THE INTESTINES AND PERITONEUM. 619 attacks the abdominal muscles, and gives rise to local symptoms similar to those of peritonitis. But the pain is not so constant, nor is it spontaneous, as in this disorder. It is also less affected by movements or by pressure. Not that these diminish it ; on the contrary, they aggravate it. Yet deep pressure causes little or no more pain than slight pressure ; and it is only during certain motions — when the muscles ai'e placed on the stretch — that the pain is severe, or sometimes, indeed, at all produced. The pain is often one-sided, or, at any rate, much more marked on one side, and we find no meteorism, and but slightly elevated temperature, and not the anxious countenance of peritonitis. More- over, the attack is apt to happen in those of rheumatic tendencies, and there is concentrated, highly-acid, scalding urine. So strong a degree of similarity may, however, exist between the two diseases as to keep judgment in suspense. In such cases it is better to treat the disorder as if it were inflammation of the peritoneum. In point of fact, it may happen that such inflammation does suc- ceed to the rheumatic affection of the abdominal muscles, and this occurs chiefly when the disturbance in the muscles forms part of an attack of acute rheumatism having a decided tendency to shift its seat. Abdominal Hysteria. — No disease simulates peritonitis more closely than hysteria. The abdomen may be extremely painful to the touch, swollen and distended with gas, fever may set in temporarily, and yet the whole disorder be purely hysterical. To illustrate : An unmarried woman, twenty years of age, placed herself under my care, on account of extreme tenderness of the abdomen and febrile irritation, both of which had become developed in a few days. The abdomen was swollen and tympanitic, and so sensitive that it would not bear the pressure of her clothes ; the pulse was frequent ; the skin dry and warm ; the tongue slightly coated ; the bowels constipated ; the countenance expressive of distress. Here was certainly a group of symptoms like those of acute peritonitis. But the absence of the wiry pulse, the compar- atively slight fever, — slighter, certainly, than was to be expected from such general and great tenderness, — and the expression of countenance, arrested my attention. I found that the patient had had similar attacks previously j that they had come on sometimes 39 620 MEDICAL DIAGNOSIS. shortly before, sometimes shortly after, her menstrual period ; but that for several months her menses had ceased to flow. The ab- dominal tenderness was in reality, as she represented it to be, very great ; yet strong pressure produced no more pain than the lightest touch. Nor was the pain increased by deep inspiration, or by coughing, or by extending the thighs. Taking all these circum- stances into account, as well as her age and sex, and her nervous temperament, instead of treating her for acute peritonitis, cold- water injections, mild purgatives, and a mixture of assafetida and valerian were employed. Under these remedies, all the symp- toms of the apparent peritonitis speedily vanished. Yet all cases of abdominal hysteria do not pass off so quickly ; sometimes they are much more persistent, or recur frequently, as I know from personal observation. They are from the onset un- attended with fever, or, as the thermometer shows, the fever is fitful and soon ceases. The absence of febrile excitement, too, especially if taken in connection with the several localized and more or less distinctly circumscribed spots of tenderness, enables us to distinguish between peritonitis and those instances of neural- gia of nerves supplying the abdominal parietes, to which women who are laboring under disorders of the uterus are so liable. It is in these cases, as well as in all instances of abdominal hysteria, that the thermometer proves a most useful aid in the diagnosis. Colic. — As already stated, the pain of colic is paroxysmal, and not attended with fever, or with much, if any, tenderness ; while the pain of an inflamed peritoneum is constant, and associated with the greatest tenderness and with fever. Cases of colic do indeed occur in which we find fever and some tenderness ; but these signs are then still out of proportion to the amount of pain. The pulse is not wiry, nor the tenderness so exquisite or so diffused. Further, it is not unlikely that in such cases the peritoneum is really in parts injected or slightly inflamed. The same remarks are applicable to those severe paroxysmal pains which accompany the passage of gall-stones or of urinary concretions, or which occur at the menstrual periods. They are frequently spoken of as varieties of colic, and, as far as their discrimination from peritonitis goes, there is no difference, — it rests on the same grounds precisely ; for when there is fever or tender- ness on pressure, it is likely tjiat inflammation has been set up in DISEASES OP THE INTESTINES AND PERITONEUM. 621 those parts in which, or in the neighborhood of which, the pain is felt. In the so-called uterine colic, an injection of the peritoneum has positively been demonstrated. Chronic Peritonitis. — ^An acute attack of peritonitis may imperceptibly assume a chronic form. The fever gradually dis- appears, or at all events lessens; but the exudations into the peri- toneal cavity, whether organized or not, remain, and so do some abdominal pain and tenderness. In this condition the patient may continue for many months, now and then a fresh inflamma- tion starting up in the peritoneum and giving rise to acute symp- toms, or an intercurrent severe diarrhoea leading to rapid loss of strength. Again, the disease may develop slowly, be latent from the onset, and may not attract attention until the abdomen swells. In all cases, no matter what their origin, if they last for any length of time, debility and emaciation become marked symptoms ; then hectic fever is observed ; decided effusion into the peritoneum is generally noticed ; the legs become cedematous ; and the patient may die worn out and presenting the symptoms of septic poison- ing. Where recovery takes place, the exudation into the peri- toneal cavity is either discharged through adjacent viscera; or may be gradually absorbed ; or may be transformed into tissue. When the disease terminates in this way, it is apt to leave its traces in a chronic thickening and roughening of the peritoneum. A friction may be often felt. Chronic peritonitis of latent origin and leading to much thickening is sometimes found to attend cirrhosis of the liver or of the stomach, or contracted kidney. Under no circumstances is chronic peritonitis likely to be an independent affection. Chronic peritonitis may be confounded with affections of the liver attended by impediment in the portal circle ; and what adds to the difficulty in diagnosis is, that the liver is apt to atrophy in chronic diffuse peritoneal inflammation. The most trustworthy signs of distinction are that, in the latter affection, tenderness exists, and is under any circumstances much greater and more diffuse; that there are evening exacerbations of temperature, a quickened pulse, dark stools ; and that, if the veins of the abdo- men are dilated, their dilatation is slight and uniform. Chronic peritonitis more usually comes on and ends in a par- ticular fashion. It is insidious in its approach, and its fatal ter- 622 MEDICAL DIAGNOSIS. mination is preceded by evident signs of tubercular or cancerous deposits in the abdominal cavity or in the lungs. The disease is not then simply chronic peritonitis, but chronic peritonitis in con- nection with a cachexia. Cases of the kind are commonly of long duration. They are attended with ascites, and often with very considerable abdominal distention. I shall, therefore, postpone most of what I have to say about their diagnosis until I come to abdominal enlargements, and shall then consider what differences there are between these various forms of chronic peritoneal affec- tions and other disorders leading to ascites and to consequent abdominal distention. Diseases attended with Pain and Tenderness in the Eight Hiac Fossa. Appendicitis. — Inflammation of the appendix is pre-eminently the disease attended with pain and tenderness in the right iliac fossa. The appendix has an average length of four inches, and the diameter of a goose-quill. It lies in the right iliac fossa, but is variable in position. It points for the most part downward, or downward and inward. A. T. Bristow and Fowler * locate for it a central point by drawing a line from the anterior superior spinous process of the ilium to the median line, and placing the central point from two to two and a half inches within the ante- rior superior spinous process. From this central point the appen- dix will radiate in different directions. The usual location of the appendix is at the edge of the right rectus muscle below a line drawn from the centre of the umbilicus to the anterior superior spinous process of the ilium. Appendicitis is essentially a disease of adolescence and of young adults. It presents itself clinically in these forms : acute catarrhal appendicitis ; ulcerative and sup- purative appendicitis ; perforative appendicitis ; chronic recurring appendicitis. Acute catarrhal appendicitis may come on from exposure to cold and wet. Fowler cites two such cases. Much more generally it is an infectious process due to hardened fsecal masses leading by the irritation they produce to exudations in which extraordinary development of bacteria, as of the bacterium coli commune, takes * Appendicitis, Philadelphia, 1894. DISEASES OP THE INTESTINES AND PEEITONEUM. 623 place. It may also be caused by other infecting processes or micro-organisms. The far greater prevalence of appendicitis since the recent wide-spread epidemics of influenza suggests that this subtle poison, too, may act as an exciting cause. The disease may also result from vascular disturbances or torsion of the part. It is at the bedside always extremely difficult to say which cause has given rise to the attack. Whatever the immediate cause, whether it is a quickly-acting one, or, as is more common, has been silently working, the attack itself is generally sudden, and announces itself by acute abdominal pain, by tenderuess in the right iliac fossa, by nausea and vomit- ing. The pain and the tenderness are very significant. The pain may be referred to the lower part of the abdomen, but it is very often referred to the umbilicus or to the epigastrium. It has, especially at first, the character of colic. It is soon noted to be associated with tenderness, which is especially manifest at or near McBurney's point. This corresponds to the outer edge of the right rectus muscle, and is most readily located by fixing a spot midway between the anterior superior spine of the right ilium and the umbilicus. The patient lies on his back, because to do otherwise means to him increase of pain, and very often the right rectus muscle is somewhat tense, a fulness or a slight tumefac- tion can be perceived in the right iliac fossa, and there is some impairment of tympanitic resonance on percussion. Tenderness and swelling, as well as the shape of the appendix, may at times be recognized by deep pressure, and palpation of the appendix, as recommended by Edebohls,* may thus become of value. In some instances, and I have met with a number of them, the sen- sitiveness is not in the right but in the left iliac fossa, and press- ing with one finger readily develops it. Sensitiveness is always a very important sign, and when it lessens both in degree and in extent it denotes decreasing inflammation. The nausea and vomiting disappear in the progress of the case, though vomiting may return should there be perforation. If the peritonitis be- come general, abdominal distention will be marked. Other symp- toms met with in appendicitis are constipation, urine diminished and frequently containing albumin and indican. * Amer. Journ; Med. Sci., May, 1894. 624 MEDICAL DIAGNOSIS. Some cases do not begin so acutely, but are rather subacute. The complaint presents the following history and symptoms. The patient has been suffering for some time from constipation, or alternately from diarrhoea and constipation. He has a dull pain referred principally to the iliac fossa, and radiating to the hips. When the iliac region is examined, it is tender to the touch, full and hard, and sounds dull on percussion, while around the dulness there is a very tympanitic sound, if the intestine, as is often the case, is much distended with gas. Colicky pains occur from time to time, but are mainly confined to the lower portion of the abdomen. No matter what its beginning, the case in its further progress exhibits varied features : it may end in resolution, and hardened fsecal matter is often passed ; or the tenderness in the iliac fossa may become greater, and vomiting, decided fever, and the marked signs of an extending peritonitis appear; or ulceration of the appendix may allow a discharge of extraneous matter into the peritoneal cavity, which produces violent general peritonitis, or an abscess forms that ruptures and perhaps leads to the same results ; or, again, the bowel may become so paralyzed or so con- stricted that it can no longer propel its contents, and the patient dies with all the distressing signs of intestinal obstruction. There are other terminations with which experience makes us familiar. The attack may end in a chronic appendicitis, indicated by persistent tenderness and some swelling, pain on walking, and often dyspeptic symptoms ; or the chronic inflammation may lead to a series of recurring acute attacks, of which in one instance, under my observation, there were forty-seven before the case was operated on. Then as complications in appendicitis we may have thrombosis of the iliac vein, iliac phlebitis, post-csecal abscess, fistula into the bladder or rectum, hepatic abscess. There are two most important questions that always arise in appendicitis : Is there pus present ? Has perforation occurred ? It is always very difficult to determine the presence oi pus, and there are no certain signs. Chills are generally absent ; the tem- perature is of little value. The most trustworthy signs are very decided tenderness, a local swelling, and waves of pain in the afiected region. Perforation of the appendix is most often seen among healthy DISEASES OP THE INTESTINES AND PERITONEUM. 625 young men. It is found chiefly in the form of appendicitis that has been caused by seeds and concretions of various kinds, cherry- stones, and foreign bodies. In a certain proportion of cases the symptoms have been latent until the perforation happened. Its most constant and the first decided symptom is sudden, severe abdominal pain. It occurred in eighty-four per cent, of the cases which Fitz in his admirable essay has analyzed.* The pain is mostly at first in the right iliac fossa, and is followed by tender- ness which gradually extends. It may be accompanied by a chill, but I have known it absent where a chill was very decided. Fever, with a temperature of between 100° and 102°, is next observed ; but it is not constant, for I have met with a temperature nearly normal in a case in which a gangrenous perforation of the appen- dix was found, t A circumscribed resisting swelling in the right iliac fossa, which forms in from two to five days, with impaired resonance on' percussion and with a sense of fluctuation from the abscess that develops, and disturbed micturition, establish the diagnosis. A rectal examination may aid us in detecting the tumor, but, as I know from experience, is not absolutely to be de- pended on as a means of recognizing the swelling or the pus that has formed. In the majority of cases general peritonitis begins from the second to the fourth day after the perforation. The cases that die from shock die before the second day ; but, as a rule, the collapse comes on more slowly than in other forms of perforative peritonitis. Leucocytosis, Richardson tells us, is invariable in perforative appendicitis. A question that arises is whether we can distinguish inflamma- tion of the appendix from an inflammation of the csecum, both of which were formerly ijicluded under the name typhlitis. There is no certainty in the diagnosis. But these facts will often aid us greatly. Most of the cases of inflammation of the csecum are due to impacted faeces, and the history of preceding long-continued constipation, a resisting elongated mass in the right groin, slight pain, and absence of fever, are very significant. Then, perfo- rating inflammation of the csecum is very rare, while perforation of the appendix is of frequent occurrence. * Transact Assoc. Amer. Physicians, 1886. f Seen with Dr. Morton. 626 MEDICAL DIAGJTOSIS. Much used to be said about inflammation of the loose areolar tissue around the caecum, perityphlitis, and consequent abscess. But we now know that the abscess nearly always has its origin in disease of the appendix, and is often the persisting result of an acute or a subacute attack. The collection of pus may find its way into neighboring viscera, or be discharged externally, or become encysted, or the sac rupture and fatal peritonitis ultimately ensue. The tumefaction which the abscess occasions is generally very evident. When, however, the pus burrows under the iliac fascia, the swelling mAy be slight. But imder such circumstances there appears a characteristic sign : the pain, on moving the right foot, is intense, because the iliac muscles become involved in the dis- order. If the swelling be great, there may be oedema of the foot and numbness of the thigh, from the pressure on the vein and nerves. Chiefly on account of the pain and tenderness, acute appendi- citis may be confounded with a number of diseases, prominent among which are colic ; bilious colic ; renal colic ; typhoid fever ; ulceration of the lower part of the ileum ; obstruction of the bowel : tumors of the kidney and abscesses in or around it ; floating kidney ; inflammation of the right ovary ; extra-uterine pregnancy ; pelvic hsematocele ; rupture of the gall-bladder ; dropsy of the gall-bladder ; abscess in the abdominal walls ; psoas abscess; hip-joint disease; abscess of the liver; distention of the caecum ; cancer of the caecum ; pneumonia. The sudden pain, the acute indigestion, the nausea and vomit- ing may cause appendicitis at its beginning to be mistaken for colic, especially for bilious colic, but the localization of the pain and particularly the tenderness in the right iliac fossa are very difierent. On the other hand, the jaundice that attends or follows bilious colic is not a symptom of appendicitis, and the pain of this does not radiate to the shoulder and the scapula. The same localization of the tenderness is of value in distinguishing renal colic, where the tenderness, if it exists at all, is most marked over Poupart's ligament. Moreover, rectal and vesical tenesmus and retraction of the testicle, common in renal colic, are very rare in appendicitis. Pain and tenderness in the right iliac fossa may be the cause of typhoid fever being confounded with appendicitis. But neither pain nor tenderness is great in typhoid fever ; then the character- DISEASES OP THE INTESTINES AND PEEITONEUM. 627 istio temperature record, the nervous symptoms, the diarrhoea, the eruption, furnish striking points of difference. Ulceration of the lower part of the ileum produces pain and tenderness in the iliac fossa. But, combined as the ulceration generally is with tubercular disease, the history of the case gives a clue to the nature of the malady. Moreover, diarrhopa occurs, and there is not present a tumefaction which sounds dull on per- cussion. Should, however, perforation of the bowel take place before the patient is seen, and general peritonitis come on, the diagnosis is not so readily made, because we are deprived of the decisive proof furnished by the swelling. Another very difficult diagnosis is at times as regards obstruo- tion of the bowel ; the more difficult because appendicitis may become a cause of intestinal obstruction. In both there' is pain ; in both constipation ; in both vomiting. But the pain in obstruc- tion is not localized, or attended with such a significant point of tenderness as McBurney's point ; the constipation in appendici- tis is not so absolute, and flatus passes ; the vomiting in this dis- ease occurs early, then generally stops ; late vomiting is the rule in obstruction, and it becomes fsecal. Though fever is not a marked symptom of appendicitis, there is generally some. An invagina- tion of the bowel has a different history, and makes its appear- ance suddenly with such peculiar signs that, although it may be likewise the occasion of a tumor in the right iliac region, it can be generally distinguished from appendicitis. Yet, where the latter leads to intestinal obstruction, the diagnosis is not always obvious ; and tenesmus and discharge of bloody mucus from the rectum may happen in appendicitis. As regards tumors of the kidney and abscesses in it or around it, the situation of the swelling is not exactly in the ileo-csecal re- gion, or at all events it is not confined to this region. The mass of the tumor lies in the loin, or above the anterior termination of the crest of the ilium ; and the urine contains ingredients, such as pus, or blood, or heavy deposits of urates or phosphates, which show that the secretion of the kidney is abnormal. More- over, there is no intestinal disturbance or marked local tenderness, such as we find in appendicitis. Jm floating kidney the mobility of the displaced organ, and the slight tenderness, are very significant. An inflammation of the right ovary gives rise to pain and ten- '628 MEDICAL DIAGNOSIS. derness in the right iliac region, and to fever. But it is attended with disturbance of the uterine functions, and occasions no very- perceptible swelling. A tumor of the ovary or of the uterus may produce a visible tumefaction ; but, springing as it does out of the pelvis, its exact seat, its bulk, its shape, the absence of marked intestinal symptoms, and a per vaginam examination, will permit its cause to be discovered. Extra-uterine pregnancy may be mistaken for acute appendix citis in consequence of the sudden rupture of a sac. But the previous history, the great prostration, the excessive thirst, and a pelvic examination will explain the true meaning of the symp- toms. In pelmo hsematocele the pain and the suddenness of the attack make us think of acute appendicitis. But the tumor that forms is generally larger, doughy ; there are no localized spots of tenderness, no marked intestinal symptoms ; and the history of irregular menstruation and a per vaginam examination will remove all doubt. Rupture of the gall-bladder may give rise to right-sided ten- derness, to rigidity of the rectus muscle, and to severe pain, and may be unavoidably mistaken, as the case of Fowler* proves, for acute appendicitis. Several instructive cases reported by the same surgeon prove that unless the history help us, and point conclusively to the occurrence of gall-stone, it is extremely diffi- cult to distinguish dropsy of the gall-bladder in which a swelling may be felt low down, from appendicitis. An abscess in the abdominal walls furnishes very many of the signs of abscess around the appendix. The most trustworthy point of distinction is that the former moves with the abdomi- nal walls and is unassociated with intestinal irritation, while the latter is commonly so combined. Then the peculiar spots of tenderness, the outline of the swelling, its want of prominence, are unlike what is found in abscess of the abdominal walls. In psoas abscess we have the association with caries of the vertebrae : an excurvation of the spine, dorsal pain and tenderness, testify to this connection. It occurs in scrofulous persons, and, although gradual in its formation, is often sudden in its mani- festation ; for not unusually a fluctuating, painless tumor appears * Op. cit. DISEASES OP THE INTESTINES AND PERITONEUM. 629 below Ponpart's ligament as the first positive sign of this formi- dable affection. This is very different from the history of an ap- pendicitis which has led to post-csecal abscess. Moreover, pre- ceding the pointing of the psoas abscess at the spot mentioned, there are often indications of irritation in those muscles in the sheath of which the pus travels ; there is difficulty in extending the leg, with inability to stand upright. In hip-joint disease the inclination of the pelvis, and the in- ability to move the joint normally, furnish trustworthy points of distinction. It is sometimes difficult to distinguish between appendicitis, especially in its chronic forms, and abscess of the liver; the more difficult because, as I know by experience, they may coexist, the hepatic abscess being consequent to the appendicitis. Another point that makes the diagnosis difficult is that the pain and ten- derness in appendicitis do not always exist in the right iliac fossa, but may be found at various parts of the abdomen ; the abscess following appendicitis may extend high up towards the liver. In these difficult instances the history of the case, as wtll as the study of the sequence in which the phenomena appeared, becomes of the greatest value. A distention of the ccecum may be mistaken for chronic ap- pendicitis. It gives rise to fulness in the right iliac fossa, and to pain, but, unless associated with inflammation, not to tenderness or to fever ; purgatives, too, clear out the fseces which accumulate from want of power of the bowel to propel them, and the dulness on percussion vanishes after the free evacuations. Another ele- ment of distinction is furnished by the circumstance that those who suffer from atony of this portion of the alimentary tube labor under it for a long time ; they are generally highly nervous persons, with impaired digestion, whose bowels are habitually constipated, and who complain of attacks of spasmodic pain and fulness in the iliac region. Yet, although there is fulness, there is no dulness on percussion, and no hard swelling is detected, unless the csecum be loaded with fseces. On the contrary, the caecum and ascending colon generally show, by the excessive tym- panitic resonance when they are percussed, that they are distended with flatus. In that rare disease, oanaer of the cseoum, there is a fixed, firm 630 MEDICAL DIAGNOSIS. swelling ; but it is of very gradual growth, and the disorder generally produces a stricture of the bowel and is associated with malignant disease in other parts of the body. Other affections than those of the bowels may give rise to signs supposed to indicate appendicitis. It does not at first sight seem likely that this would be the case with pneumonia. Yet the mis- take has been committed. Pain is sometimes referred to the right groin in pneumonia, and there is soreness there, connected prob- ably with the efforts at coughing and the disordered breathing. Nay, I have known poultices applied to the right iliac fossa to relieve the inflammation which really was in the chest. An ex- amination of this part of the body will of course at once explain the true character of the symptoms. Disorders attended with Constipation, and of wMch it is a Prominent Symptom. An inactive state of the bowels is often but a concomitant of some discfrder which presents phenomena much more striking than the imperfect voidance or the prolonged retention of the faeces. But there are cases in which the constipation is the most impor- tant symptom, and in which it furnishes by far the most decisive proof of a serious morbid condition of the intestine. Now, these cases are either those in which the constipation arises suddenly, or at any rate becomes suddenly aggravated, is attended with se- vere symptoms, and is often insuperable; or those in which it is an habitual state and not associated with any signs of urgent distress. Intestinal Obstruction. — Intestinal obstruction, when com- ing on suddenly, manifests itself generally in the following man- ner. A person, previously in good health, or perhaps of costive habit, notices that his bowels have not been moved for several days, and that he has an uneasy feeling in the abdomen in conse- quence. He takes the purgative he is wont to employ, but with- out the usual effect. Something more active is tried, and still the bowels remain obstinately bound. Colicky pains have in the mean time made their appearance. He becomes alarmed, and sends for his physician, who sees that there is indeed cause for alarm. The abdomen is found to be distended, but not painful, or only slightly painful, on pressure. But through its parietes DISEASES OF THE INTESTINES AND PERITONEUM. 631 may be noticed the violent, rolling motion of the irritated intes- tine. Vomiting sets in, — first, of the substances contained in the stomach or of a bilious fluid, and, as the case progresses, of ster- coraceous matter. In this way, unless nature or art comes to the rescue, the disease continues ; and signs of inflammation of the bowels, and with them fever, appear as preludes to the fatal ter- mination. Sometimes, however, the patient becomes gradually exhausted ; there are no tenderness and fever, but a cool skin, a quick, small pulse, a countenance ghastly and panic-stricken. Severe paroxysms of pain, alternating with intervals of ease, may occur to the last moment. But, in spite of the utter prostra- tion, the mind generally retains its clearness. Should recovery take place, large quantities of faecal matter are discharged, and the symptoms of the impediment speedily disappear. These phenomena are too striking to permit of errors in diag- nosis. Yet errors are of frequent occurrence, because the history of the attack and the sequence of the symptoms are not taken into account. Many a person laboring under peritonitis has been violently purged to remove the stubborn constipation believed to be due to a mechanical hinderance in the bowels ; and, on the other hand, many a case of intestinal obstruction has been treated solely with reference to the inflammation that may attend it, and without regard to the source of the inflammation. Yet it is not ordinarily difiicult to distinguish which is cause and which efifect. A case that begins with colicky pains and obstinate constipation, in which at first, in spite of the pain, there is little or no tender- ness ; in which -the thermometer does not indicate materially- raised temperature ; in which vomiting and tympany soon occur ; in which fulness on palpation and dulness on percussion may be detected at or above the point of stoppage ; and in which fsecal matter is ejected by the mouth after a stoppage of the bowels of a few days' duration, — is not primarily, whatever may be the ultimate complications, enteritis or peritonitis. A case presenting almost from the onset fever and great and extended tenderness ; in which vomiting of feecal matter, if it happen at all, does not happen until late ; in which diarrhoea is sometimes found to super- sede the enduring constipation, — is inflammation of the peritoneum, but not a mechanical obstruction. Only in very rare instances, and especially when the bowel is invaginated, is the malady so 632 MEDICAL DIAGNOSIS. quickly succeeded by inflammation as seemingly to make its ap- pearance with the signs of peritonitis. On the other hand, per- forative peritonitis, with its signs of collapse, shows a much stronger likeness to acute obstruction of the bowel than ordinary peritonitis does. The symptoms dwelt upon as pointing to an intestinal obstruc- tion bear a close resemblance to those of external strangulated hernia. In truth, they not only resemble but are identical with those of this aifection. Hence in every case of obstinate consti- pation each point which may be the seat of a hernia must be explored by the eye and the hand. No motives of false delicacy, no reluctance, should prevent the physician from insisting on a search, the neglect of which may cost a life. It would be foreign to the object of this work to discuss the external signs by which a strangulation of the intestine at a her- nial opening manifests itself. It need only be mentioned that it is at the groin, at the umbilicus, at the side of the anus, or through the ischiatic notch that the gut descends and forms a tumor, and that these are, therefore, the regions to be scrutinized. But there is one part of the subject, of importance alike to the physician and to the surgeon, which cannot be passed by without a few words, since it may be a cause of much perplexity, — namely, the possi- bility of intestinal obstruction taking place in a person laboring under an irreducible hernia and simulating strangulation M'ithout any strangulation having occurred. Of this the following case furnishes an example. A number of years since I was requested by a physician to see with him a woman, the mother of thirteen children, who had been for days laboring under obstinate constipation. Large doses of mercurials, croton oil, and turpentine enemata had failed to pro- cure a passage, and the patient was becoming much frightened. Nor was her situation free from danger. She had considerable pain in the abdomen ; she had been vomiting stercoraceous matter profusely ; the rolling of the intestines could be plainly perceived. On her right side was a small irreducible femoral hernia, which, on inquiry, was found to have e:^isted for many years. It was not painful on pressure, nor was the skin covering it discolored ; neither did the mass itself communicate an impulse during the act of coughing. Here were signs of a serious impediment to the DISEASES OF THE INTESTINES AND PERITONEUM. 633 onward passage of the intestinal contents, as the faecal vomiting and the rolling of the intestines showed plainly. But was it due to strangulation at the hernial opening? Was it an internal intestinal obstruction? An accurate examination of the abdomen did not throw much light on these questions. The belly was moderately tympanitic, and not painful to the touch, except when the pressure was con- siderable. The rolling of the intestines was perhaps more obvi- ous on the left side ; but nowhere could a tumor be felt. Taking all the circumstances of the case into account, — the fact that the patient was of costive habit ; that she was subject to attacks of colic and of obstinate constipation ; that there was nothing to prove that the hernia had recently increased, or was in any way inflamed, — the conclusion arrived at was that the case was not one of hernial strangulation, but of internal intestinal obstruction. Copious warm-water injections were thrown into the colon through a flexible tube ; her abdomen was rubbed with mercurial ointment. But all in vain : she continued vomiting fsecal matter. Her situation now appeared desperate. She had not had a passage for six days ; she was steadily sinking. Knowing that sometimes the gut may be strangulated at a hernial opening with- out much pain or tenderness, the counsel of an eminent surgeon was sought, to aid in determining whether this was not the cause of the impediment. He thought it probable that it was, and proposed an operation, to which consent was reluctantly given. The patient was etherized, and the hernial section performed ; but no constriction was found. The wound was closed, and large doses of opium were administered, so as to mitigate, as far as practicable, the torture of the only termination to the case which seemed possible. On the day after the operation, the intestines had ceased to roll; there was no vomiting. But stercoraceous vomiting reappeared two days afterward, and the rolling of the intestines was occasionally, although faintly, perceptible. The patient's exhaustion was now extreme ; her pulse was very quick and small ; her skin cold, of a dirty look ; the odor of the breath and of the whole body offensive; and the eyes sunken and surrounded by a broad leaden ring. There was slight pain on pressure between the umbilicus and the sigmoid flexure. The vomiting had ceased, or occurred only very occasionally. Al- 634 MEDICAL DIAGNOSIS. though there was little hope, we had, as soon as admissible after the operation, recommenced rubbing mercurial ointment over the abdomen, and giving injections in the manner before described. This was continued until, to our great gratification, one morning, after a tube had been passed a distance of several feet into the colon, the patient had a copious discharge of tarry fsecal matter from her bowels, — seventeen days after the symptoms of complete intestinal obstruction had declared themselves by the occurrence of stercoraceous vomiting. This case is instructive in more than one respect. It teaches that recovery may take place most unexpectedly after many days ; and, in a diagnostic point of view, it illustrates a difficulty which any physician may have to encounter in attending a patient the subject of a long-standing hernia. Supposing that the symptoms are altogether owing to an ob- stacle at some portion of the intestine within the abdomen : can we determine the exact position of the impediment, and its nature? We know how varied are the conditions which lead to sudden and invincible constipation. We know that strangulation from bands and adhesions, or gaps in the omentum, or the pedicle of an ovarian tumor ; that intussusception ; that twists and knots ; that strictures and tumors; that abnormal contents, such as foreign bodies, impacted faeces, gall-stones, worms, concretions of drugs, as of bismuth, may all occasion intestinal obstruction. We also know that in certain cases the obstruction is from spas- modic contraction of the intestine,* or paralysis of the bowel ; in others is congenital. f Can we distinguish these different lesions at the bedside ? In certain cases we can, — we can determine ex- actly both the position and the character of the lesion ; in others there is no clue to an accurate discernment of either. From the method of the introduction of the whole hand into the rectum much has been expected ; but experience has not confirmed these expectations. Obstruction of the bowel may clinically present itself as an aoute or as a chronic malady. The same symptoms occur in both. It is the mode of origin that is different. Nay, the same lesion may occasion in some instances an acute, in others * Archives Generales, Aug. 1868 ; Flint, Practice of Medicine, t Gould, Transact. Clin. Soc. Lond., 1882. DISEASES OP THE INTESTINES AND PERITONEUM. 635 a chronic, affection. Invagination, internal strangulation, volvu- lus, impaction of a large gall-stone, are generally acute ; strictures, tumors, contractions, and, for the most part, faecal accumulation, lead to chronic obstruction. Among the forms of intestinal obstruction, intussusception or invagination is very frequent and at the same time the least dif- ficult of recognition during life. Part of the bowel becomes in- verted, slipping into the cavity of the adjoining upper or lower l)ortion. Inflammation is soon set up, produces infiltration of the tissues, and often leads to adhesions between the opposed serous surfaces, and to effusions of blood and mucus into the canal. The inflammation may spread rapidly over the serous membrane, and the patient may die from general peritonitis. But sometimes in this inflammation that is lighted up at the seat of the ileus lies safety. It may give rise to adhesive inflammation of the opposed serous coats of intestine, and ultimately to a sloughing off of the invaginated part and its discharge into the bowel, while the annular mass of adhesive lymph surrounding the seat of ulcer- ation maintains the continuity of the intestinal canal, and thus the inflammation may pave the way to a favorable issue by restoring the calibre of the tube, — sufiiciently, at any rate, to permit of the transit of its contents. These pathological peculiarities develop special symptoms which frequently enable us to determine the nature of the obstruction. When the intussusception takes place rapidly, a sudden local pain is produced, recurring in paroxysms, and likely to be referred to the seat of the disturbance. The pain is quickly followed by vom- iting, by constipation, by tympany, and by peritonitis. But the constipation is not so absolute as in other cases of intestinal im- pediment. Not unusually, in fact, owing to the invaginated bowel remaining open, the liquid contents of the intestine pass through the intussuscepted part and produce a deceptive diarrhoea; yet oftener will occur tenesmus, and discharges of the bloody mucus and serum which have accumulated in the intestine. Both of the latter signs are eminently diagnostic of the lesion. Still more so is feeling the end of the invaginated bowel by an exploration of the rectum, or finding the loosened segment in the stools. But it is only in cases in which the lower portion of the canal is affected, or which have been sufficiently protracted to allow of the curative 40 636 MEDICAL DIAGNOSIS. efforts of nature being accomplished, that signs so pathognomonic are met with. The casting off of the sloughed portion of the intestine is attended with hemorrhage. Whether this be the only cause of the hemorrhage or not, it is undoubted that purging, or some- times vomiting, of blood, is among the differential signs of intus- susception. A sign more valuable, because so much more common, is the presence of a tumor, frequently of cylindrical shape. Its seat varies with the seat of the lesion ; and as the most common invaginations are those of the ileum and csecum into the colon, or those at the inferior portion of the ileum, it is at the lower part of the belly, and generally passing in direction from left to right, and in the right iliac foss i, that the swelling is detected, and often it may be felt through the rectum. The malady is generally due to irregular peristalsis. It is often preceded by diarrhoea ; there is rarely much tympany. Sometimes it is caused by tumors of the intestine, particularly by lipoma.* The majority of cases of invagination happen in children under ten years of age. The course the affection pursues is rapid ; the patient dies generally in less than a week after the occurrence of the accident, utterly prostrated. Yet the records of medicine furnish us with instances in which life has been prolonged for months. The cases which get well recover either gradually after the invaginated bowel has been discharged, or, in very rare instances, more quickly by the inverted bowel righting itself. Acute obstruction from internal strangulation is almost inva- riably seated in the small intestine. Its most characteristic feature is furnished by the history of an old peritonitis, an operation on the abdomen, or an appendicitis. There is rarely fever ; the ob- struction soon becomes complete ; nausea and vomiting set in early ; fsecal vomiting usually begins from the third to the fifth day. It is the exception to find a tumor ; tympany is often marked, but no flatus escapes by the bowel. Of further significance in the diagnosis of internal constriction are the signs dwelt on by Fagge : f the sudden onset of the illness ; the occurrence of col- lapse at its beginning ; the frequency with which it is found in * Clos, De 1 'Invagination intestinale, etc., Paris, 1883. t Guy's Hosp. Kep., 3d Series, vol. xiv. DISEASES OP THE INTESTINES AND PERITONEUM. 637 young adults; the severity of the pain, which is generally re- ferred to the umbilicus ; the absence of external or of discover- able obturator hernia ; the absence of precursory symptoms and of visible peristole, — such as happen in stricture and contrac- tions, — of tumor, of hemorrhage, and of dysenteric symptoms, — as seen in intussusception, — and of that extreme intensity and rapidity of development which characterize the more acute forms of volvulus. Obstruction by a band connected with a diver- ticulum scarcely evex occurs except in males under twenty years of age.* Acute obstruction from volvulus or twist begins with severe abdominal pain, soon becomes associated with nausea and vomit- ing and extreme distention of the abdomen, and rarely presents a tumor or visible intestinal coils or elevation of temperature. f It most frequently affects the sigmoid flexure. But it cannot with any accuracy be separated from internal strangulation. It is most commonly met with in men between thirty and forty years of age. As regards other forms of intestinal obstruction, they are, with our present knowledge, undistinguishable from one another. However desirable it might be on therapeutic grounds to be able to diagnosticate with certainty a blocking up of the intestine by hardened fseces, or gall-stones, or enteroliths, or its strangulation by bands or by rents in the mesentery ; however desirable to know whether, if medical means do not bring relief, laparotomy may be attempted with hope of success, or whether the impediment is not even to be removed by such a mode of succor, — it must be con- fessed that there are few signs which enable us positively to decide on the nature of the obsta,cle. Yet there are sometimes circumstances in the case which help to a correct decision. For example, if the complaint occur in one who has suffered from the passage of gall-stones, especially in a fat, elderly woman,J it is likely that a large concretion of this kind ha.s been arrested in its passage through the small intestine. Should the disorder be encountered in a person over forty years of * Fagge, Practice of Medicine, vol. ii. t Pitz, Acute Intestinal Obstruction, Transact, of Congress of American Physicians and Surgeons, vol. i., 1889. J Pagge, Practice of Medicine, vol. ii. p. 210. 638 MEDICAL DIAGNOSIS. age, who at all times has difficulty in voiding the contents of the tube ; whose faeces present peculiarities in shape and size, and are sometimes mixed with blood ; whose health has been gradually brea;king ; whose abdomen is much distended and yields a ringing tympanitic resonance on percussion, — should such a person have an attack of constipation unusually protracted, attended with enor- mous distention of the bowel, and in which the remedies that hitherto barely procured a passage now fail utterly, it would not require much sagacity to discern that a stricture of the intestine, probably of a cancerous kind, is the source of the cruel and irre- mediable suifering. If, in addition to the symptoms enumerated, a bougie passed into the rectum meet in its course with a decided obstacle, an error in diagnosis is hardly possible. When, how- ever, the stricture is not accessible to instrumental examination, although we can commonly recognize its presence, we cannot fix its site. The distention above the narrowed part is often so ex- treme as to lead to displacement of the colon and to an almost uniform swelling of the whole abdomen. For instance, in a case reported by Albert H. Smith, the enormously-dilated colon had broken loose from its attachments and concealed the rest of the viscera. It was in several places eighteen, in none less than fifteen, inches in circumference ; and fully two gallons of liquid fseces were found in the bowels.* In the majority of cases the stricture is either in the rectum or in the sigmoid flexure. Other causes of stricture besides cancer, though less common ones, are cicatrization of extensive syphilitic, tuberculous, or dysenteric "ulcers. A contraction in the small intestine similar to the true stricture of the large bowel is seen chiefly as the riesult of chronic peritonitis binding down the bowel, and may lead, like a stricture, to chronic obstruction.f Faecal accumulations also produce chronic obstruction. We dis- tinguish this form chiefly by its occurrence in women, especially hysterical women, or in hypochondriacs, by the tenderness over the fsecal tumors, the gradually-increasing constipation, the late occurrence of pain and of vomiting, and the extreme foulness of the breath. J * Proc. of Pathol. Soc. of Phila., Dee. 1858, vol. i. t Pagge, Guy's Hosp. Kep., 3d Series, vol. xiv. J Treves, Lancet, Oct. 29, 1887. DISEASES OF THE INTESTINES AND PERITONEUM. 639 "With reference to the frequencr/ of the different forms of intes- tinal obstruction, the elaborate studies of Fitz * give us valuable information. Strangulation is the most frequent cause of acute obstruction, occurring in fully one-third of the cases ; a number of cases are noted to follow operations upon the pelvic organs in women, though the disease is very much more common in men than in women. Intussusception comes next in frequency, and is especially seen among children and young adults. Volvulus or twist is mostly encountered in men, and in half the cases is in the sigmoid flexure. Strictures and tumors, that are such common causes of chronic obstruction, very rarely lead to acute obstruction. In any kind of obstruction the location of the lesion is difficult to determine. There are, however, a few circumstances which may aid us in arriving at such a determination : one is the fact pointed out by BarloWjt that the higher up the obstruction is in the canal, the nearer therefore to the stomach, the smaller is the quantity of urine passed ; another is the early occurrence of the vomiting and the want of stercoraceous character of the matters ejected, — both of which render it likely that the impediment is in the small intestine and remote from the csecum. Still another is the speedy presence and the greater severity of hiccough when the mischief is in the small intestine. Sometimes the patient is himself aware of the exact seat of the cause of his suffering ; he notices that the injecting tube or the enemata seem to reach a certain point and go no farther; so, also, with the rumbling of the wind. Again, these borborygmi are especially apt to occur in obstructions of the large intestine, and, if joined to tenesmus, are signs of some importance. Indican is found in the urine in greatly-increased quantities in stoppages of the small intestine. We may also be able to come to some conclusion about the seat of the lesion by inflating the large intestine, or by finding out how many quarts of warm water we can inject into it. The position of the pain, too, may furnish a clue to the position of the impediment. If this be in the small intestine, the pain is * Transact, of Congress of Amer. Phys. and Surg., vol. i., 1889. f Guy's Hosp. Bep., 2d Series, vol. ii. Brinton accepts this statement only in so far as the amount of vomiting, which is apt to be greatest when the obstruction is high up, influences the amount of urine passed. 640 MEDICAL DIAGNOSIS. apt to be chiefly, if not entirely, in the neighborhood of the um- bilicus. Another circumstance on which some stress may be laid is the distention of the intestine above the point of intusussception. Indeed, this distention may occasion a visible fulness, sounding extremely tympanitic on percussion ; at times, too, a slight dulness is found, attended with some resistance at or immediately above the seat of the obstruction. But with reference to the swelling and the tympanitic dilatation of the bowel there are — as William Brinton * sets forth — several reasons which render these signs un- certain guides. The distended intestine may not be capable of being traced by the eye or by per'cussion, owing to its occupying a large portion of the abdominal cavity. Moreover, a stoppage at the descending part of the large intestine, for instance at the sigmoid flexure, may lead to most palpable distention of the csecum, and to pain in that region ; while pain and swelling are also observed in the same locality in obstructions which aifect the small intestine. Thus there are several modifying circumstances which prevent too much importance being attached to any of the signs mentioned as proofs of the seat of the obstacle ; for, with the exception of a tumor dull on percussion and resistant to the touch, there is nothing absolutely iridicative of the lesion being at a particular spot. It is hardly necessary to say that a swelling of this kind cannot always be found. In referring to the usual seat of pain and swelling in the right iliac fossa, and to the difficulties which on this account beset the recognition of the precise site of the hinderance, one source of error deserving of special notice was not mentioned. The pain and the fulness in this region may be caused by an appendicitis. Moreover, affections of this part of the alimentary tract, like intestinal occlusion, give rise to constipation which is most ob- stinate and in some instances incurable. Therefore they in reality enter at times into the category of intestinal obstructions, from the other varieties of which they are undistinguishable save by the history of the case, the localization of the symptoms, and the different sequence of the phenomena. The tumor and the other local signs do not follow the insuperable constipation, but precede it. Stress may be laid upon the occurrence of * Croonian Lectures, and work on Intestinal Obstruction. DISEASES OF THE INTESTINES AND PERITONEUM. 641 chills, of waves of pain, and of marked local tenderness, as in- dicative of the presence of pus, or upon the signs of collapse in perforative appendicitis. In acute hemorrhagic pancreatitis there may be also the signs of intestinal obstruction, not to be distin- guished except perhaps by the history, the extremely rapid course of the disease, and the marked peritonitis. , Habitual Constipation. — This is a chronic state, unattended with urgent symptoms of any kind. Still, it is an annoying and very prevalent disorder. The symptoms encountered, indepen- dently of the rare and difficult fseeal evacuations, are headache, giddiness, sluggishness of the mind, a want of the natural appe- tite, ansemia, cutaneous eruptions, and, joined as the complaint not unfrequently is to derangement of the stomach and of the biliary secretion, digestive disturbances and a sallow complexion : an altered state of the blood from the absorption of ptomaines may exist. In women there are also often added to the list of evils to which costiveness gives rise, neuralgic pains, palpitation of the heart, cold feet and hands. Infrequent evacuation of the bowels does not always produce such unpleasant consequences. It may, indeed, in individual cases be compatible with perfect health ; for what is costiveness in one person may be a natural state in another.* But when the bowels are acting less frequently than is their wont, the disagreeable symptoms mentioned are apt to arise. Habitual constipation is produced by various causes. It may be brought about by the peculiar nature of the diet. It may depend upon a deficiency or a faulty composition of the intestinal secretions, or upon disorders of those neighboring glands which pour their secretions into the intestines. It may result from im- paired power of the bowel to propel its contents, the consequence either of some mechanical interference with its action, or of ner- vous influences, or of exposure to the poisonous effects of certain substances, as of lead. To particularize the numerous conditions which furnish illustrations of each of these different causes would serve no useful purpose, A few only need be specially noticed. We have often to treat constipation in those who are dyspeptic and suffer from piles. In them there is, in all probability, some * In the American Journal of the Medical Sciences, Oct. 1874, a case is reported in which the constipation lasted eight months and sixteen days. 642 MEDICAL DIAGNOSIS. eongestion of the portal system, and not unfrequently a constant derangement of the flow of blood through the liver. The normal secretion of intestinal juices is interfered with, healthy bile is not supplied, and thus costiveness results. A similar, congestion of the intestinal mucous membrane has its share in producing the constipation which is encountered in diseases of the heart. Some- times, however, enough healthy fluid is poured out within the intestine ; yet there is a deficiency, because the inclination to go to stool is resisted, and the liquid that has been mixed with the matter to be voided is reabsorbed. In women who neglect the calls of nature because circumstances prevent their being obeyed at the proper time, this is a common cause of constipation. The influence of the nervous system on the alimentary tube is shown by the confined state of the bowels which attends excessive intellectual exertion and violent emotions. And when these states are protracted, they lead to a permanent and annoying debility of the intestine. The colon especially becomes torpid in its action, and all the evil results of constipation show themselves in their most marked degree. Not that an atony of the bowel is always due to psychical agencies. Any disorder which induces loss of power in the muscular fibres may give rise to it. We find it where the blood is watery and deficient in red corpuscles, and in those who lead, as far as bodily exertion is concerned, a sluggish life. In some cases — fortunately rare — the weak intestine dis- tends greatly, and becoming, as above explained, unable to propel the accumulated faeces, insuperable constipation occurs. The same complete paralysis of the tube, attended with the same unfortunate consequences, may be brought about by chronic lesions of the brain or spinal cord. Yet the inveterate constipation which is so constant an accompaniment of these states is partly owing to the powerless condition of the abdominal muscles. Among the different organic changes in the intestine which, by interfering mechanically with the peristaltic wave, set up constipa- tion, we find distention of the tube, with atrophy of the muscular fibres; various infiltrations into the walls, producing a narrowing of the calibre, as in carcinoma ; and adhesions between the serous coats of the intestines, or between these viscera and the parietes. Of the first, it need only be said that the symptoms are due to the same paralyzed condition of the intestine, whether complete or in- DISEASES OF THE INTESTINES AND PERITONEUM. 643 complete, which has been already considered. The second group embraces those infiltrations which result from inflammations, and new growths of different kinds which lead to strictures. The former of these are recognized, as far as they can be with certainty, by the history of the case. The latter present peculi- arities in the form and size of the faeces, distention of the bowels above the seat of the narrowing, vomiting, attacks of colic, gradual wasting and exhaustion ; besides which, extreme costive- ness, deepening gradually into invincible constipation, furnishes a key to the grievous nature of the affection. When the constipation arises as the result of peritoneal adhe- sions, there are sometimes signs in the case — such as tenderness at a particular spot from still existing inflammation, or partial distention or retraction of the abdomen — which point out its nature. In the absence of these, the history is our only guide, except in those instances in which, as Bright* first informed us, a peculiar sensation is communicated to the touch, varying between the crepitation produced by emphysema and the feel derived from bending new leather in the hand. From long-standing constipation stercoral ulcers may arise. The sacculi of the colon are filled with little hard fsecal balls, which irritate the mucous membrane and produce ulceration. Mucus, or muco pus, with stains of blood, is occasionally dis- charged with the small scybala, and at times there is diarrhoea. Disorders in which Morbid Discharges from the Bowels occur, Matters very unlike the healthy alvine evacuations are often voided from the intestinal canal : loose watery stools, large quan- tities of mucus, pus, or blood, may be discharged. The disorders which occasion these discharges may be here described. Diarrhoea. — Like constipation, diarrhoea will be merely treated of as we meet with it constituting the entire ailment, or at all events its most prominent symptom. There are several varieties of diarrhoea. Difference in time gives rise to marked varieties, * Cases illustrative of the Diagnosis of Adhesions and other Morhid Changes of the Peritoneum, Med.-Chir. Transact., vol. xix. 644 MEDICAL DIAGNOSIS. — to an acute and to a chronic form ; and of both it has been pointed out already how often the lesion is an intestinal catarrh. Acute Diarrhoea. — Acute diarrhoea proceeds from more than one cause : it may be excited by the irritating character of the food taken, or by impure water; it may be brought about by the morbid nature of the secretions poured into the intestines ; it may be owing to atmospheric influences, — to heat, to moisture, to contaminated air ; it may be caused by chilling of the surface of the body, or by irritant poisons, retained faeces, or worms. It may be occasioned by pyaemia and septicaemia, by reflex irrita- tion, as in dentition, or by mental emotions, and especially by fear. Sometimes it occurs in an epidemic form due to some unknown miasm. Its symptoms are thirst ; abdominal uneasiness ; griping pain in the bowel ; pallor ; slight debility ; and frequent fluid alvine evacuations, which may finally become almost colorless. In the diarrhoea caused by a debauch or by indigestible food, nausea and a furred tongue are added to the list of symptoms mentioned. This kind of diarrhoea is generally of short dura- tion. It is an effort of nature to get rid of obnoxious matter ; and when this is effected, the looseness of the bowels ceases. The variety of diarrhoea under consideration sometimes goes hand in hand with a disturbance of the biliary functions, and the stools discharged are fetid, and present the appearance generally described as bilious. This "bilious diarrhoea," too, is not un- common in persons whose livers are habitually sluggish. It is also frequently encountered during the hot months of summer and early in the autumn, and has a tendency to run on. There are cases of diarrhoea attended with pain, considerable soreness to the touch, and, what is not ordinarily met with in diarrhoea, some febrile disturbance. These kinds of acute diar- rhoea, or rather of acute intestinal catarrh or of muco-enteritis with diarrhoea as a symptom, are often the result of irritant poison- ing, or are common as the result of the influence of cold, or of acrid drinks and unripe fruit. They are also observed as sec- ondary disorders in typhoid fever and in the exanthemata. Chronic Diarrhoea. — In chronic diarrhoea the lesions encoun- tered are much more marked than they ever are in the acute form. The mucous membrane is tumid and discolored • its follicles are not unfrequently ulcerated. Chronic looseness of the bowels DISEASES OF THE INTESTINES AND PEEITONEXTM. 645 originates in a diarrhoea which is permitted to continue, either from neglect or because the patient remains for a long time ex- posed to the original cause. But the disorder, no matter under what circumstances it originated, is apt to prove rebellious, and to end by breaking down the constitution. When of long stand- ing, the patient becomes gradually weaker and weaker, and more and more emaciated. The abdomen is sunken ; the complexion is pale ; the eyes are surrounded by a dark ring. The character of the discharges is various. They are often dark-colored and very offensive. Sometimes the looseness of the bowels alternates with an opposite condition ; but the irritability of the intestines never intermits. This morbid excitability of the intestinal tube is especially brought about in persons of nervous temperament and of dis- sipated habits. The abuse of purgatives, too, induces it, and in consequence chronic diarrhoea is not an uncommon result of the cathartic pills which patrons of quack medicines habitually swallow. But perhaps the most persistent irritability of the intestines is found in the diarrhoea to which soldiers are so liable, and which is apt to pass, no matter what its beginning, into the chronic form of the disease. This complaint, which follows impure water, de- fective diet, exposure, malaria, and scurvy,* which is generally associated with a morbid state of the large intestine as well as of the small, and which combines therefore some of the features of chronic dysentery with those of chronic diarrhoea, is one that often clings to its victim through life : many a soldier, in truth, escapes the bullet and the sword, only to die of the intestinal affection long after his return to his home. Then, the affection is very often witnessed as a complication of other disorders. Two-thirds of the fever patients received in the hospitals of Constantinople during a long period of the Crimean War were affected with diarrhoea or with dysentery. Diarrhoea was so very general that nearly all disorders were preceded by acute diarrhoea and terminated in chronic diarrhoea, f It was * Woodward, Outlines of the Chief Camp Diseases, p. 253; see also the elaborate analysis of the alvine fluxes in vol. ii. of the splendid " Medical and Surgical History of the "War of the Rebellion," Washington, 1879. f Baudens, La Guerre de Crimee. 646 MEDICAL DIAGNOSIS. much the same in this country during General McClellan's penin- sular campaign. But chronic diarrhoea, as the practitioner of medicine commonly sees it, is often attendant on general constitutional aifections, or on abdominal diseases that have led to a secondary disorder of the secretions, or even of the coats of the intestine. Thus, we find chronic looseness of the bowels in scurvy, in pyaemia, in Bright's disease, in scrofula of the mesenteric glands, and in tuberculosis. In the last of these complaints the diarrhoea may be occasioned by changes in the secretions of the intestinal glands ; but it is not seldom dependent upon a true tubercular disease of the intestines, which, like the disease of the lung, leads to soften- ing and ulceration. The discharges are generally copious and veiy offensive, and show traces of blood. The diarrhoea is con- tinuous and intractable ; the abdomen is retracted, and presents spots very tender to the touch. There, are marked fever and emaciation, and there may be severe intestinal hemorrhage. Yet, after all, only the signs of tubercle elsewhere furnish any positive indications by which the true nature of the wasting malady can be discerned. Indeed, it may happen that the reverse of diarrhoea occurs, for acute primary miliary tuberculosis may simulate an acute intestinal obstruction.* In all cases of suspected tubercular diarrhoea the stools should be examined for tubercle-bacilli, and these will be found very generally. Tubercidar ulceration is the most prominent type of ulcerative enteritis. But ulceration of the bowel is also met with under other circumstances. We find it in the diarrhoeas of children ; it occurs then as follicular ulceration. Ulceration is also occa- sionally observed from cancer, or as a solitary ulcer leading to perforation. The seat of the latter is generally the caecum or colon. Albuminuric ulceration, the careful analysis of Dickin- son t shows, is almost invariably associated with contracted kid- ney. Simple ulcerative colitis is usually met with in middle-ao-ed persons. It lasts generally about two months, J and is ushered in with abdominal pain, which remains a symptom. There is diar- rhoea with very fluid movements, but there are no dysenteric * Thoman, Allg. Wien. Med. Zeit., 1887. t Med.-Chirurg. Trans., vol. Ixxvli. , 1894. X Hale White, Guy's Hosp. Keports, 3d Series, vol. xxx. DISEASES OF THE INTESTINES AND PEEITONEUM. 647 stools ; blood in the discharges is common. The diarrhoea may alternate with attacks of constipation ; often there is vomiting. The disease may lead to perforation. Unhealed typhoid ulcers form another variety of ulceration of the bowels. In the diagnosis of all forms of intestinal ulceration, we must lay stress on the diarrhoea, on the character of the discharges, on the pain, and on the occurrence of hemorrhage from the bowels. In the discharges, mucus and pus and shreds of tissue are valu- able signs. In follicular ulceration little sago-like masses of mucus are met with, but they are not patliognomonic. The stools may be very frequent ; this is especially the case if the ulcer is in the lower part of the colon. Abdominal pain may or may not be associated with tenderness. Pain, as in other forms of coHtis, is often referred to the prsecordial region. With refer- ence to the frequency of this, Potain * tells us that, of one hun- dred persons complaining of heart-disease, about seventy have an affection of the colon. In the chronic diarrhoea of sb-umous children there is sometimes a scrofulous infiltration into the intestinal walls, sometimes marked scrofulous enlargement of the mesenteric glands, sometimes both, but in some cases neither. Improper nourishment, however, may be here, as in any other form of the diarrhoea of childhood, the exciting cause of the continued purging. At times chronic diarrhoea assumes an intermiitent type, and its malarial nature is clearly proved by the readiness with which the disorder yields to quinine.f In this respect malarial diar- rhoea differs from cases of diarrhoea we sometimes encounter, in which the pain and discharges come on at an early hour of the day and cease toward evening and during the night. Another form of looseness of the bowels is the membranous. Here the discharges show shreds of membrane, either in con- nection with the loose stools, or sometimes in such quantities that the whole mass voided seems to consist of them. Griping pains and tenderness usually precede this kind of diarrhoea, which may happen in attacks of a subacute form, or as a persistent and very * JVUnion Medicale, Nov. 1894. t See contri'bution by Sanford B. Hunt on Diarrhoea, in Medical Memoirs of U. S. Sanitary Commission, p. 306. 648 MEDICAL DIAGNOSIS. obstinate disorder : the former variety is the more common. The ftecal discharges are loose, but occasionally there is constipation. The disease is often associated with peculiar hysterical symp- toms or occurs in neurasthenics. The so-called membranes, in this membranous enteritis, contain a large amount of mucus, as I have elsewhere described.* Dysentery. — Frequent and painful passages of mucus mixed with blood, accompanied by straining and bearing down, are the characteristic symptoms of dysentery. In the acute form we find thirst, restlessness, and heat of skin superadded ; and sometimes, especially when the disease prevails epidemically, those symptoms of prostration which are commonly designated as typhoid. Acute Dysentery. — The acute disorder is at times ushered in by a chill ; at times it is preceded by diarrhoea. The fever which attends it is not generally intense. It is the exception to find it exceed 103°, and in light cases the temperature is only slightly raised ; the pulse is not tense. More or less pain is always pres- ent. It has its seat mostly at some part of the colon, and this is tender on pressure. It is intermitting and shifting, and is often accompanied by a feeling of weight near the anus, which causes a continual desire to go to stool. Yet no relief follows the frequent attempts; the violent straining only adds to the discomfort. The matters voided are small in quantity. They consist of blood mixed with mucus ; but they are composed not simply of mucus, but also of leucocytes, granules, and large quantities of cast-off epithelium, with many swollen round or ovoid epithe- lial cells. The stools are in some cases highly offensive, and re- semble the washings of meat ; in others they are like jelly, or greenish in color. They do not contain fseces, or only here and there small, firm lumps of faecal matter. When the dysenteric inflammation subsides, the bowels are unloaded of their contents ; in consequence, the passage of quantities of small, hard masses of fseces is generally a sign that the acute malady is inclining to a favorable termination. Sometimes the stools are very dark and slimy and have a putrid odor, and here and there pieces of sloughed-off tissue can be detected. This kind of stool marks * American Journal of the Medical Sciences, Oct. 1871. DISEASES OP THE INTESTINES AND PERITONEUM. 649 the diphtheritic or gangrenous variety of the malady, though it is not constant even in this. How long it will take for the disorder to run its course, or whether the acute disease will pass into chronic dysentery, cannot be foretold. Generally this is not its termination ; it very often ends, within a week from its beginning, in recoveiy. But severe cases occur which are of much shorter duration, in which the symptoms hasten on to complete prostration and death takes place early in the malady. In these frightful cases — most fre- quently encountered in epidemics — collapse may happen with almost the same rapidity as it does in malignant cholera. Dysentery is essentially a disease of hot climates. It is very common in this country in summer and in autumn. Eating green fruits, exposure to a chilly night after a hot day, and sleeping on damp ground, are prolific exciting causes. It is occasionally found in combination with malarial fevers, adding greatly to their danger, or with scurvy. It also occurs from drinking water full of impure substances or micro-organisms. It may be seen in a sporadic or in an epidemic form. It is very common in armies and in jails. The immediate cause of most of the symp- toms is inflammation of the large intestine, and especially of the descending colon. Yet in many cases of dysentery we see phenomena manifested which are clearly not to be accounted for solely by the local morbid appearances detected after death, and which show that dysentery mostly belongs to the infectious mal- adies. In truth, inflammation of the colon may give rise to the symptoms of acute diarrhoea ; for it is a great mistake to suppose that the cause of diarrhoea is to be sought only in some abnormal change in the small intestines. Thus, colitis is not always dys- entery ; and dysentery is often more than mere colitis. But, whatever be the ultimate cause or the form of dysentery, we find that it presents peculiarities which render it easy of recognition at the bedside. Yet we must take good care to ascer- tain that the supposed characteristic tenesmus and bloody dis- charges are not really owing to 'piles, or to morbid, especially Cancerous, growths in the rectum, or to its ordinary limited in- flammation. In the latter case, or proctitis, there is much pain when the hardened fseces are discharged, the rectum is forced down during the efforts, the sphincter contracts spasmodically. 650 MEDICAL DIAGNOSIS. Strangury and hemorrhoids are not uncommon symptoms ; and, as the consequence of the inflammation extending to the parts around the anus, an abscess may follow. Rectal pain often ex- tends to the thighs. Dysentery is not apt to be confounded with diarrhoea, for symptoms exist in the former which do not belong to the latter. Diarrhoea differs essentially from dysentery by the liquid fsecal evacuations, and by the fact that neither tenesmus, nor bloody stools, nor discharges of mucus occur. Yet in practice we meet with cases which begin with diarrhoea and terminate in dysen- tery, or begin with dysenteric symptoms and terminate in diar- rhoea, and in which it becomes, therefore, puzzling to say which disorder we are dealing with. There are some clinical varieties of dysentery which it is important to separate. The ordinary form seen in temperate climates to follow errors in diet or exposure is the catarrhal form. In tropical climates, where dysentery is very common and is met with frequently as an epidemic, we find mostly a kind that is characterized by the presence of the amoeba coli, or amoeba dysenteriae, as Councilman and Lafleur,* to whom most of our knowledge on the subject is due, call the micro-organism. Amoebio dysentery does not, as a rule, run so rapid a course as ordinary catarrhal dysentery, and local tissue degenerations in the liver, or single or, it may be, multiple abscesses of the liver, are common attendants. The abscesses, like the discharges from the bowels, contain amoebae. The evacuations, as the disease pro- gresses, lose their dysenteric characteristics, except the mucus, and become very liquid ; the tenesmus disappears. The amoebse are most active in alkaline stools. The diarrhoea has marked exacerbations and remissions, and is attended by striking ansemia. The fever is very moderate. In some instances hemorrhage from the bowels, in others peritonitis, happens. It is not unusual in protracted cases for the urine to become albuminous and to contain casts. In tropical climates, too, though also seen elsewhere in persons who have low forms of pneumonia, or who have become cachectic from scurvy, from Bright's disease, or from long-standing disease * Johns Hopkins Hospital Keports, vol. ii. DISEASES OF THE INTESTINES AND PERITONEUM. 651 of the heart, a form of dysentery attended by extensive exuda- tion and sloughing of the membranes is met with. This diph- theritic dysentery, as it is called, has generally high fever, much abdominal pain, great prostration, and delirium. The discharges are very frequent; the blood gradually disappears from them. Vomiting, especially at the onset, is common. In the progress of the case, which is generally to a fatal issue, the temperature becomes irregular, and hiccough is not uncommon. Chronic Dysentery.- — In chronic dysentery this mingling of the two complaints is especially apt to happen. We rarely see chronic dysentery without chronic diarrhoea. At all events, we seldom find instances of the former in which the tenesmus and the dis- charge of blood and mucus mixed with pus are not accompanied by frequent loose alvine evacuations, by griping, by the same gradual wasting and the same irritability of the bowels as are encountered in chronic diarrhoea; nay, the symptoms of the latter, and the difficulty of determining the presence of pus when mixed with fluid faeces, may so obscure the true nature of the malady that what has been regarded as chronic diarrhoea turns out, at the autopsy, to be chronic dysentery. The mucous membrane of the colon is found to be extensively inflamed ; its texture altered and irregularly thickened ; its surface riddled with ulcers. In such cases the patient goes on steadily losing flesh, has some elevation of temperature ; but no pain on pressure or localized distress ex- ists to denote the ravages the disease is making in the alimentary tube. Many die from exhaustion ; others, in consequence of ab- scess of the liver, which chronic as well as acute dysentery may induce. Intestinal Hemorrhage, or Melaena. — This is commonly the result of a mechanical hinderance to the flow of blood through the liver, as in cirrhosis, or of disease of the heart, or of a depraved state of the blood, — such as exists in typhus fever, in yellow fever, in scurvy, or in purpura. Occasionally the bleeding proceeds from a fungoid growth in the intestine, or from an ulcer in the duodenum or ileum, or from an invagination, or from faecal impaction, or from amyloid degeneration of the mucous membrane of the bowel, or is due to a disease of the spleen, or to the bursting of an aneurism, or follows extensive burns of the abdominal parietes. In very young infants a dis- 41 652 MEDICAL DIAGlSrOSIS. charge of blood, both by the mouth and^ by the rectum, is not unusual. The blood passed by stool is generally of dark color, like tar. "When it is not, we may fairly infer that it flows from the lower part of the intestine and has not had much chance to become ad- mixed with other matters. In all such cases, however, we must make sure, before arriving at any conclusion as to the source of the bleeding, that it does not pi-oceed from hemorrhoids. The exact seat of the hemorrhage cannot be determined ; nay, blood may be evacuated by the bowel and not be poured out at all from the intestine, but from the stomach. In some instances the blood accumulates in the bowel, and, before the clots moulded to its shape are discharged, death results.* When the bleeding pro- ceeds from hemorrhoids it is very seldom vicarious.f In point of diagnosis the first thing to determine is, that what is supposed to be blood is really blood. Very dark bilious stools, or stools blackened by iron, may mislead. If doubt exist, water should be poured on the stool, and, when blood is present, a reddish tinge is imparted to the water ; still more accurate is it to examine with the microscope or the spectroscope. We next have to ascertain the disease with which the intestinal hemorrhage is associated ; and this is often a very difficult matter. We must lay the greatest stress on the history of the case, look for the complaints — of which most have been above mentioned — that are apt to give rise to the bleeding, especially investigating for cirrhosis of the liver ; searching for intestinal ulcers in con- nection with typhoid fever, or tuberculosis, or a duodenal affec- tion ; or examining for the evidence of scurvy in the gums and skin ; or for purpura with its characteristic spots ; or for splenic 'enlargement, the result of chronic malaria, or perhaps combined with bone disease or syphilis and joined to amyloid degen- eration of liver, kidneys, and intestinal walls. Embolism of the superior mesenteric artery may also occasion intestinal hem- orrhage. But unless we have with the bloody stools marked abdominal pains, peritoneal exudation, and obvious causing ele- * See observations of Cheyne, Dublin Hospital Reports, vol. 1 , and of Bel- combe, Medical Gazette, vol. iv. t Lee on the Rectum. DISEASES OF THE INTESTINES AND PERITONEUM. '653 ments of embolistn or signs of it elsewhere, the diagnosis is most uncertain. Fatty Diarrhcea. — The occurrence of cases in which large quantities of fat, mixed or pure, are voided by the rectum, is well attested. In some of these cases oil was at the same time passed with the urine ; in others the urinary secretion was healthy j some cases ended fatally, others in recovery; some were found to be connected with a disease of the pancreas, others were not; in some the disorder was not of long continuance, while in others it lasted, with intervals, for years. As a rule, the occurrence of fatty stools is a matter of serious concern. The recognition of the malady is easy. The white, fatty masses, or the oily matter which collects on the discharges, are soluble in ether, and are readily proved to be fat by the micro- scope ; they burn, too, like fat, with a flame. In some instances the bowels are very constipated, and lumps of hard faeces are discharged along with the fatty substance. This happened in a marked example of the disorder that came under my observation. The patient, a man twenty-six years of age, passed a consider- able amount of fat both by the rectum and with the urine. He suffered much from digestive disturbance, from constipation, and fi'om weakness. He had a good appetite, but a dislike to fats of any kind. In his case there was, as far as the other symptoms and the physical signs indicated, no tumor in the region of the pancreas. The man's condition was much improved by the ad- ministration of cinchona and rhubarb ; but whether permanently or not I cannot say, as I lost sight of him. I have also met with instances of fatty diarrhoea associated with saccharine diabetes and with disease of the pancreas. In ex- amining into the subject of fatty stools it must be borne in mind that the clay-colored stools of jaundice, owing to the absence of the emulsifying properties of the bile, contain considerable fat, which may be found in oil-drops or as iine needle-shaped fat- crystals. Diseases attended with Vomiting and Purging. There is a group of diseases in which vomiting and purging are very prominent symptoms. It embraces those disorders in 654 MEDICAL DIAGNOSIS. which the intestine and the stomach are equally involved. To this group belong some affections which have already been considered, which begin in one viscus and then spread to the other. But those in which both are primarily affected still remain to be described. The most important of them are the various forms of cholera. Now, there are several very different complaints classed together under the head of cholera. Cholera Infantum. — And first, of the so-called cholera of infants. It is an endemic in the larger cities of the United States during the hot months, and one fraught with danger to all young children. It begins generally with diarrhoea. Vomiting soon follows ; and for a time the two go hand in hand ; but, unless the case be of short duration, the spontaneous vomiting ceases, or at all events gives way to occasional exacerbations of irritability of the stomach, while the looseness of the bowels remains, or even augments. The discharges are colorless, or yellowish, or green- ish. There is thirst ; sometimes fever. The abdomen may be sunken or swollen ; and it may be tender. Sometimes the dis- ease runs its course within three or four days ; at the end of which time the child dies, M^orn out by the constant vomiting and purging. More generally the disorder is of longer duration ; for weeks or for months it continues, the diarrhoea improving and then returning with redoubled severity, and kept up or increased by the irritation of teething. The irritability of the intestinal canal, and the utter impossibility of retaining enough food to nourish the wasting body, gradually wear out the system. The child before death is wan and distressingly emaciated ; sometimes hypostatic congestion of the lungs, broncho-pneumonia, boils, suppression of urine, plaintive cries, rolling of the head, strabis- mus, and coma precede the fatal termination. Such is a sketch of grave and intractable cases. Yet very many cases are far from being desperate. Under judicious treat- ment a large number are annually saved. Recoveries would bear a still higher proportion to the deaths, were it not that the great- est sufferers from the disease, the children of the poor, are unable to obtain the means most certain to restore them to health — change of air. Cooped up in crowded neighborhoods, surrounded on all sides by filth rapidly decomposing under the burning rays of the sun, they are compelled to breathe the hot, noxious atmos- DISEASES OP THE INTESTINES AND PERITONEUM. 655 phere which has been the chief agent in producing the liability to the complaint. The disease is an entero-colitis from a milk infection leading to bacterial fermentation in the intestines, with enlargement of the solitary glands, and even at times of Peyer's patches. The researches of Vaughan have demonstrated that a ptomaine i}- pearing in milk, tyrotoxicon, is its most frequent source. Tem- porary diarrhoeas in children occurring in hot weather could alone be mistaken for the disorder. But the fact that they are tem- porary, not followed by vomiting, and not associated with the grave symptoms of approaching collapse, shows us the differ- ence. Cholera Morbus. — This, or cholera nostras, is, like cholera infantum, a disease of the hot season ; yet it is also observed at other times of the year. But, although the chief predisposing cause is undoubtedly heat, there is generally an exciting cause which develops the disorder, — such as exposure, checked perspira- tion, drinking large quantities of ice-water, or imprudence in eating. The attack is characterized by spasmodic pains in the abdomen, by cramps in the legs, by rapid loss of strength, and by repeated vomiting and purging. The matter ejected both from the stomach and from the intestines is liquid, and contains a large quantity of bile. In truth, the affection is in reality a cholera, a flow of bile, which its more formidable namesake, Asiatic cholera, is not. Finkler and Prior have found in the stools a comma- bacillus, vibi^io proteus, which is larger and thicker than the ba- cillus of Asiatic cholera, but with shorter spirilla, and cultures of which, unlike the latter, rapidly liquefy in gelatin, and grow on potato even at ordinary temperatures. Cholera morbus may be preceded by colicky pains, nausea, and rumbling in the intestines. More generally it comes on suddenly. When at its height, the cramps in the calves of the legs cause the muscles to rise up in hard, knotty masses ; the stools are fetid ; the vomiting is constant ; the thirst is great, and the skin is cool or cold. But the patient does not remain long in this condition. In the course of a few hours, or at the utmost of a day, the symptoms mitigate, or yield entirely to treatment ; and, pale and visibly emaciated though he be, he speedily regains his health. Only in some cases the disease proves intractable, and, after 656 MEDICAL DIAGNOSIS. running on for several days, passes into a state of hopeless collapse. There are not many morbid states with which cholera morbus is likely to be confounded. It may be mistaken, as we shall presently see, for epidemic cholera. We find many points of similarity between it and irritant poisoning. But there are also strong points of difference. The vomiting and purging pro- duced by an irritant poison do not come on at the same time : the vomiting precedes the purging. The pain is first in the epi- gastrium, thence it may spread. Moreover, we often detect signs in the mouth or fauces which prove the irritating character of the substance swallowed. The vomiting and the subsequent acute gastritis are accompanied by fever and a small, tense pulse; whereas the skin of cholera morbus patients is commonly cool, and the pulse very compressible and feeble. In acute gastric catarrh, as we meet with it mostly from indigestion, there is vomiting, but not purging. Cholera. — The formidable complaint known as epidemic chol- era, Asiatic cholera, malignant cholera, or by the simple name of cholera, has some striking features of resemblance to the disorder just considered. It shares with cholera morbus the vomiting and purging, the cramps, the sudden depression ; but it is an affection of different origin and of much more serious import, and presents symptoms not encountered in the cholera that occurs yearly during the hot weather. And although, on account of the gastric and intestinal disturbances which form so prominent a part of its manifestations, it is here described among the disorders of the alimentary tube, I am doing so for the sake of clinical conve- nience, and contrary to sound pathology ; for cholera is not an affection either of the stomach or of the intestines ; it is an epi- demic constitutional disorder of the most formidable character, generated by a poison transmitted to us from the East. The poison leads to a casting off of the epithelium of the mucous membrane of the alimentary tube; perhaps to changes in the membrane. But the engorged veins all over the body ; the ready exosmose of the watery parts of the blood ; the frightfully-rapid prostration ; the sudden blight which befalls the nervous powers, — are elements which are even more characteristic, and which throw more light on the nature of the fearful malady, than the DISEASES OF THE INTESTINES AND PERITONEUM. 657 comparatively uncertain and far from uniform appearances of irritation in the intestinal canal. The access of cholera is at times sudden and most unexpected ; the patient, previously in good health, is stricken down without warning by the force of the poison. More generally there is a premonitory stage : a stage of languor, low spirits, uneasiness, headache, and diarrhoea. The effects of the morbific matter are indeed visible in hundreds of individuals who, during the preva- lence of cholera, suffer from tliese premonitory symptoms without any of greater danger arising. Nay, the same influences which give rise to a choleraic diarrhoea in healthy persons have the effect of rendering the bowels of those habitually constipated regular, and sometimes even loose. When the malignant disease is fairly developed, there is vomit- ing as well as purging. The contents of the stomach and intes- tines are first voided, and then large quantities of a rather turbid fluid resembling rice-water, with whitish particles like rice float- ing in it. They are the epithelial cells of the alimentary tube, which have been thrown off from the mucous membrane; and in the dejecta we find the comma-bacillus discovered by Koch. This may be seen by examining microscopically the bacilli ob- tained from a small amount of cholera dejection that has been mixed with an equal amount of alkaline meat broth at a tem- perature of 30° to 40° C. and allowed to stand for twelve hours in an open glass. The cholera-bacilli develop on the sur- face. They are readily stained, in about ten minutes, with a diluted alcoholic solution of fachsine or methyl-violet. They are decolorized by Gram's process already described. After the staining, which must take place with the infected side downward, the cover-glasses are taken from the solution with the forceps, washed in water, dried with the prepared side uppermost, and mounted in Canada balsam. Prior to the staining a drop of the infected broth or a particle from a stool is dried in air, after having been rubbed between two cover-glasses and passed three times through the flame of a Bunsen burner. The bacilli of cholera may be recognized even without the microscope by a rose- violet color, the cholera reaction, that becomes apparent in a few minutes if a ten per cent, hydrochloric acid solution is added to cholera cultures. The cholera-bacillus is confined to the intes- 658 MEDICAL DIAGNOSIS. tine. In the extensive observations made by Shakespeare in India and elsewhere * it was not found in the blood or in the tissues or organs outside of the intestinal canal. Fio. .55. The comma-bacillus of Koch, from culture in blood-serum. Zeiss ^, homo, im., Go. 4. Simultaneously with the vomiting and purging, or very shortly after, come on severe spasmodic pains in the abdomen and cramps of the muscles of the belly and of the extremities. With all this there are a burning sensation in the epigastric region; an unquenchable desire for cold drinks ; a cool skin ; a pulse slightly more frequent than normal ; a temperature which may be normal or may fall to about 95°, and which often shows many degrees of difference between the rectum and the axilla ; an oppressed breathing ; and a rapidly-progressing exhaustion. The case now stands on the verge of collapse. Should this follow, a state of things is witnessed which, once seen, remains indelibly engraved on the memory. The pulse is quick, but hardly perceptible. The discharges cease, and so do often the cramps. The skin is cold, * Report on Cholera in Europe and Asia, Washington, 1890. DISEASES OF THE INTESTINES AND PERITONEUM. 659 covered with a clammy sweat, and has a bluish look. The nails and the lips have the same unnatural appearance. The whole body shrinks, and seems at times almost to wither visibly even while under inspection. The countenance assumes the aspect of death ; the eyes are sunken and have a glassy look. The tem- perature is low ; it may fall to 79°. The intellect is commonly clear ; but, when the patient talks, the words fall strangely on the ear. It seems as if a corpse had spoken, and the voice is husky and faint. The tongue and the expired air are cold. No symptom, indeed, has struck me more forcibly than the icy breath. But the symptoms do not always take place in the order de- scribed, nor are they all uniformly present. The vomiting and purging may be wanting from the onset, and so too may the cramps. Only one symptom is never absent, — the tendency to early sinking. Sometimes a stage of perfect collapse is reached with frightful rapidity : instead, as is commonly the case, of sev- eral hours elapsing before complete prostration comes on, the vital powers are at once laid low by the assault of the dreadful malady. When cholera prevailed in Philadelphia some years since, I at- tended a woman who at six o'clock in the morning was in perfect health and who in a little more than half an hour afterward was lifeless. There was neither vomiting nor purging ; nothing but cramps, stupor, and speedy collapse. Such cases are not uncom- mon in the home of cholera, — India. Post-mortem inspection shows the thin rice-water fluid locked up in the alimentary canal. Nature makes an effort to eliminate the poison ; but before she completes her task, life is palsied. In those cases that recover, or in those of light character, chol- erine, the vomiting and purging gradually subside, the skin be- comes warm, the pulse fuller, the urine — which, while the disease was at its height, was not passed, perhaps not secreted — is again voided, the patient falls into a refreshing sleep, and, the symp- tom most favorable of all, bile reappears in the stools. Even in apparently hopeless cases of collapse we may be fortunate enough to witness these favorable changes. But where the prostration has been great, the reaction is apt to be violent. A decided fever of low type, with rapid pulse and heat of skin, and attended very often by alarming cerebral symptoms, succeeds ; and the urinary secretion, even if it had been restored, becomes again very scanty. 660 MEDICAL DIAGNOSIS. Thus the period of reaction brings with it new dangers, and of a kind which are sometimes insurmountable. And this low form of fever, very similar to typhoid, though readily enough distin- guished by the preceding symptoms, may last for upwards of a week before death takes place or the signs of danger gradually yield. Now, this cholera typhoid may be preceded by scanty urine and marked uraemia, but it may also exist independently of this morbid state, though probably equally due to the blood being loaded with broken-down material. In cases in which ursemia sets in, whether it be followed or not by a fever of low type, there is at first but little, if any, heat of skin, and a slow pulse ; the patient is wild, restless, or drowsy ; the kidneys act very imper- fectly, the urine is greatly deficient in urea, and usually contains albumen. These are very dangerous cases, and if the secretion be seriously retarded for more than twenty- four hours they are likely to perish. In any case of cholera, convalescence is apt to be slow. For weeks or months irritability of the intestinal canal remains ; and I have met with instances in which it has never disappeared. It would be needless to go into any minute description of the difierences between cholera and other affections : its features are not to be mistaken. Cholera morbus is the only disorder which really resembles it. The dividing-line is drawn by the absence of bile in the discharges, the rice-water evacuations, the greater severity and more rapid progress of the symptoms, the bluish color of the surface in the stage of collapse, and the epidemic character of the more fatal disease. In the truly epidemic nature of the distemper, in the presence of the cholera-bacillus in the evacuations, and in the speedy collapse, which shows but too plainly that some highly deleterious matter has poisoned the sys- tem, lie, even in doubtful cases, the proofs that we are dealing with malignant cholei'a ; for sometimes rice-water discharges occur in bad cases of cholera morbus; occasionally, too, this disorder appears to be epidemic ; but it is only on a very small scale. To speak more accurately, it is an endemic on a large scale. We find no proofs of a virulent poison directly conveyed by human intercourse and traffic, and so noxious as to smite animals as well as man. Certain rare cases of irritant poisoning, especially from arsenic, bear some resemblance to cholera, although generally DISEASES OF THE LIVER. 661 more to cholera morbus. The severe vomiting in advance of the purging, the usual absence of rice-water stools, the presence of bloody evacuations, and the traces left by the poison in the mouth, furnish significant features of distinction. The mortality of cholera is very various. In many epidemics one-half, or more than one-half, die. In some the havoc is far less. The first cases that occur almost invariably perish ; and, taken altogether, the malady ranks among the most destructive to life. Its epidemic visitations are what the plague was to the Europeans of the seventeenth century, and what yellow fever still is to the inhabitants of this continent. It is at least as dangerous ; its true nature is as hidden ; its management is as unsatisfactory. SECTION III. DISEASES OF THE LIVER. We have already inquired into the clinical methods of exam- ining the liver with a view to forming a judgment of its physical characteristics. Let us now look at some of the symptoms. Pain is one of these. It is generally dull, and radiates from the seat of the liver to the upper portion of the thorax, to the scapula, to the shoulder, and to the umbilicus. Commonly it is persistent and increased by strong pressure; yet the exceptional cases are numerous. As happens Avith other symptoms of disease of the liver, with vomiting, with jaundice, it may be noticed that the pain is sometimes strangely periodical, suggesting malaria, but uninfluenced by quinine.* Digestive troubles are usual accompaniments of hepatic affec- tions. They are of all grades, from mere indigestion to the signs announcing chronic gastritis. Disturbance of the portal circfulation, is another frequent conscr quence of disease of the liver. The flow of blood is interfered * See on this subject a paper by Cyr, Arch. Gen. de Med., May, 1883. 662 MEDICAL DIAGNOSIS. with, and the result is seen in the occurrence of dropsy, of piles, of partial peritoneal inflammation, of hemorrhages from the en- gorged stomach and intestines, and of enlargement of the spleen and of the veins on the surface of the abdomen. Jaundice. — The most significant manifestation of hepatic dis- order is jaundice. This marked sign shows itself by the yellow tinge imparted to the skin and to the conjunctiva. Yet the yel- lowness is not confined to these structures : it may be found in internal organs. Besides the peculiar aspect of the surface, icterus is usually attended with depression of spirits ; with slow pulse ; with itching of the skin ; with high-colored urine, in which the main ingredients of bile can be detected, and sometimes small quantities of albumin, or hyaline and epithelial casts without albumin; with constipation, the faeces passed being hard and knotty, and often of bad odor, and almost devoid of color, or of a leaden hue. Jaundice is due to the presence of biliary constituents in the blood; they get there from the bile, in consequence of some impediment to its outward passage, being reabsorbed and con- veyed into the circulation ; or it happens because the liver-cells cannot perform their functions ; or because some poison changes the proper relation between blood destruction and liver secretion, and the elements of bile accumulate in the blood. In the jaun- dice from reabsorption, the most common form of jaundice, it has been demonstrated that the bile may get into the blood in conse- quence of altered pressure in the vessels. Lower pressure in the vessels causes the bile to flow into them. The diagnosis of jaundice is easy. The only morbid signs with which it is liable to be confounded are the slightly yellowish hue of chlorosis, or of some cachectic conditions combined with organic visceral disease, and the yellow appearance of the con- junctiva which is natural to some persons. The changed color of the countenance due to chlorosis is told by its association with a bluish-white or pearly-tinted eye, and with pale lips and tongue and transparent ear. The absence of a yellow tint from the con- junctiva is of equal importance in discriminating from jaundice the yellowish hue of cancer, of malaria, of lead poisoning, and of granular kidneys. The history of the case also aids us. The yellow look of the eye sometimes found in health, and at times DISEASES OF THE LIVEE. 663 dependent on subconjunctival fat, is known by the unequal dis- tribution of the color and by the absence of a yellow hue of the complexion. But in negroes — and it is in them especially that we meet with the discolored conjunctiva — we have to judge by the character of the coloration alone. In any doubtful case, the chemical tests for bile-pigment in the urine will solve the doubt. When once jaundice has been recognized, the diificulty in diag- nosis may be said to begin. Of the many distinct sources of icterus, which one is before us? Now, clinically speaking, the causes may be thus grouped : 1. Diseases of the liver. 2. Dis- eases of the bile-ducts. 3. Diseases of parts remote from the liver, or general diseases leading to a disorder of the viscus. 4. Certain poisons acting upon the blood. In the first two of these causes there is, as it were, a mechanical difficulty impeding or arresting the excretion of bile ; in the third and fourth no impediment exists. Let us look at some of the peculiarities of these groups. 1. The jaundice connected with diseases of the liver is, as a rule, recognized by its association with changed dimensions of the organ, and with pain or other palpable signs referred to the hepatic region. It is met with in all disorders of the liver, but does not exist in all in the same degree of intensity. It reaches a high development and is combined with cephalic symptoms in axjute yellow atrophy. In fatty liver, in waxy liver, in cancer, in cirrhosis, and in acute hepatitis, it is not marked, and may be, indeed, absent : in truth, it can hardly be looked upon as belong- ing to the first-mentioned morbid states. The jaundice of this class of cases is due to interference with the secreting function of the liver-cells. 2. Jaundice arising from disease of the larger biliary ducts, such as their catarrhal swelling ; or in consequence of their obstruction by pressure exercised by a morbid enlargement of adjacent parts, as of the pyloric extremity of the stomach or the pancreas ; or by tumors, aneurismal, cancerous, or faecal, closing the orifice of the duct ; or by the stoppage of the ducts by inspissated bile or a biliary calculus, or by hydatids or foreign bodies from the intes- tines, — is a form of the malady in which the icterus is commonly intense. The obstructive jaundice occasions no head symptoms ; and when these are absent in a case of very deep jaundice, 664 MEDICAL, DIAGNOSIS. when, further, the stools are completely discolored, we are gener- ally correct in attributing the morbid phenomena to an impedi- ment to the flow of bile through the common bile-duct or the hepatic duct. If this impediment be due to the impaction of a gall-stx)ne, a constant sense of weight and recurring severe colicky pains are encountered in addition to the sig..' just mentioned. In the jaundice due to reabsorption — precisely the form of jaim- dice, therefore, that happens if any serious obstacle in the biliary passages exist — the biliary acids pass into the blood, and thence into the urine. But this is not a certain sign of obstructive jaun- dice. Traces of the bile-acids have been found in healthy urine. 3. Illustrations of jaundice following some local lesion of other parts of the body, or appearing in the course of a general consti- tutional affection, are furnished by the jaundice which happens in some cases of pneumonia, or which is encountered in remittent, in typhus, in relapsing, or in yellow fever. In these fevers the yellow hue is generally found to be connected with an acute enlargement and with structural changes in the organ ; and in the latter malady, with disordered hepatic circulation and a fatty degeneration of the secreting-cells. But, besides the interference with the secreting power of the cells, the blood alterations in these manifestations of jaundice must be considered. To recognize the form of jaundice under discussion, we must examine all the viscera of the body with care, laying stress upon the history of the case and the phenomena attending the jaundice. Otherwise, too much importance will be attached to this symptom, and the disturbance of the liver will be regarded as forming the whole complaint, when it is but a small part of it. 4. Poisons acting upon the blood sometimes give rise to jaun- dice very rapidly ; for instance, the jaundice from snake-bites or from pysemic affection is apt to be suddenly developed. As a rule, the tint is light. In the history of the accident and the signs of alteration of the blood we possess the means of distinguishing this form of jaundice. Certain mineral poisons, such as phospho- rus, copper, antimony, come into the same category. Chloroform and ether, too, may lead to abnormal blood changes producing jaundice. The urine enables us to a certain extent to tell blood jaundice from jaundice caused by liver disorder. We find hsemo- globin in the urine, or get from its hsematin the hsemin crystals DISEASES OF THE LIVEK. 665 of Teichmann. These are obtained by drying urine on a slide, adding a little salt, and then glacial acetic acid under the cover- glass. The slide is heated until bubbles rise, and on cooling the characteristic blood-crystals form. If these or haemoglobin be found, there is a strong probability of the jaundice being of blood origin. Thus, then, we can bring, clinically speaking, most of the varieties of jaundice under one or the other of the four heads mentioned ; and, roughly speaking, they come really under two, — obstructive jaundice, where the disorder results from obstruction of the common duct, and jaundice without such obstruction. But tliere are a few kinds of jaundice which it is not easy to classify with precision : one of these is the jaundice from mental emotion ; the other, the jaundice of newly-born children. As regards the former, no satisfactory explanation has been given. All we know is, that violent anger or fright may lead within a very brief space of time to the development of jaundice, and that the quickly -occurring discoloration is not dangerous or of long duration. The perverted innervation caused by concus- sion of the brain leads to a similar kind of jaundice. The jaundice of newly-born children^icterus neonatorum — is ordinarily a mild complaint, which appears soon after birth and rarely lasts over two weeks. The yellow hue of the skin is often very deep ; yet the child does not suffer, and has no febrile excite- ment. The bowels are constipated, but the stools are not neces- sarily altered in their color; nor do they usually present the clayey look which might be expected from the aspect of the skin and of the conjunctiva. West states that the disorder is most frequently observed in children prematurely born. The prognosis of jaundice depends upon its cause. In general terms, we may say that if the icterus last upwards of two months it is always a matter of some danger, as showing, in all likeli- hood, an organic lesion of the liver or of the biliary passages, or unyielding pressure on them. If the discoloration of the skin be attended with cerebral symptoms, the patient's state is precarious. Icterus accompanying affections of the blood, peritonitis, or pneumonia is an unfavorable sign ; so are wide-spread ecchymoses, or a very dark color of the skin. Indeed, cases of " green" or " black" jaundice generally prove fatal. 666 MEDICAL DIAGNOSIS. Before examining the hepatic maladies according to their clin- ical features, let us look at their pathological classification : Diseases of the Liveb. Diseases of hepatic parenchy- Diseases of biliary passages. Hyperemia . Inflammation and its conse- quences Atrophy Hypertrophy . Degeneration and new for- mations r Inflnmrnation of gall-bladder and gall-ducts Occlusion of biliary pas- Acute congestion. Chronic congestion. Acute hepatitis. Chronic hepatatis. Interstitial inflammation ; cir- rhosis, atrophic and hyper- trophic. Abscess. Softening. Syphilitic hepatitis. Acute yellow atrophy. Simple chronic atrophy. Red atrophy. Partial. General. Patty liver. ' Waxy liver. Pigment liver. Cancer. Sarcoma. Lymphatic growths. Gummata. Tubercle. Hydatids. Simple cysts. Catarrhal. Exudative. Suppurative. Dilatation of gall-bladder. Morbid growths. Foreign bodies ; concretions, such as gall-stones. |_ Biliary fistulje. Diseases of f Of hepatic artery . blood-ves- J ^„ , _ I Of hepatic vem. [ Of portal vein r Inflammation. ■\ Sclerosis, l Aneurism. f Suppurative inflammatioiL I Thrombosis. DISEASES OF THE LIVER. 667 Acute Diseases of the Liver attended generally with Slight Enlargement of the Organ, and with more or less, though rarely very much. Jaundice. Acute Congestion. — This arises from organic disease of the heart, from obstructed portal circulation, from irritating food and drink and disturbed digestion, or from malarial poison ; sometimes it is caused by a high temperature, by a blow on the hepatic region, by arrest of the menstrual flow, by a protracted chill, by violent exercise, or, as Frerichs points out, by injury to the semi- lunar ganglia. The acute congestion is characterized by pain in the right shoulder and loin, by an unpleasant sensation of weight and of tension in the right hypochondrium, increased after meals, and by nausea and vomiting. At the same time the action of the bowels is deranged, being generally too frequent; the tongue is coated ; there is flatulency, as well as depression of spirits, with loss of appetite and of strength ; and the liver is enlarged. But we find ordinarily only slight jaundice, and no fever. Gradually these signs disajDpear; the increased hepatic dulness, however, remaining for some time after the gastric and intestinal disturb- ances have abated. Not unfrequently the acute disorder passes by imperceptible degrees into a chronic state. Acute Hepatitis. — The symptoms of this affection are much the same as those of acute congestion, except that we observe rise of temperature, and in some cases enlargement of the spleen, and albumin in the urine. The pain is dull, and is increased on pressure, yet not much so, unless the peritoneal covering of the liver be involved. Jaundice is not generally marked ; indeed, at the beginning of the disease it is often absent. Acute hepatitis is common in hot countries, and many of the cases are connected with dysentery, particularly with amoebic dys- entery. It may end in resolution ; but, especially in persons of indolent or intemperate habits, it often terminates in suppuration, and pus collects in the substance of the liver. The occurrence of this, the tropical abscess, as Murchison * called it, is indicated * Diseases of the Liver, 2d edit., 1877. 42 668 MEDICAL DIAGNOSIS. by recurring rigors, by fever of remittent type, by clammy perspira- tions, by prostration and loss of flesh. Kot unfrequently, too, a decided fulness of the side may be noticed, and occasionally careful palpation detects deep-seated fluctuation. After an abscess has formed, the danger is great ; secondary abscess may follow, and the patient is apt to perish from peritonitis, or from blood-poison- ing. Yet recovery may take place. The matter may be dis- charged through the abdominal walls, or burst into the intestine, or find its way through the diaphragm into the pleural cavity, to be discharged through the lung. But, as the phenomena of ab- scess of the liver following acute inflammation are in the main the same as when the collection of pus is consequent upon other morbid states, we shall not here consider what we shall presently fully examine. Let us now examine the maladies with which acute inflam- mation of the liver may be confounded, premising that, making allowance for the febrile phenomena and the other slight signs of difference just indicated between hepatic inflammation and hepatic congestion, the same remarks will apply to the distinction between this morbid condition and the affections about to be mentioned. The complaints resembling acute hepatitis are : Perihepatitis ; Inflammation of the Portal Veins ; Pigment Liver; Chronic Hepatic Diseases with Acute Symptoms; Acute JSTon-Hepatic Diseases with Jaundice; Diaphragmatic Pleurisy ; Acute Infectious Jaundice; Inflammation of the Biliary Passages; Acute Yellow Atrophy. PeriJiepatitis. — Inflammation limited to the serous covering of the liver is not a frequent disease. Unless it be of syphilitic origin, it is scarcely ever observed as a primary affection ; it is generally caused by the extension of inflammation from organs adjacent to the liver, — as from the stomach, intestines, diaphragm, or pleura, — and may therefore be looked upon as a local tierito- nitis ; or it is an attendant upon disease of the liver itself. In the latter case it presents no peculiar symptoms, except that it adds tenderness to the signs of the hepatic malady it complicates. DISEASES OF THE LIVER. 669 Under other circumstances it is more likely to be confounded with acute inflammation of the liver- texture. Yet the far greater tenderness, the severe pain upon motion or deep inspiration and its marked increase when the patient lies on either side, an occa- sional grating friction sound, the normal size of the gland, the history of the case or the evidences of a disease in the neighbor- hood of the liver that is likely to cause the malady, the absence of jaundice, and the slight fever, distinguish the perihepatic in- flammation. Inflammation of the Portal Veins. — An inflammation of the portal veins, terminating in suppuration or in their infection by a general pysemia, or through local processes in the portal circle, is very liable to be mistaken for acute hepatitis. Nor are there, in truth, any positive symptoms by which we can discriminate be- tween the two maladies. Still, we may suspect that the veins, rather than the structure of the liver, are the seat of inflammation, if, with the signs of acute and painful enlargement of the organ, we find- jaundice, thiu and copious stools, recurring chills and profuse sweats, emaciation, increase in size of the spleen, without any apparent fluctuation or other signs of an hepatic abscess ; if there exist pains between the ensiform cartilage and the umbilicus, or in the epigastrium or right hypochondrium, or shooting to the lumbar and sacral regions ; if following these symptoms appear swelling of the veins of the abdominal walls and striking evi- dences of hectic fever or of peritonitis ; and if these phenomena be encountered in a person who, on account of a previous affec- tion of the intestines or the appendix or the spleen, or of any other organ having a connection with the portal circulation, is liable to disease of the portal system. Marked enlargement of the spleen is a constant feature of impediment in the portal vein, whether from inflammation or from thrombosis. Pigment Liver. — In accumulation of pigment in the liver, which is most common as the result of a deep malarial poisoning, the liver is not the only organ implicated in the morbid process : the spleen is commonly affected ; the blood becomes watery, its cor- puscles are broken down, and it contains the malarial corpuscles and large quantities of pigment ; and pigment accumulates in the kidneys or in the brain. If ow, the effect of all this is to occasion marked symptoms, besides those referable to the derangement of 670 MEDICAL, DIAGNOSIS. the liver ; for it is not unusual to find grave cerebral disturbance, albuminuria, hemorrhage from the intestines, profuse diarrhoea, and enlargement of the spleen. Irrespective of these manifesta- .tions, we may note the singular ash or grayish-yellow color of the skin, and the evident ansemia. The fever that accompanies the morbid condition is of an intermittent type ; the pulse is not, as a rule, much accelerated, and the jaundice is generally slight. In India, pigmentary degeneration of the liver tends to suppu- rative hepatitis.* When we contrast the phenomena described with those of acute hepatitis, we see at once the difference. The fever, the aspect of the patient, the blood full of dark pigment and malarial corpuscles, and the frequency of cerebral symptoms, are entirely unlike. Chronic JJepatio Diseases with Acute Symptoms. — "We occasion- ally meet with patients who seem to be laboring under an acute affection of the liver, either some form of inflammation of the liver-structure or of the biliary passages, or congestion of the liver, but in whom the acute symptoms have merely supervened upon a chronic complaint. Such cases are puzzling; we may have to wait for their solution until the acute symptoms sub- side. In hepatic cancer the sudden and rapid development of the malady amid the signs of acute congestion is not very un- common. Occasionally the peculiar physical phenomena of indi- vidual hepatic diseases, such as the nodular tumors of a malignant growth, or the fluctuation of a hydatid cyst, will assist materially in the diagnosis. Acute Non-Hepatic Diseases with Jaundice. — There are many acute affections, such as pneumonia, pysemia, puerperal fever, and some forms of poisoning, in which jaundice may coincide with febrile symptoms and excite suspicions of acute hepatitis. But the yellowness of the skin which may attend the non-hepatic dis- orders mentioned is accompanied by symptoms so different that a mistake is not likely to arise if the history of the case be taken into account and other viscera besides the liver be explored. Diaphragmatic Pleurisy. — The manifestations of inflammation of the pleural covering of the diaphragm are in several respects similar to those of inflammation of the liver. We find in this * Aitken's Practice of Medicine, vol. ii. DISEASES OP THE LIVER. 671 diaphragmatic pleurisy pain in the right hypochondrium, nausea and vomiting, dry cough and embarrassed respiration, occasion- ally jaundice, — much the same symptoms which we observe in hepatitis, especially if the serous envelope of the liver be at the same time implicated. But the pain in diaphragmatic pleurisy is far greater, more suddenly developed, is much more aggravated by movements and by full inspiration, and is always evoked by pressure. The diaphragm on one side is immovable ; the hypo- chondriac region is retracted ; the breathing is purely costal and short ; the difficulty in breathing amounts to orthopncea ; the body is bent forward. We often encounter hiccough, great anxiety, and delirium, sometimes a sardonic grin on the features, and the cough comes on in frequent paroxysms; and although, as a case recorded by Andral * proves, there may be jaundice, yet this is in reality so generally wanting as scarcely to belong to the symptoms of diaphragmatic pleurisy. Then in this complaint we may find friction sounds, — ^though the physical signs will not always aid us, being often uncertain, f and consisting simply in enfeebled breathing, with perhaps a few fine moist rales at the lower portion of one side of the chest. The fever with these imperfect physical signs may be slight or be very marked ; it is generally ushered in by a chill. There is generally, in addition to the pain along the cartilages of the false ribs, a tender spot in the epigastrium, on a level with the tenth rib, one or two finger-breadths from the linea alba. There are shooting pains along the clavicle and in the tract of the superficial cervical plexus, and the phrenic nerve of the afiected side, pressed on in the neck, is very sensitive. The pain on pressure is generally most intense along the costal insertions of the diaphragm, especially of the tenth rib ; it is stated that upward pressure affords a means of diagnosis, as it relieves the pleuritic pain.J The difficulty in expectorating, owing to the pain, may be so great as to hasten death. § Acute Infectious Jaundice. — This malady, || also known as Weil's disease, presents many symptoms of acute hepatitis. It is very * Clinique Medlcale, tome ii. t Cases by Habershon, Guy's Hospital Eeports, 1869. J Britisb Medical Journal, Aug. 1871. ? Frank Donaldson, Jr., Amer. Journ. Med. Sci., April, 1885. II Described by Weil, Deutsches Arehiv fiir Klin. Med , Bd. xxxix. 672 MEDICAL DIAGNOSIS. doubtful, however, whether it is an affection of the liver, but is not rather an infectious fever due to the invasion of a specific micro-organism through the gastro-intestinal tract. Jaeger * has, in cases of Weil's disease, isolated from the urine during life and from the tissues after death a short curved rod, provided with cilia, which he designates " bacillus proteus flavescens." "Weil's disease is marked by jaundice, swelling of the spleen, nephritis, and blood-alteration. It mostly affects vigorous young men in hot weather ; butchers and soldiers are especially liable to it. It has been also observed in persons who have bathed in water contaminated by fowls suffering from an analogous disorder.f It begins abruptly with headache, dizziness, and decided elevation of temperature. The jaundice Is moderate, the liver slightly swollen and painful ; there is great weakness, with delirium and somnolency, increased thirst, and general malaise, with loss of appetite. Besides albumin and tube-casts, the urine may contain blood ; both bile-pigment and bile acids are found in it. There are pains in the limbs, especially in the calves ; the bowels are usually loose. The symptoms abate quickly ; from the seventh to the eighth day the temperature falls gradually to normal. A return of fever after a period of its absence from one to seven days may happen, but this return does not last more than three to six days. The convalescence is extremely slow. Fatal cases have presented fatty degeneration of the liver, acute parenchymatous nephritis, and enlargement of tlie spleen.J The disease resembles relapsing fever, but the spirilla have not been found in the blood. Nor is defervescence attended with a critical discharge followed by sub- normal temperature. Further, the ascent of the temperature of the secondary fever is gradual, while that of the paroxysm of relapsing fever is sudden. The return of the fever makes it unlike abortive typhoid with bilious symptoms. Then, it shows no eruption, except herpes and an erythema.§ Besides, jaundice and nephritis are rare in typhoid fever. Between acute yellow atrophy of the liver and Weil's disease * Zeitschrift fiir Hygiene und Infektionskrankheiten, Dec. 9, 1892. f Jaeger, loc. cit. i Ibid. § Piedler, Deutsches Archiv f. Klin. Med., Feb. 1888. DISEASES OF THE IJVEE. 673 there is a close resemblance. But the former has a prodromal period, while the onset of the latter is abrupt. The second is attended with elevation of temperature of peculiar range ; in the first the temperature is, as a rule, not elevated, and may be sub- normal, and the bowels are constipated. In acute yellow atrophy the jaundice is gradually progressive and the liver is at first en- larged and subsequently reduced in size ; the jaundice of Weil's disease is slight and soon subsides, and the liver remains enlarged throughout the attack. In acute yellow atrophy the urine may contain albumin and tube-casts, but there are not the pronounced symptoms of nephritis that Weil's disease presents. The ten- dency to hemorrhages is far greater in acute atrophy of the liver than in infectious jaundice. The one condition is almost invari- ably fatal ; the other is, as a rule, followed by rapid improvement and recovery. Weil's disease in some respects resembles yellow fever, but it is an affection of several paroxysms. Inflammation of the Biliary Passages ; Acute Yellow Atrophy. — Both of these maladies may be confounded with hepatitis. But the former, although presenting more jaundice than the other maladies of the group now under discussion, is otherwise so similar that it will be described as one of the main affections of this group ; and, in truth, in temperate climates acute affections of the liver are mostly catarrhal jaundice. Acute yellow atrophy belongs clinically to diseases characterized by decrease in size of the liver; and it is while discussing these that we shall point out its characteristic differences. Inflammation of the Gall-Bladder and Gall-Ducts.^ Inflammation, when it attacks the biliary passages, is most apt to affect the gall-bladder and the ductus choledochus. Frequently the morbid process is propagated from the stomach or intestines, and nausea, furred tongue, a feeling of weight in the epigastrium, feverishness, and diarrhcea, occur previous to the discoloration of the fseces, to the jaundice, to the increased hepatic dulness, and to the slight tenderness on pressure in the right hypochondrium ; in other words, the symptoms of gastric or gastro-intestinal catarrh precede those of " icterus catarrhalis," — by far the most common form of inflammation of the gall-bladder, for suppurative inflam- mation is very rare. Catarrhal icterus does not cause any great enlargement of the 674 MEDICAL DIAGNOSIS. liver, and the swollen organ remains smooth on palpation. Nor is the tenderness decided, except over the tumid and projecting gall-bladder. The jaundice, at first slight, becomes after a few days, as the bile-ducts are obstructed, intense, and the stools are white and devoid of bile. There is now no fever, or this is but very slight ; the pulse is usually slow. The affection is the most common cause of marked jaundice in young persons ; when found in the middle-aged or in the old it is apt to be associated with a gouty diathesis or to have followed syphilis ; and at any age it may be secondary to other diseases of the liver, and is then apt to be lasting. Generally catarrhal icterus is a tractable disorder ; and after continuing for two or three weeks, it usually subsides. But it may persist for as many months ; and in rare instances the inflam- mation leads to an occlusion of the bile-ducts, and to a fatal issue. I had such a case in 1863 under my charge at the Philadelphia Hospital. The patient, a man upward of sixty years of age, died deeply jaundiced and comatose. He had presented, during life, the signs of enlargement of the liver ; little or no tenderness in the hepatic region ; no fever ; but much gastric irritability and obstinate constipation, both of which had existed for three weeks prior to a noticeable discoloration of the skin. The whole disease was, as far as could be ascertained, of only two months' duration ; and the jaundice steadily deepened from the time of its first ap- pearance. At the autopsy, the gall-bladder was found enormously distended, its coats thin, yet otherwise scarcely abnormal ; but the common duct was obliterated by inflammation. The stomach and the upper bowel were congested, while the coats of the stomach toward the pylorus were thickened. A similar case has been described by Tyson.* Now, in point of diagnosis, it is not generally difficult to dis- tinguish the catarrhal inflammation of the gall-bladder, except in those rare instances in which the common duct or the hepatic duct is obliterated. It differs from congestion of the liver by the different etiological elements in the history of the case, — the one disorder happening commonly in connection with disease of the heart, or an obstruction of the portal circulation, or a miasmatic * Transactions of the Pathological Society of Philadelphia, vol. iv. DISEASES OF THE LIVEE. 675 poison, the other following usually exposure to cold and damp, or the eating of quantities of indigestible food. Then, inflam- mation of the gall-ducts gives rise to decided jaundice. Catarrhal jaundice may occur as an accompaniment of some general morbid condition, or in an epidemic form. These cases are distinguished by the history, by the tendency to acute disease of other organs, such as the lungs and kidneys, and by enlarge- ment of the spleen.* From the jaundice of chronic hepatic maladies — such as cancer or cirrhosis — we separate catarrhal icterus by the non-existence of the physical signs of these maladies, by its acute course, and by the dissimilar progress of the symptoms. Still, as regards cancer we must bear in mind that we encounter in elderly gouty persons cases of long-persisting catarrhal icterus attended with frequent vomiting and marked emaciation which strongly resemble cancer, yet slowly yield to treatment. Inflammation of the biliary pas- sages with the jaundice arising in consequence of biliary calculi is distinguished by the severe pain, the sudden appearance of the icterus subsequent to the paroxysms of pain, its increase after them, and its often rapid fading after the gall-stone is voided. The symptoms of the early stages of acute atrophy of the liver, as well as those of some cases of acute inflammation, may be so like the symptoms of inflammation of the gall-bladder and gall-ducts that their discrimination is for a time impossible; but the phe- nomena which soon follow clear up the obscurity. In some cases of inflammation of the biliary ducts, especially where an occlusion of the ducts takes place, a peculiar parox- ysmal fever is developed, with temperature ranging from 103° to 105°, which might readily be mistaken for a malarial outbreak. This hepaiic fever is generally ushered in by a violent chill, and the paroxysms, which are repeated at irregular times, are apt to be followed by increased jaundice. Their irregularity, — to which, however, there are exceptions in the earlier part of the case, — , their resistance to quinine, the frequent occurrence of vomiting and of pain in the region of the liver, and the history of the case, distinguish them from malarial fever. From abscess of the liver the affection is more difficult to discriminate, and we must lay * Heitter, Wien. Med. Wochenschr., 1887. 676 MEDICAL DIAGNOSIS. stress on the deep jaundice, which mostly happens after the fever outbreaks, and on the different physical phenomena. Sweats occur in both, but they occur only at the end of the marked paroxysm in the so-called hepatic fever. The febrile attacks are explained'by Pepper * as mostly due to a purulent lesion at some point of the biliary canals, or to the development of ptomaines, owing to the ptomaine-desiroying function of the liver being inter- fered with when the bile is pent up. We also find similar attacks of rigors and intermittent pyrexia associated with hepatic pain in obstruction of the common bile-duct from gall-stones. Charcot looks upon them as septic, as does Osier ; f Ord J holds the fever- outbreak to be due to local irritation of the mucous membrane, and this is the view I hold. Hepatic fever bears a close relation to malaria. Those who have malarial poison in their systems are more liable to it, and it is likely to be in them connected with a biliary catarrh, and with inspissated bile rather than with an impacted gall-stone. Now, considering the question of operative interference that may arise, it is of the utmost importance to distinguish the cases in which the obstruction is purely catarrhal and not connected with gall-stones from those in which it is. The most certain test undoubtedly would be having found gall-stones on previous occa- sions, or finding them after the fever paroxysms. The cases with gall-stones are very much more frequent than the cases of hepatic fever without them ; the jaundice is more distinctly con- nected with the attacks, and generally passes off more completely between them ; the pain is greater and ceases more abruptly ; and the febrile paroxysms are not brought ou by cold, exposure, and fatigue, as they are often in hepatic fever without gall-stones. Acute Diseases characterized by a Decrease in the Size of the Liver and by Deep Jaundice. Acute Yellow Atrophy. — ^This dangerous affection consists in a rapid diminution of the liver, with disintegration in the secreting-cells. Its functions are almost wholly suspended, and * Medical News, March 29, 1890. t Johns Hopkins Hospital Reports, vol. ii. No. 1, 1890. i Boston Med. Journ., 1887. DISEASES OP THE LIVEE. 677 the evil effects of the accumulation of the elements of the bile in the blood show themselves in the deep jaundice and in the pro- found disturbance of the nervous system. To this disease belong most of those cases of malignant jaundice which terminate rapidly in death after violent cerebral symptoms. The malady scarcely ever lasts a week ; generally a few days only elapse before the patient becomes comatose and dies. The complaint is sometimes ushered in by nausea, a coated tongue, irregular action of the bowels, and a frequent pulse ; at other times it begins abruptly with pain in the head, and with vomiting, at first of the contents of the stomach, but soon of coffee-ground material, which is evidently altered blood. The skin is yellow, and becomes from hour to hour more discolored. Jaundice is, indeed, never absent : it may not make its appearance before the other urgent symptoms, but sometimes it precedes the signs of serious difficulty for several days, or even for longer, — perhaps for upwards of two weeks.* That the jaundice is not due to obstruction is proved by the stools containing bile. There are not uncommonly pain at the epigastrium and in the hepatic region, muscular and arthritic pains, dyspnoea, meteorism, enlargement of the spleen, epistaxis, and hemorrhage from the bowels. The pulse exhibits extraordinary changes : it is generally very rapid, but sinjis at times, without any assignable reason, to a normal frequency ; during the deep coma of the last stages of the malady the beat of the artery is apt to become slow and full, but it may be very quick and very small. There is fever, not, however, ac- tive ; the temperature may be, indeed, after the early stages of the disease, below the norm until towards the end, when it has been known to be 104° or 105°. The surface may be covered with petechias. But, if we except perhaps the deep jaundice and the lessening hepatic dulness, the most significant symptoms are those referable to the nervous system. Severe headache, de- lirium, involuntary discharges, tremors, spasms, convulsions, or a constantly-increasing stupor and sluggish pupils, show clearly what disturbance the poisoned blood is creating in the nervous centres. Acute atrophy of the liver scarcely happens in children or after * As in Observation No. XVII. of Frerichs on Diseases of the Liver. 678 MEDICAL DIAGNOSIS. forty years of age ; it is much more common in women than in men. We find it not unusually following violent mental emotions or drunkenness and venereal excesses; or it occurs during preg- nancy, and is then accompanied by renal disorder. Now, how does this fatal malady differ from acute inflammation of the liver ? By the marked jaundice, the cerebral symptoms, the rapid diminution in the volume of the liver, the dry, brown tongue, the frequent, changeable pulse, and the occurrence of hem- orrhages. Then the circumstances under which acute atrophy makes its appearance are very dissimilar. Indeed, the diagnosis is not generally a difficult one, — not nearly so difficult as between acute atrophy and typhoid fever, or between the former affection and yellow fever or certain local diseases, such as peritonitis, pneu- monia, and meningitis, when accompanied by jaundice and de- lirium. The character of the eruption, the presence of diarrhoea instead of constipation, the milder nature of the mental wandering, the significant temperature record, and the slower progress of the disease are of much value in enabling us to distinguish between typhoid fever and the typhoid symptoms of acute yellow atrophy of the liver. From yellow fever, acute atrophy differs by the epi- demic character of the former, by the injected eye, by the intense pain in the back, limbs, and forehead, by the stages the febrile malady presents, by the decided fever, temperature, by the com- parative absence of cerebral symptoms, and by the enlargement rather than the lessened size of the liver. From the other affections named, the hepatic disorder may be discriminated by a thorough examination of the various organs of the body, and by a careful weighing of all the symptoms. In truth, it is thus only that we can avoid error ; since, unless we can establish the most positive sign of acute atrophy, the diminution of the area of percussion dulness of the liver, — and there are cases in which we cannot establish this, particularly if there have been enlargement from previous disease,* — there is no manifesta- tion of the hepatic malady that may not occur in the diseases mentioned, when they are complicated by jaundice. It is true that vomiting of blood is scarcely among their symptoms ; but this does not invariably happen in acute atrophy. ' In many cases * As in a case in my ward at the Pennsylvania Hospital. DISEASES OF THE LIVER. 679 of doubt we may seek in the urinary secretion for the sediments of tyrosine or for leucine ; and the test for urea, which is greatly deficient or absent. So may be the uric aeid, the chlorides, the sulphates, and the earthy phosphates. We may in this con- nection remark that leucine and tyrosine have been also found in the blood and in many tissues. This was observed in a case which I saw with Dr. H. C. Wood, and which he has carefully reported.* Acute yellow atrophy may happen occasionally in children, f An affection like it occurs from phosphorus-poisoning ; and in- deed there are those who believe that acute yellow atrophy is really due to phosphorus accidentally introduced into the system.J The occurrence of the fatal malady in pregnant women has already been referred to. Jaundice from mental emotion, or produced by the pressure of the gravid womb, is in them not unusual ; and we may be called upon to distinguish this harmless form of icterus from that of yellow atrophy. In the serious derangement of the nervous system, and the graver character of all the symptoms, lie the marks of separation. Chronic Diseases attended with Enlargement of the Liver, and with slight or no Jaundice. Chronic Congestion. — This morbid condition is observed chiefly in persons of sedentary habits, or in those who indulge too freely in the pleasures of the table, or use large quantities of alcoholic drinks or fermented liquors. It is frequently met with in hot climates and in malarial districts. It may also occur in scurvy, and in connection with abdominal affections which inter- fere with the portal circulation, or it may happen in consequence of a disturbance of the flow of blood through the liver, dependent upon disease of the heart. Whatever the source of the hypereemia, the symptoms are sim- ilar. They are impaired appetite, bitter taste in the mouth, a coated tongue, flatulency, a feeling of tension and weight in the * Amer. Journ. Med. Sci., April, 1867. f Duckworth, St. Barthol. Hosp. Rep., vol. vi. ; Tuckwell, i6., vol. x., 1874. t Perls, Handb. d. Allg. Pathol., i., points out an anatomical distinction: in acute atrophy there is fatty degeneration ; in j)ho3phorus-poisoning the liver-cells are only infiltrated with fat. 680 MEDICAL DIAGNOSIS. right hypochondrium, depression of spirits, loss of strength, im- poverishment of blood, deposits of lithates from the highly-col- ored urine, headache, dry cough, and occasional nausea and diar- rhoea, or looseness of the bowels alternating with constipation, and, in protracted cases, hemorrhoids. The conjunctiva has con- stantly a more or less jaundiced tinge ; the dulness on percussion in the hepatic region is increased in extent. In some cases the habitual congestion leads to an altered condition of the bile-ducts and of the secreting-cells of the liver ; but ordinarily, unless the hypersemia be kept up by some exciting cause which it is impos- sible to remedy, — such as an abdominal tumor, or an organic aifection of the heart, — it can be removed A troublesome feature of the malady is its disposition to return. By attention to the signs mentioned, there is usually little dif- ficulty in recognizing chronic hepatic congestion. How it may be discriminated from other forms of enlargement of the liver, we shall presently inquire. It is sometimes confounded with, or rather there is sometimes mistaken for it, a liver which has been pushed downward by the habit of tight lacing. But the absence of any signs of hepatic derangement, and the lowered outline of the upper border of the displaced right lobe, will generally enable us to distinguish this state from chronic congestion of the liver. Chronic hepatic congestion, as indeed any disease of the liver which leads to its enlargement, may be confounded with chronic gastritis. But the outline of the dulness when the liver is in- creased in size, the jaundiced hue of the conjunctiva, the altered character of the stools, and the less marked gastric symptoms will enable us to arrive at a correct diagnosis. Yet we must not forget that the two morbid states may be conjoined. Hypei'trophy of the liver may present the manifestations of congestion. The little we know of an increased formation of the liver-cells teaches us that this may happen as a partial hyper- trophy, to compensate for loss of substance, in instances in which a portion of the gland has been destroyed ; or as a more general increased growth in diabetes, in leukaemia, and as a consequence of malaria. Perhaps the history of the case may enable us to arrive at the discrimination of the rare disekse. Yet there is never any certainty in the diagnosis. So-called torpor of the liver, in which there is supposed to be a DISEASES OF THE LIVER. 681 deficient excretion of bile, has much the same symptoms as con- gestion. Indeed, it is a question whether this is not often present as at least a secondary result. In persons of middle life who eat freely and take too little exercise in the open air, or those of sed- entary habits in whom anxiety and worry have lowered the nervous tone, the well-known symptoms of headache, languor, depression of spirits, loss of appetite, drowsiness after meals, sallow hue of skin, dingy conjunctiva, urine depositing lithates, stools black and offensive, or more often pale or whitish, bespeak this "bilious" state, and we can only distinguish the functional disorder from the ordinary forms of chronic congestion by the history, the con- current symptoms, the tension in the region of the liver, and the enlargement of the organ, which these present. The symptoms of chronic congestion of the liver, as indeed of other hepatic derangements, show themselves at times more par- ticularly in the nervous system. Headache, vertigo, dimness of sight, and noises in the ears are common ; and I have often known the same to happen that Murchison states to be not infrequent, — I have known tingling and pricking sensations and a feeling of creeping in the extremities cause needless alarm that paralysis was imminent, and disappear under blue pill and a few saline pur- gatives. On the other hand, we must be careful not to regard as evidence of an hepatic disorder signs of stomach and liver de- rangement which are really due to an affection of the nervous system. Twice it has come under my observation that altered character of the stools, bitter taste in the mouth, vomiting, and slight discoloration of the conjunctiva, existing in connection with tumors at the base of the brain, were considered as purely of hepatic origin. Clifford Allbutt* cites a case of M^nifere's dis- ease, in the person of a physician, where the vomiting and giddi- ness received this false explanation. In such instances, of course, attention to the occurrence of disordered gait, and of the persistent noises in one or both ears, and to the loss of power of hearing of one ear, shown when a tuning-fork is placed in contact with the skull on the affected side, tells the true meaning of the other symptoms. Chronic Hepatitis. — It is difficult to say what are the symp- toms of the malady, because most of the chronic affections of the * St. George's Hosp. Ecp., vol. riii. 682 MEDICAL DIAGSrOSIS. organ, especially the congested, the fatty, the albuminoid liver, and hypertrophic cirrhosis, are included in its description. The liver is enlarged in size. The inflammation may be chronic almost from its onset, and be developed under much the same circumstances as chronic congestion ; or it may succeed an at- tack of acute hepatitis. But chronic hepatitis is not a common disease, except in hot climates, and is scarcely to be distinguished from persistent hypersemia of the organ, unless when the inflam- mation leads to the formation of abscesses. Abscess of the Liver. — Hepatic abscesses may form as the result of inflammation of the liver. In the tropics this is not unusual ; in temperate climates we seldom encounter the affection, save as the consequence of embolic or pysemic inflammation of the liver, or in connection with some disease of the intestines, or of abscesses around the rectum, or as a sequel of gastric ulcer, or of gall-stones which have produced ulceration of the gall-bladder and gall-ducts and secondary abscesses of the liver, or of trauma- tism, or of suppurative disease of bones. The symptoms of hepatic abscess are obscure. Sometimes the only symptoms are debility, great irritability of the nervous system, and irregular slight febrile attacks. More usually the formation of pus gives rise to rigors, leads to night-sweats, and not unfrequently to the development of a fever simulating that of a quotidian or tertian intermittent or remittent, and attended during certain hours of the day with considerable elevation of temperature. Jaundice occurs, but is generally slight, and is often absent. There is no enlargement of the abdominal veins, nor is there, save exceptionally, ascites or oedema of the lower ex- tremities. Dry cough, quickened breathing, and gastric disorder, especially loss of appetite, are frequent, and obstinate vomiting, singultus, and meteorism are not unusual. In the advanced stages of the malady typhoid symptoms are apt to develop. But the disease may be latent. The local signs, too, are far from being always obvious, or indeed uniform. In some instances the hepatic region is more prominent than natural, and we can detect fluctuation over portions of the enlarged gland ; but neither sign is constant, and the latter depends greatly upon whether or not the abscess is deeply seated. Tenderness, either general or limited, is found only in a certain proportion of cases, especially when DISEASES OF THE LIVER. 683 the abscess is near the surface. It is frequently associated with a throbbing or a dull pain, which may be transmitted to the right shoulder. According to Annesley,* this sympathetic pain in the right shoulder indicates that the convex part of the right lobe of the viscus is affected. Conjoined to the feeling of weight, and to the throbbing in the hepatic region, is at times a tension occasioned by palpation of the abdominal muscles, especially of the rectus. Twining f regards this as veiy significant of deep-seated abscess. Cyr J tells us, with reference to the exact position of the abscess, that when it is in the front convex part of the liver there is pain radiating to the chest and shoulder, dyspnoea, but rarely jaun- dice ; when in the central part of the organ, there are few signs of local affection of the liver itself or adjacent organs, except de- cided jaundice if the abscess be large. In abscess limited to the under surface, thoracic symptoms are absent, but gastric symp- toms, especially uncontrollable vomiting, occur; the pain is apt to radiate towards the groin. A positive diagnosis of abscess of the liver is often a very diffi- cult matter ; for there are a number of affections with which it may be readily confounded. Prominent among these are hydatids, cancer of the liver, actinomycosis of the liver, affections of the gall-bladder, and a pleuritic effusion on the right side. From hydatids of the liver, the febrile symptoms, the disturbed nutrition, and the pain distinguish an hepatic abscess, except in those cases in which the cyst becomes the seat of suppuration. Under tliese circumstances error can scarcely be avoided, unless we are fully cognizant of the previous history. Cancer of the liver differs from an abscess by its dissimilar history, by the hard nodular masses, and by the absence of fluc- tuation. It is only in rapidly-growing medullary cancer that we can discern a sense of fluctuation; but even here we can generally distinguish some nodules which do not fluctuate ; and should the soft cancerous matter impart a feeling of fluctuation, it is rarely as distinct as that of an abscess. Further, the marked fever and the other constitutional symptoms are not like what occur in hepatic cancer ; for in this affection, as in all cancers, the tem- * Researches into the Diseases of India. f Diseases of Bengal. t Traite des Maladies du Poie, 1887. 43 684 MEDICAL DIAGNOSIS. perature, except in instances of large rapidly-spreading growths, is but little affected, — may, indeed, be subnormal. Actinomycosis of the liver may give rise to a collection of pus, and the abscess may discharge through the loins or through the lungs, as in hepatic abscess. The hepatic swelling is painful on pressure, but is unlike that of hepatic abscess in arising suddenly from the parts beneath, and in being surrounded by a firm base in the liver. These characters distinguish it from an ordinary abscess as well as from hydatid of the liver.* Yet it is by the history, and by finding the ray fungus in pus from other diseased parts of the body, that the diagnosis is mostly established, for actinomycosis of the liver is almost never primary. Of the affections of the gall-bladder, the one most liable to be confounded with hepatic abscess is distention. This occurs either from a closure of the cystic or of the common duct, especially the former, or from an inflammation of the gall-bladder itself, and perhaps a subsequent closure of the ducts. In such a case tiae gall-bladder may become enormously distended with decomposing bile and puriform matter, and thus may be occasioned a fluctu- ating tumor, tender on pressure, and readily mistaken for an abscess. Now, we are sometimes able to distinguish the soft swelling caused by a diseased gall-bladder by its situation, its pear-shaped form, its mobility and the absence of adhesions to the abdominal walls, its distinct and persistent fluctuations; by its never having been hard ; by the normal appearance of the parietes of the abdomen ; by the absence of tenderness over the liver, merely tenderness over the tumor being found ; and by the fact that affections of the gall-bladder are frequently preceded by repeated attacks of violent pain due to the passage of biliary calculi, or by bilious fever. Then we find little jaundice, or none at all ; and no hectic fever. But to., neither of these cir- cumstances can we trust implicitly. For there is apt to be in- tense jaundice in an affection of the gall-bladder, if the common duct also be implicated ; and jaundice is, in abscess of the liver, a symptom more frequently absent than present. And with refer- ence to hectic fever, the continued suppuration in the distending sac may produce it, and lead, indeed, to great constitutional dis- * Harley, Med.-Chir Transact., vol. lxi\-., 1886. DISEASES OF THE LIVEE. 685 turbance.* Further, these biliary abscesses may, like hepatic abscesses, open externally, or burst into the chest. At times the communication is with the bronchial tubes, and gives rise to very anomalous symptoms. Thus, Simmons t <^6tails a case in which there was a circumscribed tumor in the epigastrium, fluctuating with a sense of intervening air or gas, and resonant on percus- sion ; a blowing sound was distinctly discerned synchronous with the respiratory act, and occasionally accompanied by a gurgling noise ; there were profuse sweats and extreme oppression, but no signs of pneumothorax. At the autopsy a biliary abscess was found communicating with the right bronchus. As regards the shape of the swelling due to an enlarged gall- bladder being diagnostic, we must bear in mind that it may be changed by contraction of the muscular coat. A pleuritic effusion on the right side is distinguished from an hepatic abscess by the same phenomena that we found, in discussing pleurisy, to separate this affection from all forms of enlargement of the liver. But abscesses of the liver may open into the right pleural cavity. Then we observe the physical signs of a pleuritic effusion subsequent to those of hepatic abscess. Generally, too, the pus which has made its way through the diaphragm destroys the lung-texture, until it reaches the bronchial tubes, when large quantities of purulent sputa are expectorated; in rarer instances it is discharged through the walls of the chest. In the former case, the accumulation of pus in the pleura may be very limited ; the inflammation of the pleural membrane may be circumscribed, while the signs of an inflammation at the lower portion of the right lung, dulness on percussion, tubular breathing, and rusty- colored sputa, are evident. These phenomena may subside, and the respiration in parts become inaudible, when a discharge of a large quantity of a reddish or whitish pus takes place, in which the elements of bile and the microscopical appearances of -■the hepatic tissue may be detected. Gradually this expectoration ceases, and the affected textures heal. But in some instances the discharge never stops, and the patient dies worn out by the con- stant drain. * As in a case reported by Pepper the elder, Amer. Journ. Med Sci., Jan. 1857. f Amer. Journ. Med. Sci., Oct. 1877. 686 MEDICAL DIAGNOSIS. In subphrenic pyopneumothorax, cavities full of air form be- neath the diaphragm and extend into the thorax. "When situated on the right side they may be mistaken for the breaking of an hepatic abscess into the chest. The history of the affection is generally significant ; the subphrenic abscesses are the result of perforating' ulcers of the stomach or of the duodenum, and their development is preceded by the symptoms of general peritonitis or by the discharge of pus by the bowels. The signs of pneumo- thorax, as Leyden* has found, subsequently show themselves, with distinct metallic tinkling and succussion sound; yet, while all breath-sound is sharply cut off below the fourth or fifth rib, up to this point the normal vesicular murmur is heard on deep respi- ration, and there are no signs of pressure in the pleural cavity or of distention of the chest, and the marked alteration, by change of position, of the dulness on percussion, from the exudation at the lower part of the chest, is strictly limited to this part. The liver reaches to the umbilicus or lower, and when a canula is passed into the cavity beneath the diaphragm and a manometer is attached, inspiration shows increased pressure, expiration the reverse, — exactly opposite, therefore, to what happens if the canula be in the pleura. When an hepatic abscess forces its way externally, it may, prior to its discharge through the thoracic or abdominal walls, occasion diificulty in diagnosis from abscesses originating in these walls. Nothing but a careful consideration of the attending symptoms and of the history of the case will lead to a differential dis- tinction. Nor does the difficulty wholly cease when the slowly- developed tumor, which an hepatic abscess forms, has opened, since it is far from always that we find in the pus the evidences of the broken-down liver-tissue, and it is only occasionally that the fluid is of yellow or greenish color and yields the reactions of bile. The means of discrimination most to be relied upon is a probe ; for by the depth to which it can be passed, the direction it takes, and the feel of the structures it encounters, we are placed in possession of many important facts bearing on the diagnosis. In doubtful cases, also, we may employ the aspirator, and a chemical and microscopical examination of the pus, other than that oozing * Zeitsehrift fur Klin. Med., Bd. i. CiSEASES OF THE LIVEK. 687 out of the opening, may tell the nature of the abscess. Indeed, the aspirator may be made a means of diagnosis of abscess of the liver under some of the circumstances above mentioned, where abscess is closely simulated by other hepatic affections. If no abscess be found, no particular harm results from the explora- tion ; nay, it has even been affirmed that the local depletion does good.* Occasionally a hernia through one of the recti muscles is mis- taken for a projecting abscess of the liver. I was called some years since to see such a case, in which the opinion that it was an abscess of the liver had been long entertained. The sound of the mass on percussion ; the clearly-defined limits of the liver ; the absence of hepatic and gastric symptoms, — taught the true nature of the malady. Much has been said of the distinction between the abscesses which are developed in the course of embolism or of pyaemia — "the pysemic abscess" — and the abscess, common in tropical climates, which forms as the result of hepatitis, " the tropical abscess." This kind of abscess is often met with following dys- entery. One of its forms occurs in connection with the amoeba cr)li, though we may have abscess of the liver due to the amceba without dysenteric symptoms. The points of distinction between pysemic and tropical abscess may be thus tabulated : Pyemic Abscess. Tropical Abscess. Many in number ; small in size. Usually a single large abscess, seated in right lobe, towards the convexity of the liver. Uniform enlargement of liver ; only Enlargement not uniform ; bulging exceptionally bulging of ribs. of ribs, or in epigastrium, or in right hypochondriuni. No fluctuation ; always pain and ten- Fluctuation usual ; pain and tender- derness. ness always absent. Jaundice present In the majority of Jaundice exceptional. cases. Enlargement of spleen usual. Enlargement of spleen unusual. Rigors and night-sweats marked ; Rigors and night-sweats less marked ; great tendency to symptoms of obstinate vomiting often present. biood-poisoning. * Maclean, Lancet, July, 1873. 688 MEDICAL DIAGNOSIS. Pyemic Abscess. Tropical Abscess. Course rapid ; three weeks to three Course less rapid ; often extends to months. three or six months, or longer. Arises after external injuries and oper- Arises in tropical climates, chiefly in ations, or internal suppurating cavi- free livers ; dysentery frequently ties or ulcerations, such as ulcers of coexists. the stomach or gall-hladder. Fatty Liver. — A fatty liver occurs in drunkards ; in persons ■who lead indolent lives and are large eaters ; in wasting diseases, especially in phthisis ; in the course of protracted diarrhoea ; and sometimes in children after exanthematous fevers. But of all these causes, pulmonary consumption is the most common. A knowledge of the sources of fatty liver is the most important element in the diagnosis ; for neither the physical signs nor the symptoms present anything which is characteristic. The physical signs are simply those of an enlarged liver ; the enlargement is generally moderate and uniform, and the lower margin rounded. In thin persons it may be possible to discern the doughy consist- ence of the organ. The symptoms are much the same as those of hepatic congestion, except that there is perhaps greater ten- dency to diarrhoea, and that we find in some instances a pale, greasy-feeling skin. There is neither pain nor ascites. The amount of jaundice is always very slight ; in truth, jaundice is most frequently wanting. Waxy Liver. — A peculiar infiltration into the structure of the liver, or its degeneration into a substance rendering it firmer and more glistening, gives rise to that appearance of the liver which is variously designated as waxy, lardaceous, or amyloid liver. The symptoms of a waxy liver are those of an hepatic derange- ment which manifests itself rather by the signs of disturbance of other organs than by the direct proof of altered function of the viscus really aifected. Thus, disordered digestion, nausea, vomit- ing, tympanites, discolored stools, and diarrhoea are much more frequent than jaundice, which, indeed, is very much oftener absent than present. There is a feeling of fulness in the hepatic region, but little or no pain ; while physical exploration exhibits an in- creased percussion dulness, and shows the dense organ to have a well-defined though somewhat rounded margin. The enlargement is uniform, but considerable ; at times so great that the liver oc- DISEASES OF THE LIVER. 689 cupies a large part of the abdomen, producing a visible bulging. The smoothness and the regularity of outline are lost if waxy liver coexist with diseases of the liver which may harden the organ in nodules^ such as cancer, fibroid changes, or cirrhosis. Enlargement of the spleen is commonly associated with the enlargement of the liver, and in many cases the urine is albumi- nous from waxy disease of the kidneys. Dropsy, as a rule, is not encountered ; but in this respect much depends upon the state of the kidneys and of the blood, or upon the existence of secondary peritonitis. Waxy liver is much more common in males than in females. It is usually caused by constitutional syphilis or coexists with scrofulous diseases of the bones, with unhealed ulcers, especially rectal ulcers, with discharges from or collections of pus in various parts of the body, with repeated attacks of intermittent fever. In some instances it is associated with cancer or with phthisis, or it results seemingly from the abuse of mercury. We cannot trace always the pathological process to any known cause; but we always find it attended with signs of impaired nutrition and occurring in persons evidently cachectic. The disease is one lasting for years. In advanced cases, besides the spleen and the kidneys, the stomach and the intes- tines are apt to be implicated; looseness of the bowels, with dysenteric symptoms, arises, and the skin and breath have a musty, disagreeable odor. Now, when we contrast a waxy liver with other hepatic com- plaints in which the liver is enlarged, we find it resembling most closely the fatty and the syphilitic affections. But in the former, although there is enlargement, there is not often so much increase in volume as in the waxy liver. Besides, the organ feels softer on palpation, and the disorder is not associated with a diseased spleen or kidney, and is much less likely than a waxy liver to give rise to dropsy. Then the history of the case is very sig- nificant. A syphilitic hepatitis, with which indeed the waxy liver is at times combined, is mainly distinguished by the promi- nent nodules felt on the surface of the liver. From congestion of the liver, M'axy liver is readily discriminated. A compara- tively slight affection in which jaundice is frequent is very different from a malady in which the hepatic disease forms but part of a 690 MEDICAL DIAGNOSIS. general cachexia and in which jaundice is very infrequent. In leuhsemiG liver we may have considerable and smooth enlarge- ment and marked cachexia. But the history of the case and an examination of the blood tell its true nature. Cancer of the Liver. — In cancer of the liver the organ is almost invariably large, and sometimes it reaches an enormous volume. The form of the gland, too, is altered. It is irregular and uneven, nodules of various size being developed in its sub- stance and projecting from its border and surfaces. These prom- inences are harder than the surrounding hepatic tissue ; but there are exceptions to this rule, for sometimes, especially in the en- cephaloid variety, the elastic tumors impart, when pressed, a very deceptive sense of fluctuation. The cancerous masses increase, and in some cases with great rapidity. The malignant disease is rarely confined to the liver ; it fre- quently supervenes upon cancer of the mammary gland or of the uterus or of the stomach. It is an affection pre-eminently of middle life or of old age ; yet it occasionally occurs in young persons. I have met with two cases of primary cancer of the liver in women not twenty-five years of age, and two in children. In primary cancer of the liver we generally find a history of cancer in the family ; and protracted grief or anxiety, Murchison tells us,* precedes the development of the malady, whether a family taint can be traced or not. The disease rarely lasts beyond a year, and it may run a j'apid course. Now, many of the pathological facts just mentioned have a strong bearing on the diagnosis of hepatic cancer. They espe- cially throw light on the most important signs of the malady, — to wit, the increased percussion dulness in the hepatic region, and the uneven surface detected on palpation. The enlarged liver is found extending across the epigastrium far into the left hypo- chondrium ; it reaches at times lower than the umbilicus, and presses the diaphragm upward. The nodules can often be felt distinctly through the abdominal walls. The diseased organ is painful, and tender to the touch. In cases in which the peritoneal covering is affected, the tenderness is greatest. And, although any of these three phenomena — the enlargement, the uneven * Lectures on Diseases of the Liver, 2d edit. DISEASES OP THE LIVER. 691 surface, and the tenderness — may be absent, they are tolerably constant attendants on cancer of the liver. The tenderness is, I think, the sign least frequently wanting. Among the symptoms of hepatic cancer, we find gastric and intestinal disturbances; pain in the right shoulder; rigidity of the abdominal muscles ; a disordered nutrition of the whole body ; a cachectic look ; occasional febrile attacks, yet, on the whole, nor- mal or subnormal temperature; and, in the later stages, some- times hemorrhages from the stomach or bowels, and diarrhoea. Ascites, too, is observed among the symptoms of the malignant malady, and is generally dependent either upon chronic peritonitis attending the development of the cancer, or upon the pressure this exerts upon the larger branches of the portal vein. Jaundice may or may not be present ; it is most frequently wanting. I have seen it, however, intense when the cancerous growth presses on the bile-ducts : in any instance in which it occurs it persists until death. There are cases in which all these symptoms are perceived ; while in others only some occur, and in others, again, even these few may not be well defined. Indeed, when we consider the amount of deposit which is generally present ; when we regard its character ; when we take into account the necessarily impaired function of one of the most important glands in the body ; when we reflect upon the pressure which the enlarged organ must occa- sion, — it is truly astonishing that often so little dropsy, so little jaundice, so little • pain, so little constitutional disturbance, are produced by the disease. Yet in point of diagnosis we can generally discern the malady by the combination of the symptoms and signs indicated. It is only at an early stage of the disease, or when the liver is not enlarged, that we are apt to be in doubt. Under the former cir- cumstance, a swelling in the hepatic region, pain upon pressure, associated with retching, with nausea and vomiting, and with fail- ing health and strength, occurring in a person above forty years of age, ujay well excite our suspicion. But, unless there be a his- tory of cancer in the family or a cancer in some other part of the body, we cannot be certain that the beginning swelling in the right hypochondrium is malignant. When the liver is the seat of cancer, but is not increased in size, the recognition of the malady is next to impossible. In these obscure cases, the persistent tenderness in 692 MEDICAL DIAGNOSIS. the hepatic region, accompanying the evidences of disturbed func- tion of the liver, ascites, anaemia, and a cachectic appearance, are the signs most trustworthy and most likely to lead to a correct con- clusion. In any instance, jaundice coming on in a person over forty years of* age, lasting for months, and associated with gastric disease and failing health, must, in the absence of a history of gout or of syphilis, be looked upon as pointing to hepatic cancer. Again, we must remember that loss of flesh and of strength not unfrequently precedes jaundice and pain, — in fact, all signs of dis- order of the affected organ. Let us pass in review the complaints with which well-marked cancer of the liver may be confounded. Omitting, because else- where discussed, hydatids, abscess of the liver, and cirrhosis, they are : Waxy Liver; Fatty Liver; Chronic Congestion. Acute Congestion ; Acute Hepatitis ; Catarrhal Jaundice. Syphilitic Liver; Affections of the Gall-Bladder ; Cancer of the Stomach; Cancer of the Omentum ; Enlargement of the Eight Kidney. Waxy Liver; Fatty Liver; Chronic Congestion. — A waxy liver presents often as much increase in size as cancer; moreover, like cancer, it is associated with evident signs of cachexia. The main points of distinction are the smooth feel and uniform increase of the liver in waxy disease, its painlessness and slow progress, its combination with enlargement of the spleen and albuminous urine, and the history of the case pointing to constitutional syphilis, or to diseases of the bones, or to long-continued suppuration, — in fact, to the causes which generally lie at the root of a waxy or lardaceous state of organs. In the differentiation of cases of infiltrated cancer without distinct nodules,, the physical ex- ploration does not aid us, and we have to lay stress on the other points. A fatty liver is easier to discriminate from hepatic cancer. The occurrence of the non-malignant malady in consumptives or in drunkards, and the total absence of pain, — in truth, of any decided indications of hepatic disease, except increased size of the organ, — DISEASES OF THE LIVEE. 693 enable us to distinguish between the two affections with certainty. The slighter signs of disturbance, both constitutional and local, the dissimilar history, and the uniform enlargement of the liver sepa- rate chronic congestion from cancer. As a mark of distinction, too, of the cancerous from all of these non-malignant disorders, Virchow lays stress on the existence of swollen jugular glands ; and a small cancerous induration in the abdominal walls, around the umbilicus, also not unfrequently aids the diagnosis. Acute Congestion ; Acute Hepatitis ; Catarrhal Jaundice. — It is rarely indeed that these ailments are confounded with cancer of the liver, because the history and the course the latter malady takes are so dissimilar to those of an acute hepatic disorder. Yet there are cases in which the malignant disease is either developed with great rapidity, thus simulating an ordinary acute affection, or has lain dormant and passed unnoticed until it begins suddenly to increase. Under such circumstances, even, we may be able to recognize the malignant complaint, if its physical phenomena be well defined ; but if these be not clearly marked, the diagnosis becomes one of great difficulty. To cite a case in illustration : A married woman, twenty-five years of age, was admitted into the Philadelphia Hospital on January 14, 1862, with jaundice and slight fever. She stated that she had been in excellent health until about two weeks before, when she caught cold by sleeping in a damp apartment. Her appetite and digestion had been good previous to her present illness, and she had been fully able to perform her household work. Since she was taken ill she had noticed a feeling of weight in the region of the stomach and liver. Rales indicative of bronchitis were found in the chest, and the impulse of the heart was feeble. The hepatic percussion dulness was increased in extent, especially that of the left lobe ; but the outline of the organ appeared regular and even. Ten- derness of the abdomen, more particularly in the epigastrium and right hypochondrium, was also noted. There was nausea, but no vomiting; the tongue was clean; the evacuations were discolored. Now, here was certainly a patient presenting none of the signs of hepatic cancer, except, perhaps, the tenderness over the en- larged gland. Yet at the autopsy, which was made witliin a week 694 MEDICAL, DIAGNOSIS. after her reception into the hospital, and therefore not three weeks from the apparent beginning of the complaint, whitish nodular cancerous spots, many of them soft, were found in the substance of the liver, but not at its edges, nor forming anywhere distinct protuberances which could have been detected during life. To the similarity of certain cases of protracted catarrhal jaun- dice in elderly persons, presenting emaciation, with nausea, retch- ing, and vomiting, we have above alluded. The physical signs of the enlargement of the liver may or may not assist us, according to their character. Syphilitic Liver. — As a consequence of constitutional syphilis, the liver may at times exhibit cicatrices on its surface, and scattered nodules, consisting of connective tissue, and extending into the parenchyma. This condition is styled syphilitic inflammation of the liver, or the syphilitic liver. The organ becomes uneven from the contraction of the cicatrized parts, and is apt to be somewhat increased in size, from coexisting waxy degeneration or interstitial .hepatitis. The patient has a pale, cachectic look, but is not jaun- diced,* except from a temporary catarrh of the bile-ducts, produced by the syphilitic poison ; nor is dropsy present, unless there be at the same time an aifection of the kidne3^s or enlargement of the spleen. But the most important elements in the diagnosis are the age of the patient, the history of the case, and the detection of syphilitic cicatrices in the throat. When contrasted with cancer, we find, besides these points, the chief distinctive marks to be : the much more usual absence of jaundice and of dropsy, the not imcommon increase in size of the spleen, the want of local hepatic tenderness, — unless this be due to passing attacks of perihepatitis, —and the smaller size and softer feel of the nodules. Syphilis of the liver may be hereditary.f Affections of the Gall-bladder. — Dilatation and cancer of the gall-bladder are both very liable to be mistaken for cancer of the liver. The former affection may result from occlusion of the he- * No jaundice is mentioned in the cases of Dittrieh, Prag. Vierteljahrsohr., Bd. vi. and vii. ; of Gubler, Memoires de la Societe de Biologic, tome iv. ; of Bamberger, Krankheiten der Leber, in Virchow, Pathologic, etc. ; or of Moxon, in Guy's Hospital Reports, 1867. In the cases of Murohison, Diseases of the Liver, 2d edit., 1877, it was a passing or an absent symptom. f Arch. Gen. de Med., June, 1884. DISEASES OF THE LIVER. 695 patic and common bile-ducts, produced by pressure of surround- ing tumors or by an impaction of gall-stones ; or it may be owing to the distention of the bladder with an albuminous fluid, — the so-called dropsy of the gall-bladder. In either instance the blad- der may attain an enormous volume, and give rise to a marked tumor at'the lower margin of the liver. The prominence is apt to be rounded or pear-shaped, and, except in those cases in which the occlusion is in the cystic duct or at the neck of the gall-blad- der, the impediment to the flow of bile is accompanied by intense jaundice and by decided hepatic swelling. Hence, in the deep hue of the skin, the uniform enlargement of the liver, the peculiar contour of the prominence, the absence of ascites, the paroxysms of pain preceding, not following, as in cancer of the liver, the other marked symptoms, and the history of the case, which not unfrequently points to repeated attacks of colic from the passage of gall-stones, we find the clue which permits us to determine that we are not dealing with hepatic cancer. Cancer of the gall-bladder is scarcely ever met with in young persons, and is, as a rule, associated with cancerous formations in the liver or in other organs. It is difficult to make out a certain diagnosis of the affection, for it presents a strong likeness both to cancer of the pyloric extremity of the stomach and to cancer of the liver. From the latter it is undistinguishable, unless the situation and form of the tumor be such that we can clearly recognize it as belonging to the gall-bladder. Sometimes it is preceded by a his- tory of gall-stones.* Jaundice, as in cancer of the liver, may be absent or present: in five cases reported by Bamberger f it was found in all, and was even intense. Frerichs, on the other hand, states that in most instances it is wanting. Musser J finds it re- ported in sixty-nine out of a hundred cases. In sixty-eight out of one hundred cases analyzed by him a tumor was discovered, the position of which is most frequently in the right hypochon- drium and the umbilical region, and which is painful on pressure. There is also generally gradually-increasing pain and a sense of weight in the right hypochondrium. The disease is more com- mon in women than in men. The signs of the cancerous cachexia * Murchison, op. cit. . f Krankheiten des Digestions- Apparates. J Transact. Assoc. Amer. Phys., vol. Iv., 1889. 696 MEDICAL DIAGNOSIS. are always strongly marked; as a rule, more strongly than in hepatic cancer. Gall-stones occasionally accumulate in the gall-bladder in such numbers as to give rise to a hard, even nodulated swelling, which may be mistaken for cancer. But the tumor is generally movable, is not painful on pressure, and does not alter in size, or does so but slowly. Sometimes the patient complains of the feeling of a weight rolling from side to side when he turns in bed, and on palpation a crackling sound is produced, which is readily dis- cerned with the stethoscope. Generally we obtain a history of bilious colic. There may or may not be jaundice ; there is an absence of the cachectic symptoms of cancer. Cancer of the Stomach. — This is discriminated from cancer of the liver by the far more constant vomiting, by the dark appear- ance of the ejected matter, by the more obvious symptoms of indi- gestion, the persistent pain in the stomach, or the pain radiating from there to either hypochondrium. Moreover, the seat of the tumor is different ; it is epigastric, or extending downward, but not often passing into the right hypochondrium, and it shows on percussion a very different contour from an enlarged liver. Yet there are cases in which we are kept in doubt ; especially those in which the left lobe of the liver chiefly is affected with cancer and presses upon the stomach, inducing perhaps — and thus making the likeness still closer — obstinate vomiting. The only traits of distinction are then found in the presence or absence of marked derangement of the functions of the liver, and in the chemical examination of the contents of the stomach. Ca7icer of the Omentum. — The absence of jaundice, and the un- altered appearance of the stools, are here, too, of great value in indicating that a tumor near or joining the left lobe of the liver is not due to cancer of that viscus. Moreover, the boundaries of the morbid mass are different from those of a diseased liver. But we cannot always trust to this. Cancerous tumors of the lesser omentum may so surround the liver, and correspond so closely to the regular form produced by hepatic cancer, that the two mala- dies cannot be distinguished ; at least not by the local signs. Again, a loop of intestine may be thrust across the enlai'ged liver at a point corresponding to the usual limit of the percussion dul- ness of its left lobe, thus dividing the most prominent nodules DISEASES OP THE LIVER. 697 from the greater portion of the viscus, and making it appear as if the tumor were to the left of, and below, the stomach, and belonged, therefore, probably to the omentum.* In such cases we have to depend entirely upon the signs of disturbed liver function. Enlargement of the Right Kidney. — A tumor formed by an en- largement of the kidney does not present the same outline of per- cussion dulness as a cancerous liver. The dulness is, moreover, bounded by the tympanitic sound of the intestine, and is not lowered by a deep inspiration ; and the signs of disturbed function of the kidney, and an examination of the urine, will generally materially assist the diagnosis. Still, cases may occasionally hap- pen in which, owing to a peculiar shape of the diseased kidney and to the obscurity of the symptoms, an error in diagnosis can scarcely be avoided.f The difficulty in discrimination is height- ened by the circumstance that many cases of morbid growth of the kidney, at least of one-sided growth sufficient to give rise to a palpable tumor, a;re cancerous, and are therefore, so far as the manifestations of a cachexia go, similar to cancer of the liver. Finally, in reviewing the diagnosis of cancer of the liver, we must inquire whether other than cancerous growths, such as sarcoma, melano-sarcoma, myxoma, epithelioma, cysto-sarcoma, angioma, lymphadenoma, can be distinguished from true cancer. They may produce identical physical signs and symptoms ; in- deed, a distinction is impossible, unless the history of the case enable us to make it. Much the same may be said of that rare disease, tubercular formations in the liver. Leuksemic livers may attain enormous size, and be mistaken for cancer ; and the cachexia that attends them makes the error more likely. But the swelling of the spleen and of the lymphatic glands and the microscopical examination of the blood furnish the points in diagnosis. Hydatids of the Liver. — The development of one or of several cysts in the liver, containing within them echinococci, is * See caae, Proceedings Pathological Society of Phila., vol. 1. p. 275. t Vidal (Bulletin de la Societe Medicale des Hopitaux, 1874) cites errors in diagnosis between tumors of the kidneys, especially hydronephrosis, and dis- eases of the liver attended with enlargement, like ahscess or cancer, made by such masters in our art as Velpeau, Nelaton, Gosselin. 698 MEDICAL DIAGNOSIS. not, as a rule, a disorder which occasions serious disturbance of the general health. Nor do the hydatids usually give rise to either jaundice, dropsy, or any marked signs of gastric or of in- testinal irritation, or to fever, or to local pain. Their most con- stant manifestations are a decided increase of the size of the liver, and the presence of elastic tumors discernible in the hepatic region. In some instances xanthelasma has been noticed.* This disorder of the skin, however, is not peculiar to hydatids, but has been observed in connection with other forms of hepatic enlargement associated with chronic jaundice. The growth of the hydatid is generally very slow, and usually in one direction only, — upward, downward, laterally. Very com- monly the hydatid tumor grows from the right lobe. In most cases it attains considerable dimensions, and the liver may be found to encroach upon the lung as far as the second intercostal space, or to extend far down into the abdominal cavity. On per- cussion, the line of dulness either of the upper or of the lower boundary of the viscus, or of both, is perceived to be very irreg- ular, and occasionally on striking a series of abrupt blows on the pleximeter, or on the fingers of the left hand used as such, we discern a peculiar vibration, similar to the sensation perceived on striking a mass of jelly, and very significant of the existence of the cyst. Owing to the pressure the increasing tumtor may exert on adjacent structures, we observe in some cases dry cough ; palpitation and displacement of the heart ; vomiting ; possibly jaundice and ascites. Hydatids ordinarily last for years. The echinococci may die, the sac become much reduced in size, or obliterated, and recovery take place ; or the cyst may discharge its contents through the stomach and intestines, through the bronchial tubes, or through the walls of the abdomen, and the patient then gets well. But so favorable a termination cannot be counted upon. A fatal issue may at any time ensue by the hydatid tumor bursting into the pleura, or the pericardium, or the peritoneum, and leading to vio- lent inflammation ; or by suppuration occurring in the sac, when the symptoms become those of pyaemia. Even when the hydatids are discharged through the stomach, intestines, bronchial tubes, * Duckworth, St. Bartholomew's Hospital Reports, vol. x., 1874. DISEASES OF THE LIVER. 699 or abdominal parietes, recovery is apt to be slow ; nor is it, in- deed, unusual to find the patient's strength giving way before the contents of the sac have been entirely voided and it has closed. In some countries hydatids are frequent ; it is not so in this country. In Iceland these growths developed from the eggs of a tape-worm are so common that they cause one-seventh of the human mortality. In point of diagnosis, it is not generally diffi- cult to detect the presence of hydatids. It is true that when these are small or deep-seated it may be imiDossible to discern them. But a large and superficially-seated hydatid tumor can usually be distinguished, and can be separated from the maladies to which it bears a resemblance. It differs from an abscess of the liver by the want of febrile action, pain, and great constitutional disturbance ; indeed, the latent character of the hydatid tumor becomes of much importance. Its slow growth, too, is very significant, much more so than the physical characteristics, which are here not to be trusted to. When, as sometimes happens, a hydatid tumor in- flames and suppurates, we have nothing to guide us in the differ- ential diagnosis but the history of the case previous to the de- velopment of the urgent symptoms. From cancel- of the liver we distinguish hydatids by the long duration of the case, by the ab- sence of evident cachexia, of local tenderness, and of the uneven- ness of the surface which the small, hard, cancerous tumors pro- jecting from it occasion. On the other hand, we have in hydatid tumor the sensation on palpation of elasticity or fluctuation. Under rare circumstances this may happen in medullary cancer, and the rapid growth of the latter and the cachectic symptoms would determine the diagnosis. A distended gall-bladder may, like hydatid tumor, be free from pain on pressiu-e, but, unlike this, it is movable, is preceded by attacks of colic, is generally accompanied by deep jaundice, and its situation corresponds to that of the normal gall-bladder. An aneurism of the aorta differs from hydatids in the severe — for the most part neuralgic — pain the patient suffers, so utterly dissimilar to the absence of pain or to the mere feeling of tension and weight of a hydatid swelling. Then the pulsation and the other physical signs aid us. In aneurism of the hepatic artery, which may also present a smooth, throbbing tumor, we are apt to have deep jaundice from compression of the biliary ducts. 44 700 MEDICAL DIAGNOSIS. Pleuritic effusions have many features in common with those cases of hydatids of the liver in which the growing tumor extends upward into the chest. All the physical signs of a large effusion may be present, even the dilatation of the thorax and a sense of fluctuation in the intercostal spaces. But the absence of constitu- tional symptoms, the irregular outline of the dulness on percus- sion of the hydatid cyst, the great displacement of the heart, and the decided lowering of the upper margin of dulness upon deep inspiration, enable us commonly to detect the real nature of the disease. When the cyst has opened into the lung and the hydatids are being expectorated through the air-passages, the harassing cough, the copious sputum, and the inflammation of the pulmo- nary tissue which is apt to be occasioned, may cause the affection to be mistaken for pulmonary abscess or phthisis. The surest marks of distinction are furnished by the changed form of the lower part of the thorax, and by finding bile and the hooks of the echinococci in the sputum. Renal enlargements, such as cysts, hydronephrosis, cancer, are discriminated from hydatids of the liver by the same physical signs by which we found them to be distinguished from hepatic cancer, — chiefly by the renal tumor having the tympanitic sound of the colon in front of it, by not being affected in position by deep inspiration, and by the direction of its growth. More- over, the history and an examination of the urine will greatly assist. Ovarian cysts, unlike hydatids, grow from below upward, are not influenced by deep inspiration, and produce enlargements greatest below and not above the umbilicus; then they have a different outline on percussion from hydatid liver. But, though we may thus generally distinguish hydatids of the liver from the maladies which have similar symptoms, there are unquestionably cases in which it is extremely difficult to arrive at a satisfactory conclusion. Under these circumstances, an explora- tory examination with an aspirator would be proper. We may at times detect shreds of striated hydatid membrane, and portions of echinococci. Besides, the character of the fluid drawn off will assist us materially in diagnosis. It is as clear and colorless as water, has a specific gravity of 1007 to 1011, and contains not a trace of albumin or of urea, but large quantities of chloride of DISEASES OF THE LIVER. 701 sodium. No other fluid in the human body, whether in health or in disease, presents these peculiarities.* Occasionally portions of the liver are transformed into a mass consisting of connective-tissue stroma and numerous large and small cells filled with a gelatinous substance. The disorder looks like alveolar carcinoma, but it is really muttilocular hydatids, or echinococcus tumors. The centre of the mass suppurates, but even this does not diminish the great resistance of the hepatic tumor ; nor is fluctuation, save in the rarest instances, perceptible. The liver may retain its normal shape, or elevations may be pei*- ceptible, such as we observe in carcinoma and syphiloma of the organ: indeed, the affection is not to be distinguished with any certainty from either, except it be by the history and the attend- ing constitutional symptoms. No jaundice usually accompanies the hard hepatic swelling ; but in cases in which the bile-ducts are obstructed we meet with jaundice without dyspeptic symptoms or previous paroxysms of pain, and usually without enlargement of the gall-bladder. In cases with icterus, unlike what we find in syphilis or in cancer, there is complete discoloration of the f8eces.t Let us now, in concluding the review of the hepatic maladies which are attended with decided increase of the size of the organ, briefly contrast their most important manifestations. We have found that, as regards the enlargement, they differ materially. Simple congestion, chronic inflammation, fatty liver, do not attain nearly the volume of cancer, of hydatids, of abscess, of waxy disease of the liver. The three affections first mentioned differ, moreover, from all the others, except the waxy liver, by present- ing a uniform and not an irregularly-shaped swelling or an un- even outline of the percussion dulness. Concerning the symptoms, we observe that, although these hepatic disorders all agree in not being in any way characterized by jaundice, yet this sign is more commonly present and more distinct in some than in others. In hydatids, and in the syphilitic liver, there is no yellow hue of the skin or of the conjunctiva; so. * Murohison, Lecturps on Diseases of the Liver, 2d edit., p. 61. t See the cases of Friedreich and of Niemeyer, referred to in Niemeyer's Practice of Medicine. 702 MEDICAL DIAGNOSIS. too, as a rule, in waxy liver. In fatty liver and in abscess it is, on the whole, most frequently wanting. The same may perhaps be said of cancer, though sometimes there is decided icterus in this malady. In chronic congestion and in chronic inflammation we ordinarily find jaundice, though it may be but a slight yellow tinge of the skin and the eye. With reference to dropsy, we are not apt to encounter it in any of the hepatic affections under consideration except cancer, and waxy disease, when more than the liver is implicated. It is in these two complaints, also, that the most obvious signs of a cachexia are met with ; while in ab- scess we find fever, and perhaps the greatest constitutional dis- turbance. As regards pain, the fatty liver, hydatids, simple hypertrophy, and the waxy liver are painless ; while, generally speaking, con- gestion, catarrhal inflammation or obstruction of the bile-ducts, chronic hepatitis, intestinal hepatitis, hepatic abscess, and cancer, are more or less painful aflections. Chronic Diseases attended with Decreased Size of the Liver, and with Abdominal Dropsy. Cirrhosis. — A liver reduced in bulk, very dense and hard, exhibiting granulations of various size separated by bands of fibrous tissue, and surrounded by a thickened serous envelope, presents the morbid state known as cirrhosis, or hob-nail liver. The inflammation which leads to these alterations in the fibrous tissue is generally consequent upon the abuse of spirituous liquors. But this cause does not explain all cases : in some, the malady is connected "with disease of the heart ; in others, with constitutional syphilis ; in others, with anthracosis ; in others, again, it cannot be attributed to any known agency. Sometimes it is combined with fatty or waxy degeneration. Again, there may be granular livers in which the fibroid matter preponderates and which never contract, — an interstitial hepatitis, or hypertrophic cirrhosis. The disease is essentially a disease of middle-aged men ; it is far less common in women, and rare in children.* In the first stage of cirrhosis, the organ is somewhat increased * See, however, cases by Howard, Transact. Assoc. Amer. Phys;, 1887. DISEASES OF THE LIVER. 703 in size ; then, as Glisson's capsule thickens more and more, the bulk becomes lessened. It is, however, doubtful whether the stage of enlargement invariably precedes that of shrinking : Hxe ■ process of reduction constitutes not unfrequently the first change. But, without entering into this question, we may state that there are no symptoms by which we can recognize the disease at an early period, for the symptoms at first are the same as those of chronic congestion, — dull pain, perhaps tenderness at the hypo- chondrium and pain referred to the shoulder, disordered diges- tion, and a sallow or a jaundiced hue of the skin. Nor can we say, even after the stage of contraction is fairly developed, that the diagnosis of the afPection is always possible. It may rest on no stronger grounds than finding in a person who is known to be a spirit-drinker, " a tippler," an intractable ascites, without any obvious cause to account for the dropsy. The dropsy, due to the obstruction of the portal circulation, consists throughout strikingly of ascites ; as it increases, oedema of the legs may be developed, and passing albuminuria, from pressure on the renal veins. Besides the dropsy, the other clinical features of the malady are not very marked. The most significant signs consist in the diminution of the percussion dulness in the hepatic region, and the detection, by the touch, of firm, irregular granulations on the margin and under surface of the liver. But both these signs are very difficult to discern, on account of the distention of the abdo- men with fluid, and the displacement of the liver this may occa- sion. In fact, it is often only after the performance of paracen- tesis that the abdominal walls will permit us to judge with any accuracy of the shrinking and altered state of the organ. This is especially true with reference to palpation ; as regards percus- sion, it may be possible, even when the abdomen is still full of dropsical effusion, to detect the lessened extent of the hepatic dul- ness. In rare cases cirrhosis happens without abdominal dropsy.* Irrespective of these phenomena, we find at times other mani- festations of disease which assist us in the diagnosis of cirrhosis. They are enlargement of the spleen; dilatation of the veins of the abdomen ; gastric and intestinal derangements ; hemor- rhoids ; marked loss of flesh and strength ; jaundice ; a decidedly * Arch. Gen. do Med , Nov. 1886. 704 MEDICAL DIAGXOSIS. cachectic appearance, with sunken features; and hemorrhages from the nose and mouth, or from the stomach, or into inter- nal cavities. Hsematemesis in an alcoholic must always arouse suspicion. The increase in size of the spleen is far from con- stant, and rarely reaches a considerable extent. The dilatation of the abdominal veins is not perceived until an advanced stage of the disease, and is sometimes connected with a peculiar vas- cular net- work, stretching from the umbilicus upward and down- ward, and, as Sappey * was the first to describe, with a decided enlargement of the epigastric and mammary veins, the blood flowing through the former in a reversed direction from what it does in health, — namely, not toward the liver, but from it to the veins of the abdominal wall, and thence to the vena cava. Other external veins share in the enlargement ; the veins of the legs may be varicose, and the venous twigs on the cheeks become de- veloped. In some cases an irregular but moderate fever not ex- ceeding 102.5° is also noticed ; generally there is none. Another symptom to which I have had my attention strongly directed is the presence of small amounts of sugar in the urine. Thus, in two cases which I saw with Dr. Simpson, Trommer's test readily detected sugar in the urine. In the one case the secretion was scanty ; in the other it was abundant. One had lasted for several years, and was slowly developing; the other had existed about sixteen months, and was rapidly progressing. Cerebral symptoms due to a toxic cause sometimes appear. They show themselves frequently in a wandering delirium of mild type, attended with confusion of persons and places. The delirium is often like that of uraemia, but there is nothing in the urine to account for it. It may not show itself until toward the end of the disease ; on the other hand, it may be of long duration. In a case I saw with Dr. Lloyd, it lasted four months. Coma and convulsions also occur occasionally. The gastric and intestinal derangements, the result of a con- gested or inflamed mucous membrane, are rarely wanting : they manifest themselves by failing appetite, impaired digestion, both gastric and intestinal, morning sickness, flatulency and constipa- tion, or the frequent voiding of pale-colored stools. The jaundice * Bulletin de I'Academie de Medecine, tome xxiv. DISEASES OF THE LIYEB. 705 does not oft«n attain a high degree ; when it does, it has a bad meaning. It shows itself usually in a yellowish tinge of the skin and conjunctiva ; but in some cases even this hue is absent, and we find the pale skin and pearly eye of ansemia. Yet not one of these symptoms is really characteristic; they become so only when viewed in connection with the dropsy, with the local signs in the hepatic region, with the history of the case, and with the absence of any organic disease of the stomach or the intestine, which might explain them. Then the age of the patient, generally above thirty-five years, and his habits, must be taken into account. The cirrhosis of young children is generally due to inherited syphilis. Gout seems to predispose to the disease. " Murchison tells us that the condition of the liver which develops gout renders it liable to suffer from alcohol. Cirrhosis of the liver often becomes associated with acute tuberculosis. At times cirrhosis runs a rapid course.* There is a form of cirrhosis due to infection. It has been de- scribed as siibaeute infectious hepatitis.f It is attended with irregular fever of remittent or intermittent type, with decided enlargement of the spleen and splenic pain, with urobilin in the urine, with greatly-lessened renal excretion of tirea, but ureic sweating, with slight jaundice and cirrhotic diminution of the size of the liver. The infection occurs, probably, through the intestine, and from the liver spreads along the hepatic veins to the vena cava, and may ultimately infect the arterial system, giving rise to infectious nephritis and purulent meningitis. A very similar disease is met with in children, a cirrhosis with jaundice after infectious maladies, such as scarlet fever or measles. Another form of cirrhosis, if it be a form and not a separate disease, by comparison rare, has been mentioned, — hypertrophic cirrhosis, or " interstitial hepatitis,'' or cirrhotic enlargement. It has the same symptoms as atrophic cirrhosis, and is undistin- guishable, except by the increased percussion dulness it presents, and by the signs of enlarged liver being usually attended with more jaundice and greater tendency to slight febrile attacks, and * Hanot, " Cirrhose atrophique a marche rapide," Arch. Gen. de Med., June, 1882. f Levi, Arch. Gen. de Med., April, 1894. 706 MEDICAL DIAGKOSIS. to peritonitis.* A peculiar mawkish odor of the breath has been spoken of as present.f But, with reference to these symptoms, there are forms of hy- pertrophic cirrhosis with but slight jaundice, without ascites or marked development of the abdominal subcutaneous veins, termi- nating in a slow cachexia. Generally, however, the disease begins with the signs of congestion, acute or chronic, with jaundice, and with some pain in the right hypochondrium, and lasts for years ; at the end there is marked jaundice, and the patient sinks into a typhoid state. Ascites may, as already indicated, be wanting throughout, or, as is more usual, it comes on late in the malady. The disease is, in my experience, not unfrequently complicated with a fatty liver, forming " a fibro-fatty liver." As regards the cirrhotic state in the markedly-enlarged liver, it is asserted that besides the increase of fibrous tissue, both within and without the lobules, the smallest biliary ducts are much developed. f In some instances of hypertrophic cirrhosis there is organic disease of the heart. The infectious nature of hypertrophic cirrhosis has been of late often affirmed. Cirrhosis of the liver due to malarial infection is also associated with enlargement, at times very great. It presents, moreover, a persistent chronic jaundice, which may last for years, and is com- bined with marked enlargement of the spleen and manifestations of the malarial poisoning. Bleeding from the nose, gums, and intestines is frequent; dropsy and distention of the abdominal veins are absent. § Let us now look at the distinction between ordinary cirrhosis and some of the maladies which resemble it ; and first let us com- pare its traits with those of other hepatic affections. From diseases of the liver attended with enlargement, such as waxy liver, fatty liver, and chronic congestion, fully-developed cirrhosis is discrim- inated by the presence of ascites and the other signs of seriously- obstructed portal circulation, by the diminished, or certainly not augmented, size of the organ, and by the different history of the disorder. From hydatids of the liver we diagnosticate cirrhosis * Hayem, Archives de Physiologie, Jan. 1874. f Duckworth, St. Bartholomew's Hospital Reports, 1874. J See an excellent review by Hanot, Arch. G-en. de Med., Oct. 1877. g Lancereaux, quoted in Sajous's Annual, 1888, p. 335. DISEASES OF THE LIVEE. 707 by the irregularity of outline of the enlarged liver in the former complaint, by the sense of fluctuation, and by the comparatively unimpaired general nutrition of the body. Cancer of the liver is unlike cirrhosis in the distinctness and size of the protuber- ances, in the obvious hepatic enlargement, in the less marked or absent ascites, and in the normal size of the spleen. But when a cirrhosed liver is associated with syphilitic nodules, or when its volume is augmented by waxy infiltration, the discrimination from cancer becomes a matter of extreme difficulty ; indeed, it may be impossible to avoid erroneous conclusions. Hypertrophic cirrhosis •may also be very difficult to distinguish from cancer, except by the history of alcoholic dyspepsia and the enlargement of the veins, and, though large and nodulated, the liver is rarely so tender. "We shall now consider and compare the clinical traits of some diseases of the liver producing, like cirrhosis, atrophy of the organ. As the result of repeated attacks of perihepatitis, we find great thickening of the capsule, with fibrous bands passing into the interior of the organ, and some atrophy. This condition, de- scribed as simple induration of the liver, is met with chiefly in con- nection with constitutional syphilis, though it is also seen following a right-sided pleurisy and diseases of parts contiguous to the liver, producing inflammation which spreads to it. The affection is not to be distinguished from true cirrhosis, except by the causing ele- ments, particularly by the syphilitic history, and by the absence of the habit of spirit-drinking ; the greater and more persistent pain and tenderness in the hepatic region are of significance; sometimes there is coexisting heart disease. In red atrophy, too, we have greatly-diminished hepatic dulness with the symptoms of portal obstruction ; it, too, is therefore un- distinguishable from cirrhosis by the symptoms alone, unless the difference may be thought to consist in the doubtful points of far less frequent or decided jaundice and in outbreaks of diarrhoea. But, in reality, the only traits of importance on which, to base a diagnosis are that the dense, reddish, homogeneous liver occurs not preceded by alcoholic dyspepsia or valve disease, but generally in those with a most marked history of malaria or of dysentery or of ulceration of the intestine. 708 MEDICAL, DIAGNOSIS. An inflammation of the portal vein, with coagula forming in it, may occasion the same manifestations of deranged abdominal cir- culation, the same or greater tumefaction of the spleen and decrease of the liver, as cirrhosis. And what complicates the diagnosis very much is, that cirrhosis is the chief disease which leads to thrombosis of the portal vein. Indeed, we cannot, under any circumstances, positively discriminate this aifection from cirrhosis. Still, we are sometimes enabled to distinguish the venous dis- order by laying stress on the sudden development of the symptoms, especially of the engorgement of the portal system, and by noting the rapidity with which the ascites returns after paracentesis, the copious gastric or intestinal hemorrhage, the severe vomiting and diarrhoea, the great enlargement of the abdominal veins, and, when not too soon fatal, the marked emaciation. Other causes, of course, than inflammation of the coats of the vein produce coag- ulation. We may have thrombosis from mere weakness of the circulation, or as the result of disease of the liver structure or of compression by enlarged cancerous or tubercular glands, or in consequence of the perforation of the vein by gall-stones. Com- pression of the portal vein and of the biliary ducts in the fissures of the liver, from inflammation of the surrounding areolar tissues, may be separated from cirrhosis chiefly by the intense icterus and the complete decoloration of the stools. Of non-hepatic affections, cirrhosis is most liable to be con- founded with chronic peritonitis; a mistake rendered the more likely because chronic congestion or even chronic inflammation of the peritoneum may exist as a complication of cirrhosis. But, even when no such complication is present, the diagnosis may be difficult. It rests chiefly upon the greater and more extended tenderness of the abdomen in peritonitis, the febrile signs, the absence of splenic enlargement and of dilated veins, the usually unchanged, or certainly not jaundiced, hue of the skin, the asso- ciation with signs of disease in other viscera, especially of the lungs, — for chronic peritonitis is generally tubercular. Under rare circumstances, cancer of the stomach may simulate cirrhosis. I had some years since a' case under my charge at the Pennsylvania Hospital, in which, with very slight digestive symptoms, and without discernible epigastric tumor, considerable ascites and effusion into the left pleural cavity existed. Owing DISEASES OF THE LIVER. 709 to this effusion, the state of the spleen could not be accurately ascertained. There was some fulness of the abdominal veins, and the hepatic percussion dulness did not extend entirely to th^ margin of the ribs. Bile-pigment was present in the urine, the bowels wei'e loose, and progressive emaciation ensued. The man had been very intemperate, and his case might certainly have been selected as an illustration of cirrhosis; yet at the autopsy the liver, though small, rather hard, and deeply congested, was not cirrhotic, and a cancer involving the whole stomach, except the pylorus, was found.* Chronic Atrophy of the Liver. — Although cirrhosis is the most frequent it is not the sole cause of dwindling of the liver. We have just spoken of its diminution in consequence of obstruc- tion of the trunk of the portal vein, as well as of other causes ; but besides these causes we find some, such as a decrease of the organ from long-continued closure of the common duct, or its atrophy in old age, or in connection with grave disease of the heart or lungs obstructing the circulation and causing long-standing hy- persemia of the liver, or as an accompaniment of chronic disease of the intestine. The first of these morbid states is mainly dis- . criminated by the deep jaundice ; the second, by the absence of any important symptoms referable to the liver and associated with the diminished hepatic dulness; the third, by the history of the case and the physical signs of cardiac or pulmonary difficulty, the more general dropsy, or at least by the oedema of the legs preceding the ascites. The fourth form, partly already mentioned under red atrophy, which it may become, presents the phenomena of cirrhosis, and cannot be distinguished from this unless the sur- face of the liver can be distinctly felt through the abdominal walls and ascertained not to be irregular. We may sometimes suspect the cause of the shrinking of the organ from the persistent and intractable diarrhoea and disturbance of the stomach. But, on the whole, this decrease in size of the liver following gastro- enteric inflammation is not frequent : in truth, there is no cause of simple atrophy of the liver so common as thrombosis of the portal vein. * For a fuller report of this case, see Proceedings of the Pathological Society, Amer. Journ. Med. Sci., vol. lii., 1866. 710 MEDICAL DIAGNOSIS. SECTION IV. ABDOMINAL ENLARGEMENT. In describing the causes of abdominal enlargement, I shall view them as they occasion a general and uniform or a more circum- scribed and partial swelling. General Abdominal Enlargement. Ascites. — The collection of serous fluid in the peritoneal sac gives rise to dropsy of the belly, or ascites. This may form part of a general dropsy, and be dependent upon an organic disease of the kidneys or of the thoracic viscera, or the accumulation of liquid may be confined to, or occupy principally, the abdomen. In either case the local signs are much the same. They are : enlargement of the belly ; a dull sound on percussion, due to the presence of liquid ; and the sense of fluctuation imparted to the hand on one side of the abdomen by a wave of fluid put into motion by a tap on the other side. As regards the former of these signs, it is uniform and pro- gressive, and is generally very evident ; although, of course, when the quantity of liquid is small, enlargement of the abdomen may escape detection. The percussion dulness is most readily perceived at the lower portion of the abdomen, where the fluid gravitates, unless when prevented from so doing by being circumscribed by peritoneal adhesions. The bowels float usually to the upper part of the liquid, and at this spot their tympanitic resonance may be distinctly discerned. When the patient is in the erect position, the intestinal percussion note is commonly discoverable in the epigastric and umbilical regions. If he be placed upon his back, the tympanitic sound is, for the most part, found to extend lower than the umbilical region, while dulness will be elicited in the hypogastric region and the flanks. If the person affected with ascites be placed upon his side, the flank which is uppermost be- comes resonant. This alteration of the level of the fluid with the change of position is thus a significant sign, and always hap- pens except when the effusion is encysted ; it is detected without abdominaij enlargement. 711 difficulty, save where great flatulent distention of the bowels or impaction of faeces accompanies the accumulation of liquid. Ordinarily, the fluctuation wave felt by the hand is easily dis- cerned. It is obscured by thickening of the abdominal walls from oedema, or from the accumulation of fat in the subcutaneous tissues ; it is, moreover, indistinct if adhesions circumscribe the fluid in the peritoneum. The amount of albumin in the fluid rises with the ascites and its duration. For all practical applica- tions the specific gravity determines the proportion of albumin, and the urinometer may be employed for the purpose.* There are no means of distinguishing the character of the fluid except by direct observation. It must be inferred from the at- tending symptoms. Ghyliform ascites has been not unfrequently found associated with tubercle.f The other symptoms often found in ascites, such as a pushing upward of the liver, spleen, and stomach, embarrassed breathing, compression of the lungs, and digestive disturbances, need not be specially described, as they present nothing characteristic. Nor is it necessary to insist upon the self-evident fact that a diagnosis of ascites is only half a diagnosis, and that we should in every instance endeavor to ascertain the cause of the collection of fluid in the peritoneal sac ; and we may at once proceed to consider the morbid states with which dropsy in the peritoneum is liable to be confounded. They are chiefly : Ovarian Dropsy; Chronic Peritonitis; Distention of the Bladder; Gravid Uterus; Chronic Tympanites. Ovarian Dropsy. — It is not until an ovarian cyst rises above the brim of the pelvis that it occasions a swelling marked enough to be mistaken for abdominal dropsy. Supposing that it has led to considerable enlargement of the belly, we are yet able to dis- criminate between the two disorders by attention to the physical signs of the history of the case. * Euneberg, " Eiweissgehalt der Ascitesflussigkeiten," Deufsches Archiy f. Klin. Med., September, 1883. •j- Busey, Amer. Journ. Med. Sci., Dec. 1889. 712 MEDICAID DIAGNOSIS. As regards the former, we perceive tliese differences : the sound on percussion over an ovarian cyst is dull in the umbilical and hypogastric regions, while at the sides the tympanitic resonance of the intestines may be obtained. Moreover, when the patient assumes different postures the dulness in ovarian dropsy does not change its position ; and, like all ovarian tumors, the ovarian dropsy causes a projection in the centre of the abdomen, not a flattening there and a bulging of the flanks, as is common in ascites. Bacelli * states that in ascites there is a deep tympanitic sound during percussion in the region of the intestines, while an ovarian cyst presents dulness on the side in which the cyst has its origin, and a tympanitic sound on percussion on the other. In ascites, vaginal and rectal touch detect fluctuation at once, and the uterns is normal in size and in mobility, sometimes it is prolapsed ; in ovarian dropsy, fluctuation is less distinct, and may not be reached at all, or may not exist in case of polycyst, and the uterus is generally displaced behind the cyst. The fluctuation from an ovarian cyst is apt to be very unequal at different parts of the distended abdomen. When the effused fluid is free in the peritoneal cavity, fluctuation may be perceived beyond the line of dulness as the fluid is thrown in waves among the intestines ; but when it is confined within a cyst, fluctuation cannot be perceived beyond the cyst-walls : hence the outline of the cyst as obtained by percussion, and that of the area within which fluctuation is perceived, must be the same. It should be remembered, however, that fluctuation in an ovarian cyst may entirely escape detection on account of the great thickness of the cyst-walls, or of the unusual tenseness of the cyst, even though it be large, or of the great density of the fluid, or of the small amount of fluid in each cyst. In ovarian cyst there is, for the most part, impairment of the general health, and the color of the face is that of cachexia. Lastly, the pulsations of the aorta are trans- mitted by an ovarian tumor to the anterior surface of the abdomen, and can be there felt by the hand. When, however, there is ascites complicating an ovarian tumor, the diagnosis is very difficult. Finding the fluctuation unequal, and an irregular outline of the ovarian growth, may aid us ; but * Wien. Med. Wochensch., April, 1890. ABDOMINAL ENLAEGEMENT. 713 a preliminary tapping, though now mostly condemned by gynae- cologists, may be necessary to arrive at an opinion. Entire reliance cannot be placed on the chemical character of the fluid, since the rule that paralbumin is significant of ovarian fluids and fibrin of serous fluids has many exceptions. Spencer Wells * accepts the presence of the " granular cell," as shown by Drysdale and W. L. Atlee,t to be characteristic of ovarian fluid. This granular cell, as described by Drysdale,^ is generally round, sometimes oval, varies in diameter from one five-thousandth to one two- thousandth of an inch, is very elevated and transparent, is much smaller and far less opaque than the compound granular cell of inflammation, and contains a number of fine well-defined granules which become more distinct on the addition of acetic acid, and nearly transparent under ether, while the appearance of the cell is not changed. There is no nucleus. In several very doubtful cases of abdominal tumor the diagnostic import of the cell was well attested. § The cell differs, Drysdale teaches us, from any other granular cell found in the abdominal cavity. In uncomplicated cases, the history assists us greatly in reach- ing a correct diagnosis. In ovarian dropsy, we can, as a rule, make out that the distention of the abdomen has begun at its lower portion, and has gradually spread upward, one side being very much more prominent than the other, until the abdominal enlargement has become considerable ,and the relative position of the umbilicus is altered. Again, we do not find those signs of disease of the liver, heart, or kidneys which are so apt to co- exist with ascites, or that the swelling is temporarily reduced by the use of hydragogue cathartics and diuretics, as in the latter disease. Attention to the history and progress of the complaint is espe- cially valuable in the class of cases in which the physical signs are modified by the intestines not being able to float to the surface of the fluid in the peritoneal cavity, in consequence of adhesions to one another, or of a diseased omentum, or in which the fluid has * Brit. Med Journ., June, 1878. t Ovarian Tumors. X Transactions of the American Medical Association, 1873. § See Transactions of the Pathological Society of Philadelphia, vol. vii., 1877; American Journal of Obstetrics, vol. xii., 1879; also Gynaecological Transactions, 1883. 714 MEDICAL, DIAGNOSIS. been limited in sacs by inflammatory adhesions. These are eases in which a peritoneal inflammation has led to the effusion of liquid ; and the history of antecedent peritonitis, or of peritonitis in connection with tubercular disease, will go far toward eluci- dating the diagnosis. On the other hand, an ovarian cyst may contain air, either from a communication with the intestine, or after tapping and decomposition of the contained fluid, and percus- sion would then give a clear note in front and a dull note below. Under either of these circumstances physical signs alone could not enable us to make a diagnosis, and we should have to seek further light from the history and the general condition of the patient. This is especially true in the diagnosis between encysted dropsy of the peritoneum and an ovarian cyst. If we obtain by tapping a spring-water fluid, it points to cyst of the broad liga- ment. Chronic Peritonitis. — Excluding the kind of chronic inflam- mation which is due to an attack of acute peritonitis passing into a chronic state, let us inquire how cases of chronic peritonitis, in which the disease was gradual in its development, can be distin- guished from pure dropsical effusion. Now, these cases of chronic peritonitis are, with the exception of those unfrequent instances of chronic diffused peritonitis of latent origin which we have already discussed, almost invariably associated with tubercle or with cancer, and only under rare con- ditions with chronic dysentery and dilatation of the colon. In tubercular peritonitis the malady generally occurs in those who have at the same time tubercles in the lungs or enlarged caseous glands ; and when we find such patients complaining of abdom- inal pain and uneasiness, of soreness to the touch, of nausea and vomiting, of diarrhoea alternating with constipation, of having more or less fever, and of losing flesh and strength ; when we dis- cover the tender abdomen to be tense and much distended, in part with liquid, but especially with wind, and sometimes very resist- ant to the touch, and exhibiting on its exterior the tracings of the convolutions of the intestines ; when in addition there is oedema of the lower limbs, and we find the fever to be irregular, at times high, at times almost ceasing, and a growing cachexia ; when we are able to exclude as the cause of the dropsy disease of the heart, disease of the kidneys, and cirrhosis of the liver, — we can hardly ABDOMINAL ENLARGEMENT. 715 be wrong in presuming the signs of chronic peritoneal inflamma- tion to be owing to the presence of tubercle. Even when the signs of disease of the lungs are wanting, or are not well defined, we shall generally be correct, if the abdominal symptoms men- tioned exist, in determining the peritoneal affection to be tuber- cular. In some instances the tubercular abdominal disorder develops with rapidity, and the disease has not so much the aspect of a chronic as of an acute complaint. The tumefaction and tension of the belly may be so great as to simulate an abdominal tumor.* A cancer of the peritoneum gives rise to many of the same phenomena as tuberculous disease. 'But the affection is far less common, and there is this difference : the malady usually happens consecutively to an external or an internal cancer, and scarcely ever save in persons advanced in years ; there is little or no fever, or, indeed, a subnormal temperature ; no diarrhoea, or but little diarrhoea, and no profuse sweats, occur. Pain, on the other hand, or at least attacks of spontaneous pain, are more frequent ; the lymphatic glands enlarge; and, as the omentum is the most common seat of the cancerous growth, we can generally detect a tumor stretehing across the upper portion of the abdomen, and extending perhaps from the epigastrium nearly to the pelvis. The morbid mass is unequal, and usually detected readily, except where separated by fluid from the abdominal parietes. Hemor- rhage into the abdominal cavity or the effusion of bloody serum occurs here as it does in tubercular peritonitis. In cancerous peri- tonitis the ascitic fluid has a turbid gray look. In the sediment that forms there is a rich cell-growth with many red blood-cor- puscles. The cells are for the most part peculiar, large swollen nucleated cells, in size like those of the white corpuscles of the blood.f In primary cancer of the peritoneum, or that following cancer of the retro-peritoneal glands, the diagnosis is very obscure, unless the tumors are marked. The cancerous malady is apt to pursue a slowly progressive course, lasting months ; but it may develop as an acute miliary disease. Retro-peritoneal tumors * See case in Liverpool Hospital Keports, 1868. t Euneberg, Deutsches Archiv f. Klin. Med., Sept. 1883; also Coe, New York Med. Journ., July, 1888. 45 713 MEDICAL DIAGNOSIS. may be readily mistaken for diseases of the liver. They may occasion jaundice from pressure on the common duct. The fact that they do not move \vith the acts of breathing, as well as that there is often a line of resonance between the dulness they occasion and the liver dulness, is a point of value in diagnosis.* Distentimi of the Bladder. — This may give rise to a sense of fluc- tuation and to very marked abdominal enlargement ; so marked, indeed, that patients have been tapped, under the supposition that they were laboring under dropsy of the abdomen. But when the bladder is so much distended as to simulate ascites, there is usually more or less tenderness on pressure over the seat of the obvious swelling ; which, moreover, presents a rounded outline of dulness on percussion. Again, we have the history either of retention or of apparent incontinence of urine.f But, to avoid all possible chance of error, in any case of doubt a catheter should be introduced into the bladder. This mode of procedure, it may here be mentioned, is the one which leads most speedily and decisively to a true appreciation of the abnormal phenomena in those rare cases of anasarca which are produced by distention of the bladder, and of which Trousseau has recorded several. The Gravid Uterus. — A gravid womb is readily distinguished from abdominal dropsy by the peculiar form of the dulness on percussion, its steady and uniform increase corresponding to the enlargement of the womb, the absence of fluctuation, the detection of the sounds of the foetal heart, the alteration in the color and appearance of the mammary areola, and the production of move- ments in the womb on making an examination per vaginam. Chronic Tympanites. — Great prominence of the abdomen, due to flatulent distention of the bowels, is, if at all persistent, very apt to be mistaken for ascites. But the large abdomen yields not a dull, but everywhere a tympanitic sound, and there is no fluc- tuation. Then the- history of the case and the attending symptoms throw light upon the nature of the ailment. Besides the complaints just reviewed, which are those most com- monly confounded with ascites, there are a few very rare disorders * Vander Veer, Amer. Journ. Med. Sci., .Jan. 1892. ■j- In a case recorded by Watson, in his Lectures on the Practice of Physic, although the bladder was enormously distended, large quantities of urine were constantly passing from the patient. ABDOMINAL ENLARGEMENT. . 717 which might be mistaken for collections of fluid in the peritoneal sac. They are : dropsy of the womb ; dropsy of the Fallopian tubes ; dropsy of the omentum ; very large serous cysts in the kidney ; hydatids of the liver, of size so great as to lead to general abdominal distention; and a dilatation of the stomach so exten- sive that the viscus occupies almost the whole abdomen. With reference to the latter affection, we may distinguish it from ascites by the history of the case and the vomiting and other marked gas- tric symptoms, by the extended tympanitic percussion note, by the indistinct fluctuation, which is not noticed except over the most dependent part of the organ, by the splashing or the metallic or amphoric sounds which are perceived when its contents are agitated, by the length to which the stomach-tube can be intro- duced, and by the chemical examination of the gastric contents. The other maladies mentioned can be separated only by taking into account their history and progress, and by laying stress upon the absence of those morbid states which generally cause ascites, and upon the occurrence of special phenomena which point to the structures implicated. Chronic Tympanites. — A collection of gas in the cavity of the peritoneum is of rare occurrence, but is frequent in the in- testinal tube, and the accumulation becomes sometimes a chronic condition, and leads to very great and uniform enlargement of the abdomen. We find this form of tympanites in some cases of hysteria ; in instances of constriction of portions of the intestinal canal, in consequence either of cicatrization, or of cancer of the bowels, or of their compression by a morbid growth, or of great dilatation of the colon ; as a sequel of enteritis or peritonitis, or of a spinal lesion ; and we also observe it in persons whose diges- tive powers are weak and who partake much of food — such as cabbages, beans, and peas — which is apt to occasion flatulency. Among soldiers this chronic tympanites — owing, perhaps, in many cases to the character of their diet and consequent digestive disturbances — is far from being an uncommon disorder, and may be a very obstinate one. It gives rise to abdominal enlargement, which is constantly mistaken for dropsy, but which does not yield a sense of fluctuation, or return on percussion any other than a well-marked tympanitic sound. The distention produces, more- over, an inability to take active exercise, sensations of cutting pain 718 . MEDICAL DIAGNOSIS. . under the ribs, and palpitation of the heart ; pressure on the ab- domen occasions much discomfort ; the soldiers, therefore, walk with their clothes unbuttoned, and find it very irksome to wear their belts. They are sometimes troubled by indigestion, and feel particularly uncomfortable after meals ; or the symptoms of indi- gestion, although they may have been present at the beginning of the complaint, disappear, but the swelling of the abdomen persists for many months. According to my experience, the aUment is always gradual in its development. Partial Abdominal Enlargement. Abdominal Tumors. — Even at the risk of some repetition, it is for clinical purposes a matter of convenience to point out connectedly the relations an abdominal swelling is likely to bear to the normal structures of the abdominal cavity, and to consider, moreover, the swelling as constituting the starting-point of our diagnosis. Let us first examine the meaning of an abdominal tumefaction occupying solely or principally one region of the abdomen. Right Hypodiondrium. — The most usual cause of a tumor in this region is an enlargement of the liver. Sometimes a tumor which is in the lower part of the right hypochondrium, or pro- ceeds from the termination of this region, is simply a displaced liver, or an affection of the gall-bladder. In the first instance, the recognition of the disorder — such as a pleuritic effusion — which has given rise to the displacement ; in the second, the his- tory of the case, the shape of the swelling, aud the symptoms attending it, — will give us an insight into its cause. Again, a tumor in the parts mentioned may be due to an enlarged kidney, cancerous or cystic, or especially hydronephrosis. Careful exami- nations of the urine and the history of the case furnish the most certain means of discrimination. Then we must also bear in mind that all enlarged kidneys displace the bowel in a particular manner ; they press it forward, and the dulness over the tumor is largely mixed with a tympanitic sound, or the dulness is, indeed, not very appreciable. Left Hypoeliondrium. — The most usual tumors in this region are those produced by enlargement of the spleen. An increase ABDOMINAL, ENLARGEMENT. 719 in size of this viscus, if acute, is generally owing to altered blood conditions and infectious maladies, as pysemia, puerperal fever, acute tuberculosis, typhoid fever, relapsing fever, or the malarial fevers. The cause of the swelling is disclosed by the history of the case and by the accompanying symptoms. Inflammation of the spleen is an affection very difficult to recog- nize. The most trustworthy symptoms are: pain in the left hypochondrium, radiating thence in various directions, as far as the left shoulder, and augmented by pressure, especially if the serous envelope be implicated, by coughing, and by a deep inspi- ration ; nausea and vomiting ; fever having irregular fits of exacer- bation ; sometimes delirium, dry cough, and a sense of suffocation. The extent of the splenic percussion dulness is decidedly increased, and, when we are sure that the spleen is not displaced, the sud- denly-widened area of dulness forms a most important element in the diagnosis. Splenitis is very rarely primary, generally meta- static. It is often observed to be connected with emboli from endocarditis, and, these being wafted also to the kidneys, albumin and blood are found in the urine. When suppuration iu the spleen ensues, the fever may assume a hectic character and the patient lose flesh rapidly, while the spleen increases in size. But there is no certainty in these signs, nor, indeed, in any of the signs of splenic abscess ; this may be latent and suddenly rupture into the abdominal cavity or the stomach. Then there may be abscesses around the spleen with manifestations similar to those in its substance or to pyo-pneumothorax.* An acute enlargement of the spleen may also be owing to hemorrhage from injury. Chronic enlargement of the spleen may be caused by hypertrophy, by waxy disease, by leukaemia and lymphadenoma, by malignant growth, by hydatids, by syphilitic tumor, by congenital syphilis, and by structural changes from malaria. There are scarcely any symptoms characteristic of these states, except the alteration the blood undergoes, as evinced by a diminution of the red globules and an increase of the white ; and even this may not be marked. Waxy hue of the face, dropsy, bleeding from the nose, from the stomach, or from the intestinal canal, and digestive disturbances, though far from infrequent, are less constant. In truth, all the * Zuber, Kevue de Medecine, Nov. 1882. 720 MEDICAL DIAGNOSIS. phenomena mentioned, except perhaps the microscopical evidences of deteriorated blood, are, in the recognition of a splenic tumor, of secondary importance as compared with the extended percus- sion dulness in the splenic region. In some cases the symptoms are very ill defined, and death may result from rupture of varices of the enlarged viscus, without any other signs of a lesion than those of increased size of the organ.* When enlargement of the spleen has reached a certain point, the organ curves into the hypo- gastric and right iliac regions, and a notch or notches may be felt on its anterior and inner surfaces, f This sign may be very valuable in distinguishing the enlarged organ from cancer of the kidney, for which it has been mistaken.]; In some instances enlargement of the spleen is hereditary.§ Having determined the persistent swelling to be due to the ab- normal size of the spleen, we must next endeavor to ascertain the cause of it. The history of the case, such as the proof of leukse- mia, of protracted suppuration, of malaria, forms, with the coex- isting phenomena in other organs, the main element in diagnosis. A fulness projecting from the left hypochondrium toward the umbilical or lumbar region may be owing to feecal acGumulations in the colon. Although these faecal accumulations do not occur so often in or near either hypochondrium as they do in the iliac regions, yet they are not very uncommon, and we should be on our guard against confounding them with organic disease, whether of the stomach, spleen, liver, kidneys, peritoneum, or ovary. Their irregular outline, a doughy consistence and painlessness, and close attention to the history of the case and to the accom- panying disorder of the digestive functions, will generally enable us to detect the true nature of the swelling. But we must not lay too much stress on the non-existence of constipation, for sometimes great irritability of the bowels or persistent diarrhoea is kept up by a large collection of faecal matter in the colon, and an irritative fever superadded gives a strong resemblance to typhoid. || Re- peated attacks of colicky pains and some soreness to the touch * Traube, Virchow's Archiv, 1869. t Fagge, Guy's Hosp. Eep., 1868. J Lancet, July, 1873. i Wilson and Stanley, Clin. Soe. Trans., 1893. II As in a case seen with Dr. Arthur V. Meigs. ABDOMINAL ENLAEGEMBNT. 721 are not unusual in cases of extensive faecal accumulation, and jaundice and ansemia have been also noticed. Besides looseness and mucus, the stools are apt to show small hard faecal masses, which may be of leaden hue. In cases of doubt, laxatives, es- pecially castor oil, should be employed before any opinion is given, and with the voiding of large masses of faeces 'the tumor and the attending symptoms may disappear. As regards swellings of any kind situated in either hypochon- drium, or in fact at any portion of the upper third of the abdo- men, it is always to be inquired into whether they are affected by the act of respiration. This, as Kennedy* has pointed out, is a valuable sign, for if the morbid mass move in consequence of the depression of the diaphragm, it is because structures are involved, such as the stomach and transverse colon, the liver or spleen, which admit of some mobility ; whereas a tumor that is uninfluenced must appertain to a fixed part, — for instance, to the aorta. Epigastrium. — The most common cause of an epigastric tumor is cancer of the stomach. The swelling is then associated with the symptoms above described. But a tumor in this region may be also produced by a disease of the pancreas. A swelling occasioned by fatty degeneration, or by uniform simple hardening of the gland, cannot, as a rule, be discerned at the bedside. In pancreatic fat necrosis, the areas of white necrotic tissue are usually also found in the mesentery and in other seats of abdominal fatty tissue. There are no diagnostic signs. In chronic pancreatitis, deep-seated epigastric pain with col- icky attacks, a large quantity of matter like saliva passed by stool, profuse salivation, sugar in the urine, fatty stools, and jaundice have been observed to attend the appreciable swelling extending across the epigastrium. The association of chronic pancreatitis with diabetes has been frequently noticed. Suppurative pancrea- titis, as we know from Fitz's analysis, is much more common in women than in men. Though chronic, it begins with sharp epi- gastric pain and vomiting, and is not unfrequently attended with irregular fever. It may last weeks or months. As regards can- cer, which can be recognized with more certainty, the most trust- worthy symptoms are : a tumor in the epigastric region ; pain * Dublin Quarterly Journal, August, 1864. 722 MEDICAL, DIAGNOSIS. there or in the back, not increased by the taking of food, but usually augmented by the erect posture ; progressive emaciation and debility ; an appetite capricious rather than diminished, and in some instances, indeed, a ravenous desire for food ; constipa- tion, and at times, but far from invariably, fatty stools, or fat- crystals in abundance in the grayish stools.* Besides these indi- cations, we commonly find, as the disease advances, obstinate jaundice and occasional vomiting. Many of these phenomena belong also to cancer of the stomach ; in truth, we never can be certain of the existence of the pancreatic malady until we have excluded the gastric affection. In a differential diagnosis of this kind, the early presence and habitual occurrence of vomiting after meals, the sour eructations, the hsematemesis, the absence of free hydrochloric acid in the stomach-contents, and the absence of jaundice, assist us in locating the seat of the disease in the stom- ach. Calculous disease of the pancreas is a very rare affection. There are, in addition to the dull sense of weight at the epigas- trium and other symptoms of pancreatic disease,— such as sugar in the urine, vomiting, fatty stools, — sharp, irregular attacks of paroxysmal pain, due to the passage of calculi. In cases of large concretions these attacks of colic may become associated with jaundice.f Pancreatic calculi may lead to atrophy of the gland and become associated with diabetes.J An epigastric tumor is sometimes simulated by a contraction of the upper portion of the rectus muscle on palpation ; but the swelling soon subsides, especially if rubbed. Occasionally, how- ever, a tumefaction due to contraction of an abdominal muscle may be of some duration.! I have known a contraction of the rectus muscle in a case of gastric cancer occasion so obvious a resistance and swelling that it was looked upon as due to ma- lignant disease of the intestine or of the peritoneum. More- over, the rigid muscle gave rise to dulness on percussion. But, * But collections of fat-crystals, Gerhardt has found, are also detected in the pale stools of icterus without pancreatic disease : when the bile reappears in the stools the crystals are no longer seen. t Pepper, Medical News, Dec. 25, 1882; and Johnston, Amer. Journ. Med. Sci., Oct. 1883; see also eighteen collected cases in Sajous's Annual, 1889, C-44. X Lichtheim, Berlin. Klin Wochensch., 1894, No. 8. J Greenhow's cases, Lancit, 1857. ABDOMINAL ENLARGEMENT. 723 though the phenomena were for a long period a marked feature of the case, it was observable that the muscle was raised and rigid to a decided degree only in certain positions ; at all events, that certain positions gave a distinct outline to the swelling, and that the latter then, like the line of dulness, was regular and straight, evidently corresponding to the contour of the muscle. And this occurs in all instances of contraction of the rectus, no matter with what associated. The muscular contractions are not always confined to one muscle, or to the whole of one muscle, and when irregular, and particularly when associated with tympanitic distention of the intestine, give rise to most of the so-called "phantom tumors" of the abdomen. • These swellings are perplexing, and are con- stantly mistaken for serious abdominal tumors. The history of the case, the absence of grave constitutional symptoms, the most frequent occurrence of the tumefaction in females, especially in hysterical females, and the usually coexisting constipation, furnish us with valuable signs of distinction. But I believe the use of anaesthetics to be the most important means of diagnosis. I was first led to employ them a number of years ago, in a case which had baiSed the skill of several eminent surgeons, one of whom had proposed to the patient an operation as the only means of relief from what was considered an ovarian disease. The patient was thirty-one years of age, a widow, and evidently of highly hys- terical temperament. She was very subject to constipation ; and the swelling of which she complained was of irregular outline and occupied the centre of the abdomen, extending some distance on each side of the median line. It was hard and resisting to the touch, but, on strong percussion, yielded a tympanitic sound. Whenever it was touched she shrank. Thorough relaxation was produced by the administration of ether ; the hand could be pressed almost against the vertebral column, and all signs of the tumor disappeared. A complete recovery took place ; and thus terminated a case which had lasted for fully one year, and in which it is highly probable, from the fact that the patient was fond of having her urine drawn off by the catheter, and had shown other manifestations of a similar type of hysteria, that the swelling was, in part at least, artificially produced. But in any of the phantom tumors I would recommend the. use of anaesthetics ■724 MEDICAL DIAGNOSIS. for purj)oses of diagnosis ; nay, they may be most advantageously employed, for similar reasons, in all cases of abdominal swelling in which the rigid state of the abdominal walls interferes with accuracy of investigation. In soldiers we at times observe one or several small movable tumors, yielding a tympanitic sound on percussion, in the epigas- tric or at the upper part of the umbilical region. They are, probably, small portions of intestine which have been pushed between the fasciculi of a ruptured rectus muscle, similar to umbilical hernia. Umbilioal Region. — Tumors which are found in this region form, as a rule, merely portions of a swelling that is principally seated in the epigastrium or in the hypochondria, such as cancer of the stomach, of the liver, of the pancreas, or of the omentum, and dilatation of the gall-bladder. The only two affections which are apt to occasion a swelling solely, or at least principally, limited to and perceptible in the umbilical region, are tuberculous disease of the mesenteric glands and a movable kidney. The symptoms of the former malady, or tabes mesenterica, are much the same as those of tubercular peritonitis. Indeed, unless the enlarged mesenteric glands can be felt through the abdominal parietes, the discrimination is uncertain. The abdomen is pre- maturely large, is slightly tender on pressure, and has often a doughy feel ; the child loses flesh, the digestion is impaired, the evacuations are frequent, liquid, and offensive. It often presents signs of scrofulous or tubercular disease elsewhere ; and under such circumstances we cannot be at a loss in determining the nature of the tumefaction in the umbilical region. The disease is very rare in adults, though it occurs.* Its simulation, especially in young women, by pseudo tabes mesenterica, has been described in reviewing the affections of the stomach. When the kidneys are not firmly held by their attachments, they become displaced, and are apt to give rise to serious errors in diag- nosis. The dislocated organ is perceived under the margin of the ribs on the right flank, or in the umbilical region, and sometimes extends across the median line. The mass is easily moved, may be, by careful and methodical pressure, returned to the renal region, * See case reported by Gairdner, Lectures to Practitioners. ABDOMINAL ENLARGEMENT. 725 and presents, on palpation and on percussion, the outline of the kidney. The lumbar region yields a tympanitic sound on percus- sion, and we find less resistance and a slight depression over the usual seat of the organ, which depression is effaced by pressing the tumor into the lumbar region. There is in some instances sensitiveness over the displaced organ, especially after fatigue, or a blow, or strong pressure ; and pressure in examining the part gives rise to the same sensation as when the renal region of the non-affected side is pressed ; but we never find any disturbance of the urinary functions, nor, in fact, except a disagreeable feeling in walking, does any real inconvenience result from the accident, save in those cases in which the movable kidney has become painful, or, by compressing the vena cava or portal veins, occasions dropsy. Yet we meet with exceptions to the rule that the disorder gives rise to no decided symptoms. Sometimes dyspepsia, especially nervous dyspepsia, is pronounced, as well as intercostal neuralgia, and so-called gastric crises occur marked by vomiting, with severe abdominal pain and fever, or there are attacks simulating renal colic. Further, we may find intermitting hydronephrosis.* There seems to be a special connection between the disorder and hysteria, gasti'ic dilatation, enteroptosis, and membranous enteritis. The disorder is most apt to occur after violent exertion, or after many pregnancies, or may be due to attacks of congestion of the organ, or to tight lacing. It is rare in men. The right kidney is ofitener movable than the left. A movable kidney is best de- tected by palpation with both hands while the patient takes a deep breath. The affection may, of course, be mistaken for any form of abdominal tumor, and if the kidney should have become ad-, herent the diagnosis is uncertain. Generally the disorder can be distinguished by the absence of signs of constitutional disturb- ance ; by the history of the case ; and by the physical phenomena mentioned. To these may be added the comparatively slight dul- ness or rather the tympanitic character of sound elicited, except on very strong percussion, over the seat of the tumor. This is an important fact as regards the discrimination of a movable and displaced spleen, in which, as the organ is generally enlarged, there * Knight, Lancet, Oct. 1893. 726 MEDICAL DIAGNOSIS, is considerable and extended dulness on percussion. Moreover, the history of the splenic disorder, which not uncommonly can be traced to a malarial aifection, the usually great tenderness, the nausea, dyspeptic symptoms, and hemorrhagic tendencies which attend the displacement of the spleen, and the notch which can be felt in it, will assist us in our diagnosis.* A movable kidney may be simulated by maligTiant disease of the eolon.'f Yet another of the abdominal organs is occasionally displaced and movable, — the liver. Now, a movable liver would be often mistaken for a movable spleen, were it a more common affec- tion. But very few well-authenticated cases are on record. J In these the peritoneal attachment of the organ had become lax, usually in consequence of pregnancy ; in the hepatic region there was a tympanitic sound on percussion ; and in the umbilical re- gion and toward the right flank a solid body was discerned, the upper border of which presented a convex outline, the lower bor- der was in the inguinal region. The displaced organ was easily pushed about, and could be replaced in its proper situation. The spleen was found in its usual seat ; the symptoms were merely those of weight and uneasiness in the abdomen. The movable or wandering organ may be painful or painless. It has the phj^sical characters of the liver, and the most certain sign is the detection, on palpation, of the notch between the right and the left lobe and of a zone of tympanitic resonance between the swelling and the lung. The diagnosis is, however, always difficult and doubtful. New growths of the kidney, as a case of Legg's proves, are par- ticularly confusing. In most recorded cases autopsies are want- * Cases of displaced spleen are recorded by Dietl, Wiener Med. Woehen- Bchrift, ITo. 23, 1856, also in Archives Generales, 1858, tome ii. ; Eokl- tansky, quoted in Brit, and For Med.-Chir. Rev., Oct. 1860 ; see, too, Clarke, Dubl. Hosp. Gaz., Aug. 1860 ; Med. Times and Gaz., Nov. 1869; G. Engel, Centralbl. f. Gynak., Leipz., 1886, x. ; Brown, Pacific Med. Journ., San Francisco, June, 1892 ; Dorsett, Med. Eeview, St. Louis, Dec. 1891. f Henry Morris, Lancet, April, 1895. { See Cantani, Ann. Univers di Medicina, 1866 ; and Meissner's article in Schmidt's Jahrb., 1869, No. 1; also ib., No 2, 1871 ; Blet, Le Foie mobile, These de Paris, 1876 ; Legg, St. Bartholomew's Hospital Reports, 1877 ; Arini, Anales del Circulo Med. Argentino, quoted in Amer. Journ Med. Sci., July, 1884; H. W.Seager, Brit. Med. Journ., Lond., 1885, ii. ; L. Landau, Deutsche Med. "Wochensch., Berlin, 1885, ii, ; Eichelot, L'Union Medicale, Paris, Aug. 1893. ABDOMINAL ENLAEGEMENT. 727 ing ; and the whole subject is very obscure. The affection is more usual in women than in men, and, besides pregnancy, tight lacing and chronic inflammation of the peritoneum are said to lead to it. Lumbar Region. — Tumors in this region, or on either flank, are occasioned by some morbid growth of the kidney, or by an abscess in it or its surroundings, or in the psoas muscles. Again, they may be due to fsecal accumulations ; or, if on the right side, to very con- siderable increase of the liver ; if on the left, to a greatly-enlarged spleen. To discriminate between these conditions, we have to determine whether the swelling fluctuates or not; we must also analyze the urine, and inquire minutely into the circumstances preceding and attending the tumefaction. It is thus only that we can attain the necessary data for a diagnosis, which has, indeed, often to be reached by the process of exclusion. Tumors behind the peritoneum may give rise to a visible promi- nence in either lumbar region, extending to the upper part of the iliac region. The most common cause of these tumors is cancer of the lymphatic glands lying by the sides or in front of the ver- tebral column. The disease is very difficult of detection. Still, we may suspect its existence if, in a patient who is evidently cachectic, and who is steadily losing flesh and strength, we dis- cover, on deep palpation on one side of the linea alba or in the flank, a tumor which, owing to its being surrounded by intestine, returns a tympanitic percussion sound. In some cases the swell- ing communicates the beat of the aorta and simulates an aneu- rism, or it presses on the vena cava and gives rise to enlargement of the abdominal veins and of those of the lower extremities, and to oedema of the legs. The disease may involve the iliac glands and the tumor extend into the pelvis, or it may reach upward to the diaphragm ; and, by the cancer spreading to the posterior me- diastinum, it may finally open the aorta, producing hemorrhages precisely like those coming from an aneurismal sac* Iliac Regions. — Tumors in either of these regions may be due to many diiferent causes. They are, as we have elsewhere discussed, principally owing to ovarian affections ; to fsecal accumulations ; to disease of the large intestine, such as intussusception or cancer ; and to pelvic abscess. Sometimes they are caused by displacement * Case reported by Haldane, Edinburgh Medical Journal, Aug. 1868. 728 MEDICAL DIAGNOSIS. of the kidney, by enlargement of the spleen, and in women by retro-uterine hsematocele, or by extra-uterine pregnancy. The ovarian tumors are, as a rule, distinguished from the other disorders mentioned by their more or less globular form, by their movability from side to side or in an upward direction, by their seeming to spring out of the pelvis, and their evident attachment below, by the displacement of the womb, by the comparatively unimpaired general health, and by their indolent and generally painless nature. These remarks do not apply to the very slight swelling occasioned by ovarian inflammation, for here the tumid spot is often the seat of severe pain. The healthy ovary is not sensitive to the touch. To examine the ovary with exactness, the abdominal muscles must be completely relaxed ; the patient is placed in the attitude recommended by Marion Sims, — on her back, with the shoulders supported, the legs drawn up so that the heels are a few inches asunder and the thighs fall easily apart. As ovarian tumors grow and spread upward they give rise to diificulties in diagnosis, which we have already examined into. We may here again mention the manner in which ovarian may simulate renal growths. Spencer Wells dwells particularly on the absence of fluctuation in the vast majority of instances of en- larged kidney ; on the renal tumor being first detected between the false ribs and the ilium ; on the signs in the urine, and on the absence of those changes in the quantity and regularity of the menstrual discharges which are common in ovarian disorders. Moreover, the ovarian growth usually displaces the intestine backward ; in the renal growth it is pressed forward ; and large tumors of the right kidney ordinarily have the ascending colon on their inner border, while tumors of the left kidney are gener- ally crossed from above downward by the descending colon. Among the causes of a tumor in either iliac fossa, retro-uteiine hsematocele has been mentioned. The tumor, commonly of rounded shape, rises above the brim of the pelvis, but is traceable into it. It forms quickly, and an examination through the vagina detects a boggy swelling in Douglas's cul-de-sac, and at times the grating of the blood coagula ; faintness and collapse attend its produc- tion. Much the same physical phenomena are presented by the swelling due to pelvic cellulitis. But the slow way in which the tumor forms, the presence of that hot, puffy, thickened, brawn- ABDOMIITAI, ENLARGEMENT. 729 like condition of the vaginal wall, so dwelt upon by Simpson, the usually greater tenderness of the swelling felt through the walls of the vagina, and the feverishness and constitutional symptoms attending the gradual formation of the abscess, are distinguishing marks, except where the contents of the hsematocele suppurate, when for a differential diagnosis we may have to rely on the his- tory of the case. Hypogastric Region. — Distention of the bladder and enlarge- ment of the uterus, whether produced by air, by liquid, by a morbid growth, or by pregnancy, are the most usual sources of a swelling in this region. If due to any one of these causes, the outline of the tumor is regular and rounded ; and by the aid of the catheter, of explorations through the vagina and the rectum, of the history of the case, and of the attending symptoms, we are generally enabled to arrive at a correct diagnosis. A tumor in the hypogastrium may also have its origin in splenic enlargement, in diseases of the peritoneum, or in hsema- tocele. In the latter case it is apt to be uniform and to extend to the iliac fossae. In concluding this sketch of abdominal tumors, we shall briefly glance at those which are likely to occupy more than one region, and sometimes even the whole or the greater part, of the abdomen. In rare instances, a cancer of the liver, or hydatids of that organ, or a fibrous tumor of the uterus, or a solid ovarian growth, or an enlarged spleen,* or a kidney the pelvis of which has become enormously distended in consequence of obstruction of the ureter, may lead to the formation of a swelling which occupies nearly the entire abdomen. But the most usual cause of so diff'use a tumor is carcinoyna of the peritoneum. This affection, when very extensive, may give rise to a uniform swelling stretching across the abdomen, and equally marked on both sides of the median line, or to several small tumors, which are evidently unconnected with any organ beneath. It is, moreover, apt to occasion a peritoneal friction sound, to exhibit a varying resistance to pressure at different points, to lead to ascites, to loss of flesh and appetite, and chiefly, by the peritonitis it sets up, to * As in the case reported by Porter, Philadelphia Medical Times, June, 1875, in which the spleen weighed twenty-one pounds. 730 MEDICAL DIAGNOSIS. the occurrence of fever. Much the same symptoms may be pro- duced by hydatid disease of the peritoneum, though here there is less fever, the swelling may be uniform or even more irregular, the abdominal enlargement greater and painless, and we may be able to detect the hydatid fremitus and the booklets in the evacuated fluid.* Yet as regards the hydatid thrill we must bear in mind that a similar sensation is obtained from large parovarian cysts f or from colloid cancer of the peritoneum, a sensation of peculiar and very superficial fluctuation,! associated, however, here with grave symptoms of cachexia, and generally with a rapidly-spreading growth. Peritoneal abscesses enclosed by adhesions will also, if large, give rise to several of the signs of a cancer ; but the history of an antecedent local or general peritonitis, the swelling not being influenced by changes in the posture of the patient or by the acts of respiration, the indistinct fluctuation of the tumefaction, and its acute course, will ordinarily enable us to distinguish the non-malignant from the malignant aflection. In rare instances the tumor may be enormous, increase rapidly, yet be simply fatty. There are no means of positively distinguishing the affection.§ Sarcoma cannot be told from car- cinoma ; it is more common in advanced age. In some cases the malignant disease is closely simulated by dilatation of the colon, caused ordinarily by fsecal tumors. This, though it may present but a single swelling, generally occasions several, which are commonly seated at the middle third of the ab- domen, are apt to appear on both sides, to be movable and painless and to bear handling without pain, to change their position slightly at intervals, and to become occasionally less in size. Then, after the case has been for some time under observation, we may be able to notice large and characteristic discharges; though we must not forget that a mere sluggish state of the bowels, or even diarrhoea, may exist while the colon is dilated and perhaps filled with fsecal accumulations. || Sometimes the mass may be seated * See the cases of Bright, in Clinical Memoirs on Ahdominal Tumors, re- published from Guy's Hospital Reports by the New Sydenham Society. f Bristowe, St. Thomas's Hospital Reports, vol. xi. J As in the instances recorded by Albert Kobin, Bull, de la Soc. Anat , 1873, and Vidal, Bull, et Mem. Soc. Med. des Hopit., 1874. g See St. George's Hospital Reports, vol. v., 1870, p. 253. II For several interesting oases of the disorder, see Kennedy, loc. cit. ABDOMINAL PULSATION. 731 above the symphysis and be mistaken for a pelvic tumor. Like a cancerous growth, it may lead to occlusion of the intestine and complete intestinal obstmction. The tympanites and the dilata- tion it occasions, which may be idiopathic, produce at times fatal results.* The dilatation may be enormous, though there is no constriction in any part of the bowel. Cancer of the intestine has symptoms similar both to fsecal accu- mulation and to cancer of the peritoneum. The marked cachexia and the signs of persistent and increasing narrowing of the bowel, as shown by the flattened fseces, the blood and pus in the stools, the frequent attacks of colicky pains, and the vomiting, dis- tinguish it from the former affection. The limitation of the swelling, the absence of dropsy, the character of the stools, the frequent change in the position of the tumor and in its distinct- ness,t and, if it affect the duodenum, the decided jaundice, separate it from peritoneal cancer. SECTION V. ABDOMINAL PULSATION. Aortic Fulsatiou. — By far the most frequent cause of a pulsation visible in the abdomen, and especially at the epigastric region, is a throbbing of the abdominal aorta. It is common in hysterical persons. Some women are liable to it immediately be- fore their menstrual periods or during the earlier months of preg- nancy. In men it is seen most often in those who suffer from inveterate dyspepsia, and is apt to come on in severe paroxysms, which are alarming to the patient, but which generally disappear under brisk purging. In hypochondriacs whose abdominal walls are thin, the beating at the epigastrium may become a source of continued distress. The increased action of the aorta, or, as happens in emaciated persons, the greater distinctness with which the beat of the artery * Gee, St. Barthol. Hosp. Eep., vol. xx. ; A. Money and S. Paget, Clin. See. Transact , 1888; Pormad, Trans. Coll, Physicians, Phila., 1892. ■f Leube, Ziemssen's Cyclopsedia. 46 732 MEDICAL DIAGNOSIS. is perceived, without there being abnormal throbbing, may be distinguished from an enlarged and somewhat displaced heart by the circumstances of the case and the absence of the pliys'cal signs of cardiac disease ; and from an aneurism, by the mode of invasion, and by the want of those signs which characterize an aneurism. Abdominal Aneurism. — Aneurism of the abdominal aorta is a disease of middle life, and of males. Its most frequent cause is excessive muscular exercise ; sometimes it is produced by a blow on the abdomen, or by syphilis. Its duration is very uncertain : occasionally six or seven years elapse from its earliest indications until the fatal termination ; not unusually the patient lives twenty to thirty months after the outbreak of the complaint. The chief symptoms are pain, and an absence of dropsy, of fever, or of any considerable constitutional disturbance. The jDain is generally felt in the back, or in the right hypochondrium, or shooting down the sciatic nerves to the lower limbs. It may be constant and dull, or occur in protracted and violent paroxysms ; ordinarily there is a persistent pain which has periods of fierce exacerbation. The disproportion between its violence and the otherwise almost unimpaired health is a striking and common feature of the disease, and is apt to continue until the aneurism be- comes very large and occasions displacement of important organs. The physical signs of an abdominal aneurism are : an impulse communicated to the hand when placed over the swelling; a sys- tolic blowing sound ; a thrill ; and in some instances a distinct prominence and alteration in the form of the abdomen. The im- pulse corresponds, with rare exceptions, to the beat of the heart, is single, and ordinarily very forcible. Genei'ally it cannot be felt from behind ; it is a beat discerned only anteriorly and on either side of the pulsating sac. Corresponding to the throbbing of the tumor, we often hear a short blowing sound, to be detected both posteriorly and anteriorly, sometimes perceived in the recumbent posture only ; or a dull, muffled sound ; rarely are there two sounds. A thrill felt at the same time as the pulsation is not unfrequently noticed ; still, jt may be absent, even in large-sized aneurisms. Aneurism of the abdominal aorta may be confounded with — Rheumatism ; Neuealgia ; Colic ; Disease of the Spine; abdominal pulsation. 733 Aortic Pulsation; Lumbar and Psoas Abscess ; non-aneurismal pulsating tumor. The first four of these affections are likely to be mistaken for an abdominal aneurism, on account merely of the pain ; the others, because of the presence of pulsation, or of a swelling, or of both pulsation and swelling. Bheumatism ; Neuralgia; Colic. — The pain caused by an aneu- rism may closely simulate rheumatism of the lumbar muscles, or sciatica, or abdominal neuralgia, or colic. There is nothing in the pain itself which will lead to the detection of its origin : this can be effected only by a recognition of the physical signs of the aneurism. When these are not well defined, the diagnosis is doubtful. Yet, even when they are slightly marked or absent, if the pain be veiy obstinate, and we have excluded the affections named or cannot trace them to their usual causes, we shall often be right in attributing the pain to an aneurism. This is espe- cially true as regards abdominal neuralgia occurring in males, — a disorder which ought always to make us examine for an aneu- rism, and which is not unfrequently found to be due to it. Disease of the Spine. — Patients who are suffering from aneurism often complain of pain in the spine, and present sometimes an obvious spinal curvature. But a careful examination, by detect- ing the physical signs of an aneurism, will enable us generally to distinguish the source of the difficulty. The constant boring pain so much complained of in cases of aneurism is usually thought to be due to absorption of the vertebrae ; but, as Stokes proved, it has no necessary connection with this lesion. Aortic Pulsation. — Simple abdominal pulsation, such as we observe in hysteria, in dyspepsia, and in pregnancy, or excessive epigastric pulsation due to an enlarged right ventricle or to insuf- ficient aortic valves, may be readily mistaken for an aneurism. But in the former case the history will generally lead us to a cor- rect conclusion, especially if taken in connection with the facts that the pulsation is not heavy and slow, as in an aneurism, but jerking and sudden ; that there is no thrill j no tumor with cor- responding dulness on percussion, if we except pregnancy; no systolic murmur audible in front of the abdomen or along the spine ; and no pain. 734 MEDICAL DIAGNOSIS. The pulsation due to disease of the heart is discriminated by the physical signs in the thorax. Kegurgitation at the aortic orifice, which is the cardiac affection most liable to be confounded with an aneurism, on account of the marked pulsation it may occasion in the left hypochondrium or at the scrobiculus cordis, is distin- guished by the single or double blowing sounds, which are heard not only over the thorax, but also over so many arteries of the body, and by the character of the pulse. ZMinbar and Psoas Abscess. — In some cases, soft, fluctuating, deep-seated tumors, which are really produced by an aneurism, may arise in the lumbar region ; nay, they may seem to point, as happens in psoas abscess, at Poupart's ligament. But, unlike an abscess, the effusions of blood give rise, with rare exceptions, to impulse and to murmur. Non-aneurisrnfial Pulsating Tumors. — When a tumor of any kind presses upon the aorta, a distinct pulsation is communicated, and the similarity to an aneurism is heightened by the circum- stance that the morbid growth may produce a murmur. The tumors which most usually occasion the phenomena mentioned are : enlargement of the left lobe of the liver, cancer of the pylorus, disease of the pancreas, or of the omentum, or of the mes- entery, and, in rarer instances, enlargement and distention of the kidney, fsecal accumulations, and cancer of the lumbar glands. Now, to avoid error, we must pay close attention to the history of the disorder ; we must trace, by percussion, the outline of the solid mass, and see if it correspond with any viscus ; we must lay stress on the presence of digestive disorders, and on the amount of constitutional disturbance, — both of which are so slight in ab- dominal aneurism ; we must examine the urine carefully, and find out whether there are renal symptoms in the case. Then, in non- aneurismal tumor the patient has almost always been in bad health before the tumor is detected, and the swelling rarely causes pain of such severity as is observed in an aneurism ; moreover, the trans- mitted aortic impulse is, as a rule, lessened by placing the patient on his hands and knees, thus taking away the pressure from the artery. A varicose state of the epigastric veins and the existence of ascites will also decide against an aneurism ; while, on the other hand, the lateral as well as the forward direction of the impulse, violent neuralgic pains in the loins or shooting down the back, and ABDOMINAL PULSATION. 735 an immovable tumor, are in its favor. Still, there are cases in which a morbid growth lying across the aorta occasions symptoms so nearly like those of an aneurism that the most skilful diagnos- tician finds himself in doubt. There are cases of aneurism in which the physical signs are absent, and in which the affection aiFords no indication of its existence, beyond, perhaps, pain. Under these circumstances we can only suspect its occurrence. But supposing that, from the combination of the physical signs and symptoms, we know that we are dealing with an abdominal aneurism, can we be sure that it is aortic ? We cannot ; for, although this is generally its seat, an aneurism of the splenic or the cffiliac ai-tery, of the superior mesenteric artery, or of the renal artery, may produce the same phenomena.* When an aneurism bursts, it gives rise to symptoms which vary with the seat of the rent. The accident is always fatal, but death may not follow for several days ; usually great tenderness of the abdomen and changes in the physical signs are at once produced. * See Ballard, Physical Diagnosis of Diseases of the Abdomen, p. 217. CHAPTER VII. OK THE UEINB, AND ON DISEASES OP THE UKINAKY ORGANS. Before discussing the diseases of the urinary organs let us notice the urine in its pathological and clinical aspects. UEIJSTE. The main function of the kidneys is to remove water and nitro- gen from the system, at the same time that they take from the blood many of its salts. The excreted liquid contains a variety of substances, and by its study we are enabled to arrive not only at the condition of the organ which prepares it, but also at the state of the circulating fluid, and often indirectly at that of several viscera, the disorders of which give rise to impurities in the blood, which the kidneys endeavor to eliminate. Hence the urine, besides being the most accurate index of the condition of the urinary organs, becomes a fair indication of that of many other important secreting glands in the body; and, further, throws light on the workings of the nervous system. To glean the full benefit from an analysis of the urine, we must explore it not merely qualitatively, but quantitatively, and examine its deposits with the microscope. Modern chemistry is especially endeavoring to find means which will bring it within the power of every one to determine, by apt volumetric processes, the exact pro- portion of the ingredients as accurately and as easily as hitherto we have detected their presence. This is a subject which cannot be more than indicated in these pages : only such of these investi- gations will be noticed as have furnished results which may be made readily available for the exigencies of professional life. It is customary, in quantitative analyses, to use the French system of measures, and to employ instruments on which cubic centimetres are marked. One thousand cubic centimetres are equal to one litre, or 2.1 U. S. pints, or to a thousand grammes of 736 THE UEINE, AND DISEASES OF THE UEINARY ORGANS. 737 water ; and one gramme is equal to 1 5.434 grains ; one centi- gramme to .1543 of a grain. Urine, in its normal state, is of acid reaction, of amber-yellow color, and of specific gravity of 1018 to 1025 as compared with distilled water at 1000. On standing from eight to twelve hours, a slight cloudy deposit takes place, consisting mainly of mucus, epi- thelial cells from the urinary passages, and a few crystals. Healthy urine freshly voided contains no bacteria, and is aseptic. Ordinarily, urine soon undergoes decomposition, which renders the results of analysis valueless. It is advisable, therefore, to examine every specimen promptly, but, as this cannot always be done, the addition of some preservative may be needed. Chloro- form seems to be the most suitable ; six or eight drops added to each fluidounce, the mixture to be well shaken, will preserve samples for months, even in hot weather. Chloroform gives a strong reaction similar to sugar with Trommer's test, but does not reduce bismuth subnitrate nor interfere with the phenyl- hydrazin test. It arrests the fermentation of sugar and of urea. In the examination of sediments great advantage, both as to time and complete collection of the suspended matters, is gained by the use of a centrifugal machine, several forms of which are now procurable. Where a motor current is available, the electric centrifuge is the best. The method tends to exaggerate the amount of material, as compared with the old method of sedimentation. We may also obtain casts and other free elements which otherwise would escape. In addition to its usefulness in urine-examination, a good high-speed centrifugal machine is of much use in other clinical work, especially in examining sputum and blood. Purdy's percentage tubes add much to the advantage of the instrument. The manner of obtaining a specimen of urine is not unimpor- tant. We should instruct our patient, as is so strongly recom- mended by Sir Henry Thompson,* to pass the first two ounces into one vessel, and the remainder into another. We thus procure a specimen of the renal secretion, in addition to anything in the bladder, separate from any urethral products, and avoid the error of confounding prostatic or urethral with vesical or renal disease. When it is essential to obtain a specimen of urine absolutely pure * Clinical Lectures on Diseases of the Urinary Organs. 738 MEDICAL DIAGNOSIS. and unmixed with products of the bladder, the same authority recommends the drawing off of the urine by means of a soft gum catheter, while the patient is standing. The bladder should then be carefully washed out by repeated one-ounce injections of warm water. The urine is now to be permitted to pass, as it will do, drop by drop, into a small glass vessel. The bladder contracts around the catheter, and the urine percolates direct from the ure- ters, through their virtual prolongation, — ^the catheter, — into the receptacle. The urine passed in the morning, immediately after rising, will be found to represent with sufficient accuracy the general process of disassimilation ; but, if greater accuracy be de- sirable, a specimen of the mixed urine of the twenty-four hours should be used. As regards the quantity of urine daily voided, the mean average of healthy persons is 1500 cubic centimetres (fifty fluidounces). In summer, when the skin is acting freely, less fluid passes off by the kidneys than in winter. The more liquid that is taken into the system, the greater is the secretion of urine, unless the other organs that eliminate water, as the skin, the lungs, and the intes- tines, are excretin;^ with unwonted activity. The quantity is diminished in all cases in which the specific gravity is increased, with the exception of diabetes ; it is dimin- ished in acute diseases, in fevers, in cholera, and in the early stages of dropsies ; in some forms of Bright's disease, particularly the acute forms, through their entire course, and often in the last stage of all forms of that disease. It is, on the other hand, augmented in cardiac hypertrophy and whenever the specific gravity is diminished; in hysteria; in contracted kidney, and in polyuria. In almost all vesical and renal affections frequent micturition is a marked symptom, — not always, however, asso- ciated with increased quantity of urine. The ingredients of urine are numerous. The principal are : urea, sulphates, phosphates, chlorides, uric acid and urates, kreat- inin, hippuric acid, mucus, coloring-matter, and a large proportion of water. The following table, by Parkes, shows the composition of nor- mal urine, the figures representing the amount passed in twenty- four hours by a male adult weighing sixty-six kilogrammes (one hundred and fifty pounds). THE UEINE, AND DISEASES OF THE URINARY ORGANS. 739 "Water 1500.00 grammes. Urea 33.18 " Uric acid .5-5 " Hippuric acid .40 " Kreatinin .91 " Pigment and minor organic matters 10.00 " Sulphuric acid 2.00 " Phosphoric acid 3.16 " Chlorine 7.00 " Ammonia 0.77 " Potassium 2.50 " Sodium 11.90 " Calcium .26 " Magnesium .27 " In the present state of our knowledge of the condition of sub- stances in solution, it is not possible to arrange these ingredients in definite combinations. Besides the elements mentioned, the quantities of which fluctuate with the food-supply and with the activity of tissue-metamorphosis and vary especially when the system is deranged, we meet, in morbid states, with substances that do not exist at all in healthy urine, or the presence of which is doubtful, such as various forms of albumin, sugar, blood, bile, fats, oxalate of lime, and certain pigments. Most of these are dissolved in the urine, and are not to be detected except by deli- cate tests ; others form in sediments after the urine has been dis- charged, and may be recognized by the microscope. Having thus, in a general manner, mentioned the constituents of the urine, normal and accidental, let us, in the same general manner, look at the points of clinical interest to be decided by an analysis ; in other words, let us ascertain what the physician, not the professed chemist, is in quest of. Usually, we endeavor to fix all these waymarks : the color, the specific gravity, the quantity, the reaction, the presence or absence of such important abnormal ingredients as albumin and sugar, and the character of the deposits. Frequently, too, we, extend our examination until we have determined approximately, if not accurately, the increase or diminution of the main con- stituents of the urine, especially of the urea, uric acids, chlorides, phosphates, and sulphates, and the distribution or non-distribution of bile and other unusual constituents through the fluid. Let us examine these points more in detail. 740 MEDICAL DIAGNOSIS. Color. — The color of the urine is much affected by food and medicine, as well as by various morbid processes ; so rapidly, in- deed, affected, that we must be chary of drawing conclusions from the appearance of the secretion alone. Yet we suspect the pres- ence of certain substances, or are nearly positive of their absence, by the appearance of the fluid. Thus, a smoky or a red aspect is apt to be owing to admixture of blood ; a very light color denotes generally an increase of water, and is commonly found in dia- betes, in hysteria, and in kindred nervous affections. In febrile diseases the urine is of dark hue. A greenish-yellow or brown- ish tint of the discharge is indicative of bile ; but a similar tinge may be present when rhubarb has been taken. A dirty-blue urine happens from an indigo sediment ; it is alkaline, and occurs chiefly in typhus and in cholera. Strong coffee darkens the urine ; tur- pentine darkens and imparts a violet odor to it ; carbolic acid, tar, and oreasote render it black ; so do disintegrated blood and mel- anotic cancer. Santonin, logwood, and senna discolor it. The first-named substance gives it a bright yellow color, which on the addition of an alkali becomes crimson. Senna may impart to it a brownish or a deep red color, which, however, like that due to rhubarb, is lightened on the addition of mineral acids, and is thus distinguished from the hue of urine containing blood. The altered "appearance is mostly due to the coloring-matter of these articles being excreted with the urine. The chemistry of the coloring-matters of the urine is still incom- plete, and the clinical significance of the color-changes still obscura The principal normal coloring-matter is urobilin, which is an oxida- tion-product from blood and bile-pigment. In febrile conditions a less oxidized product is excreted, which MacMunn has named pathological urobilin and declares to be identical with the color- ing-matter of the faeces, stercobilin. He further states that the presence of this body in the urine is to a certain extent an indi- cation of the absorption of fsecal matter and ptomaines which have not been destroyed by the liver. Other pigments have been described, among which may be named uroerythtine and uroehrome. The employment of the spectroscope is one of the means of dis- tinguishing between these colors, but a description of their minute differences would be beyond the scope of this work. Specific Gravity. — We take the specific gravity of urine to THE URINE, AKD DISEASES OF THE UEINAEY OEGANS. 741 judge of the solid matter it contains. The readiest means is the urinometer. For the implement to yield trustworthy results the fluid should be brought to the temperature at which the urinometer has been graduated. A difference of 7° F. corresponds to about 1 degree of the urinometer. Most instruments are graduated for use at 60° F., and the cheaper forms are often inaccurate. Squibb makes a urinometer adapted for use at 77°, which is convenient for office work. It is easy to obtain instruments sufficiently ac- curate for clinical use. More accurate than the urinometer is the specific gravity bottle, or the Westphal balance. If there be but a small quantity of urine for examination, we note the amount and how many volumes of distilled water it takes to fill the vessel to the height required to float the urinometer. We then multiply the number above ] 000 that the instrument shows, by the total number of volumes of the mixed fluid. This is only approximate. From the specific gravity we may calculate approximately the quantity of solid matter passed by multiplying the number above 1000 by 2.33. This may be done whether we estimate in grammes or in grains. For instance, in urine of specific gravity of 1010 there will be 23.3 grammes of solid matter in each 1000 grammes of urine; in urine of 1030, 69.9 grammes. This in- formation obtained, it is easy to find the whole amount of solids contained in the urine of twenty-four hours, after ascertaining the quantity passed in that time. To take the first illustration : if 1000 grains yield 23.3 grains of solid matter, how much would be yielded by 20,000 (the quantity passed, let us say, in twenty- four hours) ? 1000 : 23.3 : : 20,000 : x. x = 466 grains. This method is not very precise ; when exactness is required, the urine must be evaporated until a dry residue is left, which should then be carefully weighed. The amount of solids in healthy urine is variously estimated. Beale places it approximately at from 800 to 1000 grains in twenty-four hours; Hofmann and Ultzmann fix it at 60 to 70 grammes, — about 920 to 1080 grains, — and in persons who are fasting, or have taken little food, as in fevers, at 30 grammes, in the twenty-four hours. As a rule, the proportion is greatest in persons of heavy weight : if, therefore, we wish to make nice 742 MEDICAL DIAGNOSIS. comparisons, the weight of the body should be always stated. To ascertain how much of the solid matter consists of mineral matters, the organic substances must be burned off at a red heat. In disease, the solids, and with them of course the specific grav- ity, fluctuate very much. We find the specific gravity decidedly increased, rising to 1030 or higher, when sugar or an excess of urea is present, and when the urine is concentrated and of deep color. A low specific gravity is met with in certain forms of Bright's disease, in many cases of hysteria, and in pale urine except that of diabetes. But to be accurate — and, indeed, accu- racy in regard to the other physical and chemical properties is unattainable without attending to the same rule — we must noi lay stress on the specific gravity without taking into account the measure of urine passed in the twenty-four hours, as well as the quantity of drink and of food swallowed ; all of which of ne- cessity influences the specific gravity. So, too, does the activity of the tissue-metamorphosis. Reaction, — Normal urine usually reddens blue litmus-paper. The acidity depends upon acid salts, especially acid sodium phos- phate. The degree of acidity is, even in health, not always equal, and is much influenced by digestion. If no food has been taken for hours, the discharge is highly acid ; that passed after a meal, and while the process of digestion is going on, is but faintly so, or neutral, or even alkaline. In about three or four hours after meals the alkaline tide turns, and the acidity of the urine slowly increases until food is again taken. There seems, however, to be a limit to the increase of acidity, for Bence Jones found that continuing to fast for twelve hours beyond the usual meal-time did not intensify the acidity of the urine. . The alka- linity of the urine after meals is rarely detected at the bedside. For, although the urine may be alkaline when secreted by the kidneys, it is generally mixed in the bladder with that which collected before or after the alkaline tide, and the mixed urine when passed may have an acid reaction. The acidity of the urine is augmented by the administration of the vegetable or the mineral acids ; yet they do not cause, even in large doses, as great variations as does digestion. We find the urine very acid during a meat diet. We find acidity of the urine THE URINE, AND DISEASES OF THE URINARY ORGANS. 743 strongly marked if any acid be present in it which sets the uric acid free, or if this be in decided excess. For determining reaction, litmus-paper is used. Solution of lit- mus is divided into two parts ; to one part nitric acid is added, drop by drop, until the color is wine-red. This is then mixed with the other half. Slips of filtering-paper are dipped in this and dried. They hare a purple tint, and are very delicate, responding to a trace either of free acid or of alkali. We thus avoid the use of two colors. Litmus-paper is best kept in a closed dark bottle. We may estimate the amount of free acid in the urine by a solution of sodium hydroxide (caustic soda) containing 4.0 grams to the litre. This solution is added drop by drop to 100 cc. of urine, which has been measured off in a beaker glass. After the addition of each half cubic centimetre, a drop of the mixture is placed, by means of a glass rod, on well-prepared litmus-paper. When the paper is no longer reddened, the analysis is finished ; and by noting how much of the standard solution has been used, we can determine the acidity of the urine, which it is customary to express as equal to so many grains of oxalic acid, the value of the sodium hydroxide solution in terms of oxalic acid having been previously ascertained. Urine, when voided, remains ordinarily acid for at least a day ; but it may lose its acidity much sooner. This is always a signifi- cant fact, having much the same meaning as if the fluid had been discharged in a neutral or an alkaline state. Now, an alkaline reaction may result from several causes : from the effect of digestion, as already mentioned ; from the presence of sodium or potassium carbonate ; or from the decomposition of the urea into ammonium carbonate. In tho former case, heat does not restore the color of the red litmus-paper, — it remains blue ; in the latter, a gentle heat soon brings back the original red tint. Moreover, in either case, the earthy phosphates are precipitated, the fixed carbonate causing the precipitation of the amorphous calcium phosphate ; while by the ammonium carbonate ammonium and magnesium phosphates, in conjunction with the calcium phosphate, are thrown down, and the triple phosphate is abundantly formed, and can be easily recognized under the micro- scope by its prismatic crystals. Alkalinity of the urine from fixed alkali is not inconsistent 744 MEDICAL DIAGNOSIS. with health. We have adverted to the effects of digestion and to the fact that alkaline urine results from the use of certain articles of vegetable food, or of the salts of sodium and potassium. Urine owing its alkalinity to ammonium carbonate is always to be viewed as pathological. The disturbance is generally long continued, and the^ urine loses its acidity in the bladder, in con- sequence of a disease of the mucous coat of the viscus, or from being long retained there, as in cases of paraplegia, or from ad- mixture with pus, which acts as a kind of ferment and leads to decomposition of the urea. Changes in the Quantity of the more Important Con- stituents of Urine. — Urea. — The amount of urea excreted by well-nourished, healthy, adult males in the twenty-four hours is estimated, in round numbers, by Roberts at 3J grains per pound weight of the body, and by Neubauer and Vogel at 25 to 40 grammes, or 0.37 to 0.6 gramme for every kilogramme of weight of the body. Purdy places the mean excretion of urea in healthy adult males between the ages of twenty and forty years at 33.18 grammes (512.4 grains) in twenty-four hours. Urea is the principal product of the change of nitrogenized substances. Its proportion fluctuates, therefore, with the food partaken of, as well as with the activity of the transformation of the structures of the system : hence it becomes the most impor- tant index of the waste and repair of tissues. Exertion of body and of mind leads to the discharge of a larger quantity of urea. If this is replaced by a nourishing diet, nothing is lost ; the body retains its health. But when the requisite amount of nitrogenized aliment is not taken, or, if taken, cannot be assimilated, owing to a disturbance in digestion, the person wastes. We notice, too, in acute febrile states, until their height is reached, hand in hand with the emaciation an increase of this significant urinary con- stituent, — a proof, then, of the rapid and unsupplied disintegra- tion of the tissues. We see the sarrie increase during paroxysms of intermittent fever, in inflammations, and in some cases of nervousness ; also from a predominant animal diet, and in certain forms of indigestion, in which the food is speedily passed off in the shape of urea instead of acting its part in the nutrition of the economy. Degenerative changes in the liver may be accompanied by a diminution of urea-excretion. THE URINE, AND DISEASES OF THE UETNARY ORGANS. 745 A lessened quantity of urea is excreted during fasting, from an almost exclusive vegetable diet, in dropsies, and in many long- continued organic diseases which gradually undermine the general nutrition and diminish tissue-change, or in states attended with diminished oxidation. But the diminished amount in the urine may also be due to a want of secreting power of the kidneys. The urea, or the products of its decomposition, then act as a poison in the blood ; and the symptoms indicative of ursemic poisoning are encountered. Urea is sometimes not found in the urine at all, or only in traces, having been replaced by leucine and tyrosine. Quantitative estimations of urea are almost exclusively made , by the use of solutions of sodium hypochlorite or hypobro- mite, which decomposes the urea, liberating nitrogen and carbon dioxide in amounts proportional to the urea present. The carbon dioxide is kept in solution b}^ using excess of sodium hydroxide or carbonate, and the volume of nitrogen is measured. The most accurate results seem to be obtained with the hypobromite, but this does not keep well, and its extemporaneous preparation is troublesome and annoying. Sodium hypochlorite is readily ob- tained, being the common Labarraque's solution. It keeps in good condition for a long while, and, according to Squibb, who has investigated the matter carefully, gives good results. It must be prepared according to the U.S.P. 1890, — that is, contain a marked excess of sodium carbonate. Several observers have reported that improved eifect results from the addition of potassium bromide (1 gramme to 25 cc. of Liquor sodae chloratse). To avoid the an- noyance of using pure bromine, when it is desired to employ the hypobromite solution, Charles Rice suggested the use of a solution of bromine in potassium bromide. This keeps well, and is more convenient to handle. In this method the solutions used are as follows : (a) 10 grammes of potassium bromide are dissolved in 80 cc. of water, 10 grammes of bromine added, and the liquid shaken until the latter is dissolved ; (6) 10 grammes of sodium hydroxide are dissolved in 25 cc. of water. For use, equal quan- tities of the two liquids are mixed and slightly diluted with water. Sodium hypobi-omite may also be prepared by adding directly 1 cc. of bromine to 25 cc. of the above solution of sodium hydroxide ; but tlie liquid must be used within a few hours, or accurate results cannot be expected. The mixture must be made 746 MEDICAL DIAGNOSIS. in a well-ventilated place, as bromine is exceedingly irritating and corrosive. For collecting and measuring the nitrogen evolved, many forms of apparatus have been devised. That of Hiifner is a standard form, but simpler and less expensive forms are now usually employed in clinical work. Fig. 56 shows a form devised by Doremus, which is much used. The apparatus is filled with solu- tion of hypobromite or hypochlorite, so that when the graduated tube is upright the bulb is about half filled. A large watch-glass or shallow dish should be placed beneath, to catch any overflow. Fig. 56. PiQ. 57. Doremus's ureometer. Greene^B ureometer. A measured quantity of the urine (1 cc.) is introduced by means of the dropping-tube, the opening being pushed well into the bend of the upright tube, and the apparatus being tilted forward to prevent any escape of bubbles or urine into the large bulb. After about twenty minutes the volume of gas is read off; 1 cc. of nitrogen may be taken to represent .0028 of urea, but the tube is usually graduated so as to read directly the percentage of urea, a definite volume of the urine being taken for each test. Squibb furnishes a simple and satisfactory apparatus. Fig. 57 shows Greene's ureometer, also a simple instrument. THE TTRINE, AND DISEASES OF THE UEINAEY ORGANS. 747 Fowler's method has been endorsed by several careful observers. It depends on the fact that the decomposition of nrea greatly reduces the specific gravity of the urine. It may be performed as follows. The specific gravity of the sample is carefully taken, and then 25 cc. added in a large beaker to 175 cc. of solution of chlorated soda (U.S.P. 1890), and, after mixing well, allowed to stand for a few hours, when the specific gravity is again taken. Multiply the specific gravity of this residual liquid by 7, add the specific gravity of the original liquid, and divide the sum by 8, subtract from this quotient the specific gravity of the residual mixture, multiply the remainder by 0.77, and the product is the percentage of urea. In case the urine is of high gravity it is better to use 12.5 cc. diluted with an equal volume of water and then add the 175 cc. of solution of chlorated soda. The result must be multiplied by 2. A method for fixing the quantity of urea approximately is that proposed by Haughton. It consists in the use of tables showing how many grains of urea are excreted in the urine, of which the amount daily passed and the specific gravity are predetermined. On the following page is the table, as abridged by Eoberts. Its main use is as a standard of comparison, and it cannot be depended on when sugar or albumin is present. Urie Acid. — Uric acid, like urea, is a product of the meta- morphosis of tissue. It was supposed by Liebig that the acid is an early stage of the transformation of urea. Hofmann teaches that uric acid is deposited owing to the decomposition of the urates by the acid phosphate of sodium. Under ordinary cir- cumstances, the deposition of uric acid occurs subsequent to the expulsion of the urine ; but should the acid sodium phosphate be in excess, the uric acid may be precipitated before the secretion is voided, and thus give rise to gravel and calculi. This may also happen through too great concentration of the urine. The amount of uric acid passed in twenty-four hours varies from 0.5 to 1.0 gramme. It corresponds in general to the amount of urea in the proportion of 1 to 33. In normal urine the pres- ence of uric acid cannot be detected without the addition of a strong acid, since it exists in the form of soluble urates, which must be first decomposed. The uric acid is gradually thrown down in small red grains, which, should it be desirable to deter- 47 748 MEDICAL DIAGNOSIS, u o w o ,13 13 o S P4 ■a H a o d OQ0«D"<*CM. 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Soc. Med. des Hop., 1880. 840 MEDICAL DIAGNOSIS. tinguish it. Among its early and significant symptoms is pain on pressing the calf of the leg on the affected side. Diseases of the Gapillariss. Some of the organic diseases of the capillaries belong to the arterio-sclerosis in Bright's disease, or to the waxy degeneration in purpura. It is difficult to say what the functional disorders are, for many of them are regarded as forming part of the per- ipheral diseases of the nervous system, and the affection of the arterioles and of the capillaries is a mere vaso-motor spasm in con- nection with the neurosis. This is supposed to be the case in the anomalous localized sensations of cold which some patients have in particular parts of the body, though their persistency is unlike the history of a spasm. The painful flushings of the feet bespeak temporary excessive dilatation of the fine vessels. The so-called " dead fingers" are regarded as a spasm of the arterioles. They are most common in emotional women, but they have also been observed in men.* The finger-tips become white and numb, warmth and feeling returning after a variable time. An attempt has been made to prove a very close connection with Bright's dis- ease, but the dead-finger symptom is not characteristic of this. The disorder may happen only at night, forming part of a pass- ing loss of power and sensation, — the so-called "night palsy." It may disappear with old age.f A spasm of the minute vessels of more permanent character may lead to profound disturbance of nutrition in a part, even to its destruction. This is the case in the so-called symmetrical gan- grene, or " Raynaud's disease." It is a remarkable neurosis, pro- ducing purple discolorations, which are very painful and on which bullae form. These symmetrical patches of blood-stasis or local asphyxia lead to gangrene, which, however, does not terminate fatally, and is generally completed within ten days. The malady is often seen in the hands, beginning in or certainly affecting cor- responding fingers. The patches of local asphyxia, believed to be due to spasm of the arterioles, may recur for months again and * J. E. Squire, Lancet, Deo. 6, 1886. •}• Donaldson, ib. DISEASES OF THE BLOOD-VESSELS. 841 again without the disorder causing mortification of the skin, or this may take place in any attack. The disease may not happen in the fingers or the toes, but on the exterior surface of the forearm and below the knee. By far the greatest number of cases occur in winter, and the disease is thought to be allied to paroxysmal hsemoglobinuria, which, indeed, has been repeatedly observed in association. Neuritis of the afiected part has been found by a number of observers. Henry * looks upon neuritis as a mere coincidence. Raynaud's disease must not be mistaken for chilblains. These do not appear, disappear, and reappear iu the manner in which the discoloration does in Raynaud's disease. In erythromelalgia, described by Weir Mitchell,t there are vascular changes, acute congestion, or cyanosis. The disorder manifests itself in the heel or the sole of the foot, and is attended with great pain. * Trans, of Assoc. Amer. Physicians, 1894. t Medical News, Aug. 1893. CHAPTEE X. DISEASES OE THE BLOOD. In the following sketch I shall attempt to describe only those diseases of the blood which are seemingly, for the most part, idiopathic, and may be recognized by well-marked clinical traits. Prominent among these, and to a certain extent characteristic of all blood disorders, are general debility, a changed aspect of the mucous membranes and of the skin, especially in color, and alterations of nutrition. In the investigation of diseases of the blood the microscope is of the first importance. It informs us with regard to the relative proportions of the white and red globules, and exhibits the pecu- liar homogeneous, fibrinous blood-plates or hsematoblasts. It tells us something as to what part of the blood-making organs the former are derived from ; it indicates whether the red globules are of the right color, whether their outline is regular, whether they form rouleaux properly, and whether their number is de- creased. In this respect recent research has aided us much by supplying us with accurate means of computation. The meth'od of determination of the globular richness of the blood introduced by Vierordt, in 1854, was to allow a stated amount of a definite dilution to dry upon a glass slide, and then by the aid of the micrometer to count the number of the globules. Imperfect as it was, by it he ascertained that the normal number of blood-corpuscles in a healthy male adult was between five and six millions to a cubic millimetre, and that in certain diseases this number was much diminished. Clinical observers confirmed these observations, and subsequent improvements have rendered the apparatus more precise and made the results more accurate. The forms of apparatus now mostly in use are the hsemacytometer of Thoma-Zeiss and the hsemacytometer of Gowers. To these has been added the graduated moist-chamber globule-counter of 842 DISEASES OP THE BLOOD. 843 Malassez. Another form of apparatus for determining the globu- lar richness of the blood is the hsematokrit of Hedin. The Thoma-Zeiss, or Zeiss, hsemacytometer is very simple. It consists of three parts : first, a graduated pipette or mixing- vessel, with rubber tube attached ; second, a counting-cell on an object-slide made of ground glass ; third, a cover-glass with ground level surfaces. When counting the red corpuscles of the human blood, the tip of the finger should be thoroughly cleaned, the middle finger of the left hand being generally selected. By rubbing the end of the finger with a coarse towel a slight hypersemia is induced, so that a cut with a spear-pointed needle will permit of the flow of a drop of blood sufficiently large for examination. The tip of the pipette is placed into this drop, and the blood carefully drawn up to the mark 1, — i.e., one cubic millimetre. After this has been accomplished, the tip should be cleaned by means of a soft cloth and the pipette inserted into a carefully-filtered ten per cent, solution of sodium sulphate, or Thoma's substitute of a three per cent, solution of sodium chloride. This is drawn up into the tube until the bulb is filled to the mark 101. The blood and fluid are then thoroughly mixed by shaking the tube, hold- ing the finger over the tip of the pipette, that the liquid may not escape. After the mixture has been thoroughly effected, half of the fluid in the bulb is blown out, and the drop that follows is allowed to flow on to the previously cleaned floor of the counting- cell. The cover-glass is then immediately placed in position, and the apparatus allowed to rest quietly upon a horizontal surface for a few moments, that the corpuscles may be permitted to settle. For the success of this operation perfect cleanliness must be main- tained throughout. In order to make the examination, the slide should be placed in the stand of the microscope and held in a horizontal position, that the corpuscles may not be displaced. The cover-glass should lie accurately ; great care should be taken that no liquid flow between the cover-glass and the ring. It is important that the drop of blood mixture shall remain standing in the centre of th^ cell, and that by the spreading of the cell the under surface of the cover-glass shall be in contact with the mixture for several millimetres. Using a one-fourth or a one-fifth objective glass to 53 844 MEDICAL DIAGNOSIS. bring into view the divisions cut upon the floors of the cell, we find that upon these lie the red blood-corpuscles. The number of corpuscles in each space is then noted. Through each fifth horizontal and vertical row of the lines an additional line is drawn, for the purpose of fixing more readily the position of the squares counted. Each field of the net-work contains a surface of o^e four-hun- dredth of a square millimetre. The distance of the cell-floor Fio. 68. <^ ~> ■\ A / \ s / \ m ^ ^ ^ ^ ^ — k *>«) ^i % £8 3 % © ?^ © <3 % © © ® D® ©® ©«) E^ vZ o9 *'# % ^S ®* © © © \® © Do % o ? — ^. ^ % TT ® O 1^ 7 ^ ^ ¥=- ^ £ "^ 1 \ iiiiliii nil II / \ k iiiipi III II y 1/ \ V. ^ / y Artificial capillary of Malassez, magnified 100 diameters. from the under surface of the cover-glass is one-tenth of a milli- metre. Each square, therefore, represents the one four-thousandth of a cubic millimetre. The number of corpuscles contained in one of these cells multiplied by the number of times the blood has been diluted will give the amount of corpuscles contained in the one four-thousandth of a cubic millimetre. The amount con- tained in a cubic millimetre can, therefore, be found by multiply- ing by four thousand. The surest method is to count at least forty spaces, to take the average of them all, and proceed as above. It is sometimes rather difiicult to distinguish the white from the red blood-corpuscles, and this difiiculty is obviated by adding the one- third per cent, solution of acetic acid to the diluted blood. Another method for computing the white corpuscles and DISEASES OF THE BLOOD. 845 I'iG. 69. their relative number to that of the red is to use, with the salt solution, a few drops of a one per cent, solution of gentian violet ; this leaves the red blood -corpuscles unaltered and stains the leucocytes a deep violet. The following method for differential counting of leucocytes in fresh blood has been devised by Elzholz. After drawing blood into the pipette, a solution composed of seven grammes of two per cent, eosin solution, forty- five grammes of glycerin, and fifty-five grammes of water is added ; then, a solution composed of four drops of concentrated watery solution of gentian violet with one drop of absolute alcohol and fifteen grammes of water, by which the polynuclear cells are more deeply stained ; the eosinophile cells are reddish violet. The hsemacytometer of Gowers is about the same as that of Zeiss, differing mainly in the number of divisions on the cell, each space being but one-tenth of a millimetre in length. The method of preparing the blood solution is not so convenient as that of Zeiss. A hsemic unit of five millions of corpuscles to one cubic millimetre of blood is assumed. By the original method of Malassez the blood was diluted with artificial serum so that it repre- sented Yw ^^ 2^ °^ ^^^ original. A small amount was then introduced into a flattened capil- lary tube of known capacity and, with the mi- crometer eye-piece, the globules were counted in the capillary tube of a certain length, say 500 micro-millimetres. The capacity of this length of the tube in parts of a cubic millimetre being already known, the entire number of globules in a cubic millimetre of the undiluted blood was easily determined by calculation. For the purpose of diluting the blood* Potain's capillary pipette (Fig. 69) is well adapted. *It is so constructed as to contain in a part of its extent a reservoir Potain's pipette. * Malassez recommends for artificial serum a five or six per cent, solution of sodium sulphate, having a specific gravity of 1020 to 1024. 846 MEDICAL, DIAGNOSIS. imprisoning a glass bead, the capacity of tliis chamber being ex- actly one hundred times that of the capillary tube leading to it. To the opposite extremity is attaxjhed a rubber tube, which, when placed between the lips, causes the fluid to ascend to the desired extent by aspiration, or by blowing through it the tube may be emptied. Malassez, in describing his new globule-counter,* recommends, without abandoning his original design, an improved cell for Fig. 70. j^'^ ' • _ - I Graduated moist-chamber of Malitssez. In the lower figure the compressor is seen attached to the slide. microscopic work. It consists of a thick glass slide having ground in the centre of its upper surface a ring or circular trench one and a half millimetres in breadth and one millimetre in depth,- which leaves a plateau about seven millimetres in diameter sepa- rated from the remnant of the surface of the slide by a narrow gutter, so that when the cover is in position water may be placed under it by capillary attraction, but cannot reach the islet in the centre. In this way any fluid may be protected from evapora- tion while under examination, — an important precaution while counting blood-cells. Outside of this ring, three or four holes' pierce the glass slide, from which the points of screws are made to * Arch, de Phys., 1880, and Oct. 1882. DISEASES OF THE BLOOD. 847 project, so as to maintain the cover-glass at exactly one-fifth of a millimetre above the surface. A micrometer scale is engraved upon the object-holder, which obviates the necessity of regulating the microscope in advance. The scale on the object-holder is divided into rectangular spaces one-fourth of a millimetre long by one-fifth broad, representing each one-twentieth of a square millimetre. Each of these is subdivided into twenty little blocks, as shown in the figure (Fig. 71). Fig, 71. Blood-mixture as seen with the square micrometer ruling of the moist-chamber of 1 nified 250 diameters. mag- In order that the cover-glass shall be placed quickly and exactly upon the screw-points and the drop of diluted blood, the cover is attached to a frame moving upon a hinge, which is clamped to the slide. The glass slide is kept perfectly horizontal, and, if it is feared that the object examined will dry, a little water or the blood-mixture may be dropped upon it, so as to surround the circle already mentioned. The number of globules contained in 848 MEDICAL DIAGNOSIS. twenty of the little squares is now to be counted, and if the fluid used be a centesimal dilution it is only necessary to add four ciphers to the number in order to obtain the number in a cubic millimetre, since the large squares represent the ten-thousandth part of this unit. To be exact, several observations should be made. The greatest care is required after each enumeration, in order to insure cleanliness. Fio. 72. Daland's HajMATOKRiT. — The cpntral cut represeDtB the complete instrument, with revolving tubes in position. To the left is the tube-holder or frame, with one tube removed so as to show the spring, by which the tube ia to be held in place. To the right is a tube containing blood that has been subjected to centrifugal force, indicating ninety per cent, of corpuscular elements, as compared with normal blood. The use of the hemacytometer in any form requires skill, pa- tience, and leisure, and even with great care the counts are not accurate, varying between two and four per cent, of error. The DISEASES OF THE BLOOD. 849 eye-strain in counting the cells in a suificient number of squares to insure even an approximately correct result is very considerable. In order to obviate this, Hedin,* in 1890, devised an ingenious apparatus, which he named the hsematokrit, by which the entire mass of the globules in a definite quantity of blood can be rapidly ascertained. The instrument consists of a capillary glass tube, correctly graduated, in which a certaiu volume of diluted blood is held, while the tube is subjected to centrifugal action, by which the separation of the plasma and the cellular elements is effected. The proportion is determined by the scale engraved upon the side of the glass tube, and the globular richness of the blood is promptly determined. If this be supplemented by a microscopic examination to determine the proportion of the leucocytes to the red cells, and the hsemoglobin also ascertained by the Fleischl hsemometer, the most important clinical data in a case of anaemia are supplied. The original instrument of Hedin has been advanta- geously modified by Gartner,t Arnold,^ and especially Daland.§ The illustration represents the form i:ised by Daland. It is essentially a .machine for producing rotation of a metal frame supported upon a spindle and arranged to carry two glass tubes, the outer ends of which fit into small, cup-like depressions, the bottom of which is covered with thru rubber. The glass tubes are held in place by springs at their inner extremities. Each tube measures 50 mm. in length, with a lumen of half a millimetre, and upon it is a scale representing one hundred equal parts; a lens front, by magnifying the column of blood, facilitates the reading of the scale. A single revolution of the large handle causes one hundred and thirty-four revolutions of the frame, so that a speed of ten thousand revolutions in one minute can be readily obtained. Daland instructs us to secure the instrument firmly to a solid table, and to oil it daily when in active use. The method of employing the hsematokrit is simple. To fill the glass tube, a rubber tube is slipped over the end of the capillary pipette, and to the extremity of this rubber tube a mouth-piece * Scandinavisches Arohiv fiir Physiologie, No. 2, 134 ; Prager Med.Wochen- schrift, 1891. f Berliner Klinische 'Wochensdirift, 1893, No. 4. t Medical News, 1894, Sept. 29, p. 348. § Transactions of the College of Physicians of Philadelphia, May 2, 1894. 850 MEDICAL DIAGNOSIS. is attached, precisely in the same manner as when the hsemacy- tometer is used. This glass tube or pipette must be absolutely clean and dry. The finger of the patient is punctured ; the blunt point of the pipette is to be placed into the blood, and the tube completely filled by suction: The finger of the operator is then quickly applied to the blunt extremity of the tube, which is next inserted into the frame, and rotated at the rate of ten thou- sand times per minute. All that remains is to read the percentage volume of blood from the scale. The divisions on the pipette are one-half millimetre apart, so that the scale can be read with- out difficulty. The entire procedure need not occupy more than three minutes, and requires no special skill, while the elements of error are so few that the results are trustworthy. In health the volume of red corpuscles is a little over fifty per cent., so that by doubling the number as read from the scale we can get a proportionate expression of the percentage of corpuscles in a specimen as com- pared with the normal. The amount of hsemoglobin in each corpuscle is approximately obtained by taking the proportion of red corpuscles obtained by the hsematokrit as the denominator of a fraction whose numerator is the hsemoglobin proportion de- termined by the hsemometer of Fleischl. The condition of even slight leucocytosis is easily recognized, and when the increase in the white blood-cells rises to thirty thousand or more, the grade of leucocytosis is readily detected. With the hsematokrit of Daland, when a column of red corpuscles obtained from a healthy man is examined, the white cells present a sharp, clearly-defined, and shallow white band. When the leucocytes are much dimin- ished in number, this white band is imperfect, and in places the red color of the biconcave disks is visible. In the Amold-Hedin hsematokrit, diluted blood is used, and the readings are made more accurate by the use of a low-power microscope ; the motor runs by electricity. Exact results cannot be obtained by any method, since the norm of five million red corpuscles is not constant. As shown by Henry, there is a diurnal variation in the number in health, so that all expressions of results of examination are only approx^ imate. Whatever be the method used in counting the blood-corpuscles, DISEASES OP THE BLOOD. 851 a number of observations should be always made. Since from any of the instruments but an approximate result can be obtained, the mean of several observations will give us estimates sufficient for all practical purposes. In the several forms of ansemia, it is neces- sary to obtain a correct knowledge of the state of the blood, not only as to the number of its corpuscles, but also as to the amount of haemoglobin contained, for in the diagnosis of any disease of the blood it is absolutely required to know the relationship exist- ing between them. Normal blood contains about five million red blood-corpuscles, nearly ten thousand white blood-corpuscles, and two hundred and fifty thousand blood-plaques or hsemato- blasts,* to the cubic millimetre, and each red corpuscle holds in suspension a certain percentage of hsemoglobia. Any marked variation in the number of corpuscles or in the amount of hsemo- globin is indicative of an abnormal state. In estimating the number of blood-corpuscles both age and sex must be taken into account. In healthy women the number per cubic millimetre is somewhat less than in healthy men, being about four million five hundred thousand ; in new-born infants it often exceeds six million^ as both Hayemf and Henry J have found by repeated observations. But in the infant the constitu- tion of the blood is remarkable for its variability. The very suggestive observations of John K. Mitchell § have shown that in adults massage increases enormously for the time being the number of red corpuscles in the blood count. The white blood-corpuscles in normal healthy blood are in the proportion of about one to six hundred of the red, this varying somewhat in different individuals without being indicative of disease. "When the red blood-corpuscles are reduced in number, the proportion of leucocytes is greater, without there being neces- sarily an increase in the number. The safest method of pro- cedure is to estimate the number of white corpuscles to the cubic millimetre, so that any increase or diminution in their amount will give their true condition irrespective of the change in the number of red disks. The same observation may be applied * Hayem, Du Sang, Paris, 1889. f Du Sang et de ses Alterations anatomlques, Paris, 1889. J Amer. Juurn. Med. Sci., April, 1890. § Transactions of the College of Physicians of Philadelphia, 1893. 852 MEDICAL DIAGNOSIS. to the hsemoglobin, for often this is only relatively diminished, whereas, if the red blood-corpuscles were counted, we should find that each disk had its normal or even an increased amount of hsemoglobin. The chief apparatuses for estimating the hcemoglobin are the hsemoglobinometer of Gowers, Fleischl's hsemometer, H6nocque's hsematoscope, and the chromocytometer of Bizzozero. Of these, the hsemometer of Fleischl is the most used. H§- nocque's is especially valuable for spectroscopic examination. , Gowers's apparatus consists of two glass tubes of exactly the same II Fig. 73. ^A i. C-nl 1-81 I ii ...J' i The hBemoglobinometer of Gowers. A, bottle with pipette-stopper; B, capillary pipette ; G, graduated tube ; D, tube contaiuiDg standard tint, fixed in £, a wooden block ; F, guarded needle. size. One contains a standard of the tint, of the dilution of twenty cubic millimetres of blood with one thousand nine hundred and eighty cubic millimetres of water. ' The second tube is graduated to one hundred degrees, which equal two cubic centimetres. The twenty cubic millimetres of blood are measured by a capillary pipette. This quantity of the blood to be tested is dropped to the bottom of the graduated tube, a few drops of distilled water being first placed in the latter, and the mixture is rapidly agitated, to prevent the coagulation of the blood. The distilled water is then added drop by drop until the tint of the solution is the same DISEASES OP THE BLOOD. 853 as that of the standard, and the amount of the water added indi- cates the amount of haemoglobin. Fleischl's hsemometer* consists of a stand to which is attached a reflector made of card-board. On the under surface of the plate there are two grooves, into which slides the frame, hold- ing in position a wedge-shaped glass colored red, the intensity of the hue being graduated from zero to one hundred and twenty degrees. The frame is moved by means of a thumb-screw so that when it is operated the tinted glass passes beneath one of the compartments of the comparing vessel. The horizontal projec- tion of the partition of this vessel should fall directly upon the outer edge of the glass wedge when the instrument is properly adjusted. In operating the instrument, care should be taken to have everything perfectly clean. Accompanying each apparatus, are a glass pipette for dropping the water into the compartments, and several minute capillary tubes for securing the blood. The compartments — that is, the blood and wedge compartments — are filled almost to the top with distilled water, and the vessel is placed in situ. The instrument should then be so arranged and the reflector so adjusted as to secure the full rays of light from either a candle, a lamp, or a gas-flame. Before securing the blood, the tip of the middle finger of the left hand should be carefully cleansed and dried. The automatic blood-pipette, with a capacity of six and a half cubic millimetres, and about eight millimetres long, to which is attached a frail wire for its manipulation, should always be greased, to prevent the blood from adhering to its sides. This is dipped into the blood sideways, to facilitate the flow into the tube : the greatest accuracy is essential to the correctness of the test. "With as little delay as possible the tube is then placed into the blood compartment and its contents allowed to escape, aiding by gently moving the tube back and forth along its own axis. The diluted blood remaining in the tube is then washed out by means of the pipette and allowed to flow into the compartment. This is filled, as is the wedge compartment, with distilled water, care being taken not to allow the fluid in the two chambers to run together, and that the upper surface of the water is perfectly level, neither curved nor concave. * "Wiener Med. Jahrbiicher, 1885, pp. 425-445: Das Haemometer. 854 MEDICAL DIAGNOSIS. The blood is now ready for examination. In looking at the compartment the eyes should be shaded, that the direct rays of light may not strike in and thus cause error in the observa- tion. The thumb -screw is turned, which slowly moves the wedge from right to left ; this movement is continued until the eye can perceive no difference in color between the two compartments : mi 90 f. 80 i( 70 S^ «)% m% •a 1S8 P IG. 74 APRIL MAY JUNE 7 9 !1 IR In '7 11 ".] R3 Sft 27 ^fl 1 3 r, 7 !) 1! 13 15 17 19 SI 9.H 25 27 29 31 2 4 8 10 12 H 10 18 20 6,000,000 6j00O,000 ^ ■^ - ^ — ^ f- ■^ 4,000,000 , - -* ^ - ^ 3,000,000 ^ ^ ^ 2,000,000 , --1 ^ 1,000,000 500,000 850,000 200,000 150,000 100,000 80,000 80,000 70,000 60,000 50,000 40,000 30,000 80,000 18,000 16,000 14,000 12.000 10,000 8,000 „ - 6,000 — — ' — ' 4,000 2,000 120 S6 llOJf 100 iS 30^ 80^ 70 )J 60% 60^ iOf, 30 JS 10^ 5J( 8S« 1* BLACK = RED CORPUSCLES RED = HAEMOGLOBIN BLUE=COLORLESS CORPUSCLES Chart showing blood changes in chlorosis. should the difference be imperceptible for a considerable distance, then the point at which the color appears lighter and that at which it appear.? darker should, both be noted and the mean ascertained. The number of degrees — that is, the percentage of haemoglobin as compared with healthy blood, which is taken as one hundred — will be found on the movable slide. DISEASES OF THE BLOOD. 855 ■ - It is often a matter of great convenience to represent the blood- exanjinations graphically. An excellent chart for this purpose is in use at the Johns Hopkins Hospital. Fig. 74 shows it, and the manner in which the record is made. Anaemia. — Poverty of blood is met with as a consequence of profuse or frequently-recurring hemorrhages, of insufficient nour- ishment, of aifections which prevent the nutriment taken from being properly absorbed or assimilated, thus impoverishing the blood by depriving it of its most needed constituents, and of pro- fuse chronic discharges, which drain the blood of many of its important elements, and especially of its albumin. Besides these causes of anaemia, we find it occasioned by particular poisons, as by malaria, by syphilis, by uterine complaints, by the retention of noxious ingredients in the blood, or by diseases of certain glands. Again, it is sometimes encountered apparently resulting from con- stipation, or without our being able to trace it to any obvious source. But under all these circumstances except in the anaemia after hemorrhage, where all the constituents of the blood are diminished together, we have to deal with a watery blood deficient in red corpuscles, and the corpuscles are often badly shaped, and shrunken at their edges. The haemoglobin may be increased rela- tively^ or it may be diminished, or it may not be materially changed. Whatever may have given rise to the anaemia, the manifesta- tions of the disorder when well marked are much the same. The patient is weak and pale ; his lips and tongue have lost their red color ; the eye is pearly ; his pulse is feeble, but generally accel- erated ; the appetite is deficient or depraved ; the bowels are apt to be costive. Yet some persons, who are apparently well nourished and are not pale, may have deficiency of red blood cells and of haemoglobin. Exercise induces great fatigue, short- ness of breath, and palpitation ; and the disturbance of the heart may be associated with cardiac murmurs or with blowing sounds in the cervical veins, and is sometimes so persistent as to lead to structural changes. In some cases, among the symptoms we meet with obstinate headache and with dropsy, and in many with a persistent pain in the left side, in the region of the spleen. Ansemia may be owing to the presence of parasites, such as intestinal worms. The very marked form which is common in 856 MEDICAL DIAGNOSIS. Egypt is that due to anehylostomiasis. The ahohylostomum duo- denale is taken into the body in the muddy water, or by eating earth containing the embryos of this worm. Anehylostomiasis is an insidious, wasting disease, characterized by progressive ansemia and by digestive and nervous deterioration, occurring chiefly in earth and brick laborers of warm climates, caused by the presence in the duodenum and jejunum of a blood-sucking, rhabditic, nematode worm. The blood shows great diminution of red blood-corpuscles and reduction of haemoglobin.* Chlorosis. — Here the pallid, wax-like countenance, the very pale lips, and the pearly eye afford unmistakable evidence of the deterioration of the blood, consisting chiefly in great deficiency of hsemoglobin, which is generally much more marked than the re- duction in the red corpuscles ; these, indeed, may be of almost normal amount. Lloyd Jonesf regards the disease as an exagger- ation of a change which occurs in the blood of the healthy female at puberty, and which leads to an increase of the amount of blood- plasma associated with a diminution of the amount of hsemo- globin. Van Noorden has shown that the assumption of Bunge that there is increased albuminous decomposition in the intestines in chlorosis is unwarranted by the facts. Meinert has noted gas- troptosis in sixty cases of chlorosis, associated with enteroptosis and occasionally movable kidney, to all of which the chlorosis is ascribed, and, as these displacements are produced by wearing corsets, his deduction is that chlorosis is due to faulty wearing- apparel. Clement has found enlargement of the spleen and occasionally phlegmasia alba dolens in chlorosis, which he ascribes to some form of infection. Considerable stress is laid on the fact that in chlorosis there is a greater tendency to inflammation of the optic nerve and retina than in pernicious ansemia, while the tendency to retinal hemorrhage is considerably less.J The complaint is especially encountered in young females, and is, as a rule, associated with amenorrhcea. Indeed, many restrict the term to the obvious ansemia combined with suppression of the menses, so often affecting girls about the age of puberty. In * Sandwiili, Proceedings XI. International Med. Congress, Rome, 1894. t Brit. Med. Journ., July, 1894. J Stephen Mackenzie, Sajous' Annual, 1895, vol. i., L. 10. DISEASES OP THE BLOOD. 857 pure chlorosis, organic diseases of the gastro-intestinal apparatus of the spleen and lymphatic glands, or of the lungs and kidneys, are absent ; the temperature shows a slight rise ; the nutrition of the body is fairly well kept up ; the urine is pale and abundant, containing but a small amount of phosphates. Forchheimer finds a diminution of urobilin in the urine, which he regards as of considerable diagnostic importance. The nervous system is irri- table. Pigmentation about the second joints of the fingers, on their dorsal surface, has been noticed.* Sometimes these symp- toms of chlorosis happen before puberty ; or there are relapses of the malady in middle age. Boys about the age of puberty may also develop the manifestations of chlorosis. Virchow has pointed out the frequent association of chlorosis with narrow- ing of the aorta and of the great arteries, and such cases are distinguished by obstinate relapses. There is a variety of chlo^ rosis in connection with tubercle, at times preceding it. Chlorosis as yell as anaemia may be associated with nasal hypertrophies or the adenoid vegetations in the vault of the pharynx,f and relieved by their removal. Both the corpuscles and the haemo- globin may be decidedly decreased in consequence of surgical shock. J Fever may occur in chlorosis, though to but slight degree. Jaccoud attributes it to anoxaemia, the deficiency of oxygen in the blood acting as a stimulant to the calorific centres. Fever may be also due to local causes, such as phlegmasia alba dolens. Pernicious AnsBmia. — This is a fatal form of ansemia, which was well known, at least in some of its varieties, to Addison, and which, since the recent researches of Biermer, has actively en- gaged the attention of the medical world. It is an extreme anae- mia advancing steadily, or with remissions, toward a fatal end- ing ; yet no certain cause can be detected for the profound and disastrous alteration the blood is undergoing. To pernicious anaemia belong most of the cases of "essential" or "idiopathic anaemia" which, since the time of Addison, have been reported. * Bouchard ; also Pouzet. fF. Oppenheimer, Berl. Klin. "Wochenschrift, Oct. 3, 1892; Sajous' An- nual of the Universal Med. Sciences, vol. iv., 1894. X Joseph Leidy, Jr., Transactions of the College of Physicians, Phila., 1893, vol. XV. p. 242. 858 MEDICAL DIAGNOSIS. The disorder is most frequent in women, and has been especially observed in child-bearing women after several pregnancies ; still, it also often happens in men, especially before the age of forty. It sometimes seems to have its origin in long-continued dyspepsia or diarrhoea, and atrophy of the gastric tubules ; or to arise after protracted hemorrhages or incessant worry, — ^after indeed slowly but steadily-acting debilitating influences ; and it has been noted to arise after nervous shock, or to be of parasitic origin, and due to worms, sometimes to a tape-worm, — bothriocephalus latus.* But in the majority of instances it originates seemingly without cause, and, although it has periods of deceptive improvement which may last for months, or, as I have known, even for a year, it progresses relentlessly toward a fatal issue, f It is true that some cases of recovery have been recorded ; but of these it is not quite certain that they presented all the characteristic symptoms. There is an insidious beginning, except at times when the anae- mia develops itself in the pregnant state. Pale tongue, bloodless lips, pearly eye, becoming paler, more bloodless, more pearly, from week to week ; breathlessness ; palpitation of the heart, es- pecially on exertion ; weak digestion ; constipation, or constipation alternating with diarrhoea ; loud systolic murmurs in the heart, and venous hum in the jugulars ; vertigo ; a marked lemon-colored hue of the skin about the large joints, at times jaundice ; finally extreme exhaustion, sluggishness of mind, fainting-fits, and dropsy, without persistent albumin in the urine, or disease of the liver, or enlargement or valvular disease of the heart, to account for it, — are the prominent symptoms. In the later stages, too, hemor- rhages from the nose and from the gums are not uncommon ; and hemorrhages from the uterus or from the kidneys, or into the skin and into the retina, may also be noticed ; the latter especially is very frequent. Yet, notwithstanding all these grave signs, the body appears well nourished ; there is certainly no decided ema- ciation, except in instances in which fever is more than commonly marked. Now, fever is a significant feature of progressive per- nicious anaemia ; it has been present in every case that I have met * Schmidt's Jahrb., i., 1891 ; also ib., No. 10, 1887 ; and Berl. Klin "Wo- chensoh., No. 40, 1886; also Deutsches Arch, fiir Klin. Med., Bd. xxxix. f See also case with remissions in Schmidt's Jahrh., No. 4, 1882. DISEASES OF THE BLOOD. 859 with. It is not an early symptom, belonging to the full develop- ment or to the latter part of the disease. It is of very irregular type, and not of high intensity, the temperature rarely exceeding 103° F. It is apt to be continued, or to show occasional exacer- bations, followed by remissions, the febrile state lasting for days, or even for a week or two at a time ; then there are periods of shorter or longer duration when it wholly disappears, to come on again in an outbreak attended with all the usual signs of a febrile paroxysm for which no cause is apparent. Toward the end of the fcase it is not unusual for the anaemic fever to have entirely ceased, and for the temperature to have fallen below the normal standard. The disease may run an acute course.* The state of the blood in this perilous malady has naturally been made a subject of minute investigation. The red globules are strikingly diminished in number, — to about a million and a half or less ; the white corpuscles are not relatively altered, or they may remain normal, and seem to be increased, because the red globules are much fewer. The haemoglobin is generally in- creased,f the white corpuscles are normal or diminished, the pale hsematoblasts are diminished and may quickly assume irregular shapes. The shape of the red corpuscles was stated by Eichhorst to be characteristically changed, in so far at least that the blood contains a quantity of ill-developed, small, spherical, highly-col- ored red corpuscles. But these are not pathognomonic ; for they have been found by Cohnheim in medullary leuksemia, and by Greenfield in lymphadenoma ; on the other hand, in a well- marked instance of pernicious anaemia examined by Bradbury | they were absent. They are the corpuscles arrested in their growth. Besides this there are giant cells of irregular shape, on which Hayem § lays great stress, also many very large normal- looking red corpuscles, some of which are, however, nucleated. Nucleated red corpuscles were detected in the bl'ood of all the patients examined by Howard :|| the blood seems to revert to a lower type. This has been also insisted upon by Henry.^ A * Lantener, Eev. Med., Louvain, 1883, ii. f Hayem, Du Sang, Paris, 1889. J British Medical Journal, Aug. 14, 1880. J Op. cit. II Montreal General Hospital Beports, vol. i., 1880. I Ansemia, P. Blakiston & Co., 1887, p. 116. 860 MEDICAL DIAGNOSIS. much larger proportion than is found normally of small disks of deep color, is regarded as important by Pye Smith.* The ac- companying cut (Fig. 75), from a well-marked instance of the Pig. 75. Blood in perniciouB ansemia, illustrating the irregularly-shaped blood-cells (Poikilocytosis). disease, shows the irregular shape of the corpuscles and their varied size and appearance ; some are nucleated. Of the real cause of the disease we are in ignorance. No con- stant lesion of the blood-making glands has been found. The structure of the spleen and of the lymphatic glands is not altered ; the marrow of the bones may or may not be,t though cases in which it is are thought to be instances of myelogenous pseudo- leuksemia rather than of pernicious ansemia. Perhaps the most constant lesion is fatty degeneration of the heart, often associated with the same change in the inner coat of the large arteries. Hunter J brought forward strong proof that the characteristic * Guy's Hospital Eeports, xxvi., 3d Series, 1883. t Pepper, Amer. Joum. Med. Sci., Oct. 1875; see also Colinlieim, Vir- ohow's ArcHv, Bd. Ixviii., and "Waldstein, Arch. f. Path. Anat., Berlin, 1883, xci. X Lancet, London Practitioner, Aug. 1888. DISEASES OF THE BLOOD. 861 anatomical change is the presence of an excess of iron in the liver, the seat of disintegration of the corpuscles being chiefly in the portal circulation. Biruli has found, by microscopic examination, hemorrhages in the substance of the cerebral hemispheres, also round structureless bodies resembling corpora amylacea, and fatty degeneration of motor cells, with shrinking and vacuolation of the cells of Pur- kinje. The existence of some toxic substance in the circulation is highly probable. It can scarcely be doubted that diminished or faulty hsemogenesis may also exist and contribute to the ansemia, as insisted upon by Van Noorden.* Lichtheim,t in 1887, directed attention to alterations occurring in the spinal cord, especially in the form of degeneration in the posterior columns, with slight changes in the lateral and anterior columns, apparently caused by some toxic substance in the blood ; Van NoordenI reported a case of progressive and apparently causeless anaemia in a woman fifty-nine years of age. The red blood-corpuscles numbered seven hundred thousand, with rela- tive increase but absolute decrease of leucocytes ; some small lymphocytes were present, and irregularly-shaped blood-cells (poikilocytes). Death occurred ten months after the onset of the affection. Microscopic sections showed distinct degeneration of the lateral pyramidal and lateral cerebellar tracts, and of the posterior columns. Bowman § regards the ansemia as primary and probably the cause of the change in the cord. Recently, Charles W. Burr || has made a careful study of the spinal cord lesions and symptoms of pernicious anaemia. He concludes that the coexistence of pernicious ansemia and of certain lesions of the cord is not accidental, and that in well-marked ansemia the latter changes are constant. The cervical swelling is the principal site of these degenerative changes. The only parts of the cord ever affected are the posterior columns, the lateral columns in and near the crossed pyramidal tracts, and, rarely, the direct cerebellar tracts. The gray matter is seldom even slightly involved. The * Quoted in Sajous' Annual for 1895, vol. i. L. 8. f Congress fur Innere Medizin. % Charite Annalen, 1891. g Brain, 1894. II University Medical Magazine, April, 1895. 54 862 MEDICAL DIAGNOSIS. degeneration of posterior peripheral roots is ordinarily insignifi- cant. There is usually marked posterior, with less marked lateral, degeneration. Almost invariably a band of normal white tissue separates the diseased area in the posterior columns from the gray matter. Burr favors the view that both the anaemia and the cordal lesions are due to a common cause, — a poison or poisons, as in diphtheria or ergotism. The diagnosis of pernicious anaemia is never an easy one, for the reason that it is difficult to be quite certain that no obscure and latent disease exists which would account for thu exhaustion and the progressive impoverishment of the blood. Indeed, it is only after the most careful and repeated examinations of all the organs of the body and the most searching inquiry into the his- tory of the case that we are justified in making the diagnosis of pernicious anaemia. I have more than once known ill-developed organia disease of the stomach, especially gastric cancer, where the tumor could not be discerned, or contracted kidney, with but little albumin in the urine, I'egarded as a typical illustration of the malady, until the autopsy revealed the true cause of the fatal exhaustion. With reference to the former affection the error is all the more likely to happen because symptoms of gastric dis- order are not unusual in progressive anaemia ; with reference to disease of the kidney the misleading part is that a trace of albu- min is occasionally present in progressive anaemia. But it is not persistent ; and microscopical examination of the urine will tell us the real amount of kidney affection. The cachectic pallor of subjects of malignant disease may be mistaken for the straw- colored appearance of the skin in pernicious anaemia. Diseases of the heart may be mistaken for pernicious anaemia. A fatty heart, in an elderly person, with or without valvular disease, with failure of strength, and with the peculiar pallid, sickly look occasioned by the malady, may mislead. But the long duration of such cases, and the absence of fever, are strong points in the case. Indeed, the error is apt to be the other way, — that, overlooking the symptoms of profound anaemia and general failure, we regard the murmurs and the other cardiac symptoms which are associated with the fatty heart of pernicious anaemia as pointing to a disease of the heart alone. The physical signs will not always assist : the murmurs may be very distinct and' loud. DISEASES OF THE BLOOD. 863 A number of trophic and vascular disturbances have followed surgical extirpation of the thyroid gland, and have also been noticed after atrophy of the gland has occurred. To this condi- tion the name of cachexia strumipriva has been given. It is distinguished from anaemia by the occurrence of signs of myx- oedema often with cretinism and circulatory disturbances, with local asphyxia and transient or intermittent albuminuria. In some cases epilepsy is developed, in others pulmonary phthisis. If we have excluded any organic disease that could account for the anaemia, we turn to the diseases of the blood itself to obtain an explanation of the symptoms. And here we find first that pernicious anaemia diifers from ordinary ansemia by the absence of the history of the causes that commonly give rise to the anaemic state, such as acute diseases, malaria, tubercular or cancerous cachexia, loss of blood, and the like, but above all by its relent- less course and the little influence the most nourishing diet and courses of iron have on it. Moreover, the distinctness of the car- diac murmurs, the slight emaciation, and the irregular outbreaks of fever are significant. The marked accessions of fever, the pres- ence of dropsy, though moderate, the retinal extravasations, the other hemorrhagic symptoms, and the unyielding blood-change, separate pernicious ansemia from the chlorosis so common at the age of puberty in girls. The pernicious malady sometimes seems to develop out of a long-standing chlorosis, and then the grave symptoms just spoken of prove its supervention. The same grave symptoms happen also, at least the hemorrhages are as frequent, and the fever and dropsy may happen, in leuksemia and in pseudo- leuksemia. But the great increase in the white corpuscles, the tumefaction of the spleen, or the affections of other blood-making parts, distinguish the former malady ; and pseudo-leukaemia, while the blood microscopically will not differ materially, exhibits the enlarged lymphatic glands, their progressive invasion, the lym- phoid tumors, the abdominal pains, and the steadily-increasing emaciation so characteristic of the disease. There are other forms of idiopathic anaemia of which we cannot clearly recognize the cause, that we shall probably soon be able to separate into groups. But for the present we have to admit that cases may occur which cannot be classified. Leukaemia. — This morbid state consists in a decided increase 864 'MEDICAL DIAGNOSIS. of the white corpuscles and a decrease of the red. Under the microscope the white globules of the blood, instead of bearing the normal proportion of about 1 to 500 of the red, are found in the proportion of 1 to 6, or even of 1 to 0.5, and cases have been met with in which near the point of death the white corpuscles have exceeded the red as high as five times. Besides the increase of white corpuscles and the diminution of the red, peculiar, color- less, shining, elongated octahedral crystals have been pointed out by Neuniann and by Charcot. Haig has stated that the propor- tion of uric acid in the blood is increased in splenic leukaemia. Jaksch * has shown that the blood is rich in peptone, although this substance is rarely met with in the urine in leukaemia. The abnormal condition exists in connection with hypertrophy of the spleen, " splenic leuksemia," or of the liver, with other dis- eases of this viscera, and with various malignant or non-malignant affections of the lymphatic glands, " lymphatic leukasmia," or of the thyroid body, especially with an increase of the cellular ele- ments. But none of the blood-glands is so constantly and so markedly affected as the spleen. Owing at times to a large pro- duction of lymphoid cells in the marrow of the bones, there is produced also a " myelogenous" or medullary form of leukaemia. The disorder may occur at all ages ; it is more common in men than in women. Leuksemia is consequent upon obstinate intermit- tents with decided enlargement of the spleen, syphilis, over-exer- tion, long-continued mental depression, chronic intestinal catarrh, and blows on tlie splenic region. The form affecting the marrow of the bones frequently results from injury to the bones. Ebstein reported cases of leuksemia following traumatism, but the causa- tive relationship is not clearly made out. But in many cases of leuksemia no adequate cause can be detected. Its beginning is usually gradual and ill defined ; sometimes it clearly follows other diseases. When fully developed, it often occasions, besides the obvious pallor and the cachectic appearance, exhaustion, diar- rhoea, extremely hurried breathing, hemorrhages from various parts, especially from the nose, profuse sweating, slight rise of temperature in the evening, increase of uric acid in the urine, fleeting abdominal pains, and dropsy dependent upon the enlarge- * Wiener Med. Presse, Oct. 1882. DISEASES OF THE BLOOD. 865 ment of the spleen or of the liver or upon the leuksemic new formations in the latter. In some cases a swelling of the glands on both sides of the throat, attended with inflammation of the mucous membrane of the mouth and the pharynx, and followed by swelling of the axillary and the inguinal glands, precedes the enlargement of the liver and of the spleen.* Indeed, glandular tumors are often present ; the glands of the groin are, as a rule, enlarged. There is disturbance of vision, connected with retinal changes, also melancholy, and in some instances deafness, and peritoneal or pleural inflammations. Pain in the bones, too, par- ticularly in the stei;num, is observed. The medullary or mye- logenous variety is especially marked by pain, which is increased or developed by pressure over the sternum and ribs and over other affected bones. f The diagnosis of leukaemia is possible only by the microscopical examination of the blood, which detects the decided increase of the white corpuscles. Mathes has examined the blood in leukae- mia to determine the existence of peptone and allied bodies. Peptone was not found in the blood, but there were deutero- albumoses in the blood and serum. In the serum of one case there was also nucleo-albumin. This probably resulted from destruction of blood-corpuscles. The excretion of uric acid was only moderately increased. In the most common variety, splenic leukaemia, we may be' also able even early to discern the enlarge- ment of the spleen, and to find the evidences of cachexia in the appearance of the patient, and in recurring epistaxis. But it is the microscopical examination of the blood alone which enables us to distinguish leuksemic swelling of the spleen from its other affections. And to have a definite diagnostic meaning the white corpuscles must be decidedly and permanently increased ; for a mere transitory, slight increase may occur in other diseases of the spleen. Some corj)uscles are larger, some smaller, than normal, and many show fatty changes ; but in splenic leukaemia the white corpuscles are mostly large. In both varieties the red corpuscles are badly shaped. Lymphatic leukaemia is chiefly recognized by * Hosier, in Virehow's Archiv, xliii. ; Dunn, Amer. Journ. Med. Sci., March, 1894, describes a case with growths in the orbits. f Mosler, Berlin. Klin. Wochenschrift, xiii., 1876; and Schmidt's Jahrb., No. 10, 1877. 866 MEDICAL DIAGNOSIS. the marked swelling of the lymphatic glands, while the spleen is less obviously affected. In the blood the white corpuscles derived from the lymphatic glands are smaller than those coming from the spleen, and have a well-developed nucleus. Yet it is very difficult to judge a case by these traits. Large round corpuscles containing granules which by ether and chloroform are found to be fatty are stated to be derived from the marrow of the bones, and, if abundant, to bespeak meduUary leukaemia.* Karyokinesis has been noted in some red corpuscles, as well as free nuclei ia the blood. Hayem f found that nucleated red corpuscles were habitually present, and that the very large yvhite cells were des- titute of amoeboid movement. Hypo-leuksemia. — A condition in which there is an actual or seeming diminution in the proportion of leucocytes has been termed hypo-leuksemia by H6ricourt and E,ichet. Maurel has more recently shown that the diminished number of leucocytes is not real, but is due to their arrest and incarceration in the finer capillaries. He therefore suggests that the name false hypo- leukaemia is more appropriate. This arrest of the white cells may be due either to vaso-motor constriction of the small capillaries or to direct action of poisonous agents upon the leucocytes, giving them a spherical shape and sluggish amoeboid movement. Gold- scheider and Jacob express the same view based upon experimental work which seems to indicate the pulmonary capillaries as the point of arrest of the leucocytes. Temporary hypo-leuksemia results from injections of plain bouillon, as well as of various organic extracts, and occurs during the course of many of the infectious fevers, as pointed out by Everard and Demoor.J Lymphadenoma. — As regards the symptoms, the closest simi- larity to leukaemia is presented by the affection described as lymph- adenoma, pseudo-leuksemia, or Hodgkin's disease. It consists in an enlargement of the lymphatic glands of the body, often with lymphoid growths in other parts, which soon becomes complicated with extreme anaemia, with weakness and signs of cachexia, with diarrhoea, with dropsy, with cardiac palpitation, shortness of breath, and attacks of suffocation, with tendency to profuse bleed- * Schmidt's Jahrb., No. 10, 1877. f Op. cit. J Quoted, Diseases of the Blood and Spleen, in Sajous' Annual for 1895. DISEASES OP THE BLOOD. 867 ings and to bed-sores, and leads usually in the course of not many months, or, at farthest, of a few years, to death. There is often a sense of fulness in the abdomen, attended with violent pains ; the temperature in advanced cases shows mostly an evening rise. Some of the superficial lymphatics are first affected, others fol- low ; the disorder then extends more decidedly, the spleen and the liver increase in size, other organs, too, may become involved, and lymphoid tumors develop in various parts of the body ; but among the internal organs the spleen is the one most constantly disturbed. The disease generally begins in the cervical glands ; far less frequently does it show itself first in the inguinal or in the axil- lary glands ; still less frequently in the bronchial or in other in- ternal glands. The afifection occurs much oftener in men than in women. It mostly happens in males between the ages of ten and thirty-five and of fifty and sixty ; it is not very uncommon in young children. Its cause is unknown ; it certainly has no defi- nite connection with either scrofula or syphilis. The chief anatomical lesion is found to be an augmented formation of the structure of the glands. The spleen is either simply hypertrophied or is the seat of numerous disseminated lymphoid growths ; in neither case is it apt to attain to any very great size. At times the follicles at the base of the tongue, in the tonsils, and in the intestines share in the morbid process ; changes in the bone-marrow are rare. The blood shows deficiency in red globules, but otherwise no constant alteration. Slight increase of leucocytes has been occasionally noticed, especially during the later stages ; but even then the white corpuscles are small. It is this difference in the state of the blood that makes the chief difference between pseudo-leuksemia and leukaemia, in which there may be glandular enlargements. Further, leukaemia is a disease, as a rule, of longer duration, and the splenic enlargement is generally much more marked. Rare cases of diffused lymphatic cancer closely resemble Hodgkin's disease ; so closely that they are undistinguishable, except by the history of the case and by a microscopical examination of any of the tumors that may have been removed ; the spleen is not involved, while the organs con- tiguous to the glandular cancer are likely to be more rapidly im- plicated. In sarcoma of the lymphatic glands the disease is at first 868 MEDICAL, DIAGNOSIS. strictly local, and then, if it spread, invades not the lymphatic tissues specially, but any part of the body ; the enlarged glands do not move freely on each other as they do in lymphadenoma. Local gland lymphomas are separated from Hodgkin's disease by their local character, by their want of extension, and by the absence of marked cachexia. Scrofulous or tuberculous glands, unlike lymphadenoma, enlarge rapidly, have thickened tissue around them, and are apt to undergo cheesy degeneration, or to soften and suppurate. Moreover, they are associated with the presence of tubercle-bacilli, and mostly affect the submaxillary glands. The anterior cervical glands are the ones chiefly and primarily affected in Hodgkin's disease. In some cases of Hodg- kin's disease fever is a prominent symptom, and this may be of intermittent type, giving rise to the belief that we are dealing with a malarial affection ; recurring chills make error still more likely. In the early stages of lymphadenoma a diagnosis is impos- sible, and we are at a loss to account for the increasing signs of cachexia, until the involvement of the lymphatic glands in rapid succession, and their quick growth, or the speedy formation of other lymphoid tumors under the skin or in other parts of the body, clear up all doubt. There will also be great uncertainty in all those instances in which the growths happen first in internal glands or structures, — as in the bronchial glands and the medias- tinum, producing severe bronchitis, extreme dyspnoea, and signs of venous stagnation in the veins of the upper part of the body ; or as in the glands around the biliary ducts, giving rise to jaun- dice ; or as in growths in the spinal cord leading to paraplegia, — until the external swellings explain the case. The kidney is not an organ that often suffers primarily ; the occurrence of more than a mere trace of albumin shows that it has become im- plicated from parenchymatous changes or disseminate lymphoid growths. There is a strong probability that in the future we shall find that there are no primary anaemias, and that all forms will ultimately come to be recognized as secondary and be traced to the lesion that determines them. The diagnosis will be directed rather to the affections with which they are associated than to the special types of the anaemia. The same will be the case with the lymph- DISEASES 'of the BLOOD. 869 adenopathies, which clinically manifest themselves as leukaemia, Hodgkin's disease, or purpura hsemorrhagica. Addison's Disease. — While seeking for the explanation of puzzling cases of ansemia, Addison discovered that a peculiar anaemia always occurs in connection with a diseased condition of the supra-renal capsules, and is characterized by distressing languor and great general prostration, remarkable feebleness of the heart's action, loss of appetite, obstinate vomiting, and a singular alteration of the skin. This consists in a dingy or smoky hue of the surface ; or the color may be of a deep amber or chestnut brown, or the altered skin may have a bronzed tinge. The change of color begins on exposed parts, such as the face and neck and the back of the hands, and deepens first there ; but we also soon find it marked in parts which are naturally the seat of much pigment, such as the axillae, the groins, and the areolae of the nipples. It is also marked around the umbilicus, on the penis, and on the scrotum, and is dependent upon a layer of pig- ment in the rete mucosum. The skin remains soft and smooth, and becomes in large portions uniforhily discolored, gradually deepening, and often presenting a hue on the face and hands like that of a mulatto. Any irritation of the skin is followed by dark streaks. Discoloration in patches is both less constant and less significant than extensive alteration of hue ; yet the darkening in undoubted cases may occur in patches, which are usually most obvious on the face or the superior extremities. The patient may seem at first sight to be jaundiced ; but the pearly whiteness of the conjunctiva soon dispels such an idea. The nails are pale and bluish ; the tongue may have patches of dark color; the body and breath at times exhale an offensive odor ; and the blood has been found to contain an excess of white corpuscles and a slight decrease of the red, although it generally does not undergo any important or charactei'istie change.* With reference to the other symptoms, the most conclusive of them are remarkable prostration, generally without any marked waste of the body, feebleness of heart's action and of pulse, and obvious ansemia. In most cases, but far from in all, these symp- toms precede the discoloration of the skin; and they are not * Greenhow, Addison's Disease. 870 MEDICAL DIAGNOSIS. unfrequently associated with pain in the back and with gastro- intestinal irritation, with breathlessness upon exertion, with ver- tigo, and with dimness of sight or impaired hearing. A peculiar odor of the body, like that perceived in the colored race, was ob- served in two cases placed on record by Mr. Hutchinson. In the last stages of the malady the temperature falls below the norm. Death may take place gradually from the constantly-growing asthenia ; or it may occur suddenly, and where the amount of prostration does not appear so excessive as to foreshadow it. According to the elaborate researches of Wilks, the destruction of the capsules is dependent upon a peculiar scrofulous degenera- tion ; and this view of the tubercular nature of Addison's disease is now very generally held.* Should this prove to be correct, — should it appear, in other words, that the nature of the disease of the adrenals influences the symptoms more than the mere fact of their being diseased, — it would explain why in some cases of absence of the glands, or of their cancerous degeneration or sup- puration, no signs of Addison's disease existed. With reference to the nature of the affection, however, tuberculous disease of the adrenals has been found without, bronzing ; f and tubercle-bacilli have been detected in the caseous glands. Many of the symptoms of the fully-developed malady may be due to the implication of the nervous branches, derived from the sympathetic and the pneumogastric, which go to the glands. Indeed, the idea of the primary seat of the disease in the abdominal sympathetic nerve is strongly advocated by some observers. Now, in the diagnosis of Addison's disease the alteration of the color of the skin plays so important a part that we must inquire whether it or something very like it may not happen in other conditions. In persons kmg exposed to the sun a bronzing of the face and neck and arms occurs ; but it is extremely uniform ; there is a striking contrast between it and the parts that are not exposed, including such as we find greatly affected in Addison's disease, the flexures of the joints, the scrotum, the textures around the nipple and the umbilicus. Moreover, there is often robust * See, for analysis of oases, Gilman Thompson, Transact, of Assoc, of Amer. Physicians, 1893. t As in the case of Ballenghien, Journ. des Sci. Med. de Lille, 1888. DISEASES OF THE BLOOD. 871 rather than impaired health. In persons who, in addition to ex- posure, are of uncleanly habits and infested with vermin, especially in elderly persons, a discoloration of the skin happens at various portions of the body, often deepest on the chest, the abdomen, and the back, which is readily mistaken for the bronzing of Addison's disease. But in this vagrants' disease the discoloration is in the superficial, not in the deeper layers of the epidermis, and the dark cuticle is harsh and raised, not soft and smooth. Then alkaline baths and washing with soap will greatly diminish the deepened hue. A similar bronzing of long standing, though of doubtful origin, is sometimes met with.* During exhausting lactation, or in pregnancies attended with much constitutional disturbance, there may be marked discolora- tion of the skin ; yet it is not most obvious on the face, and the circumstances of the case are important aids in the diagnosis. So is the history in those instances in which a bronze hue is hereditary,^ or in which a very deceptive discoloration follows yellow fever, or the malarial fevers, or chronic disorders of the liver. In these diseases, too, the discoloration is not so great, and it is not marked at the sites most affected in Addison's disease. Greenhow has pointed out how certain very long standing in- stances, of phthisis exhibit an appearance exactly like that of the earlier stages of Addison's disease. Yet the abnormal pigmenta- tion does not deepen or increase, and the symptoms remain only those of the pulmonary malady. Stains on the skin from pity- riasis versicolor or from syphilis have not the characteristic seats of Addison's disease, and they are in patches and surrounded by healthy skin, and certainly the syphilitic affection coexists with other significant eruptions or signs. Malcolm Morris J has called attention to the mistake of pronouncing a case of acanthosis nigricans one of Addison's disease. The fact that the pro- cesses in the former are confined to the upper layer of the skin, and characterized by an abnormal development of the younger not yet cornified elements of the upper layers, — the so called prickle- layer, — will serve to separate it pathologically from the secondary and relatively unimportant changes of the skin that attend the * Crocker, Transact. Clin. Soc. Lend., vol. xlv., 1881 ; also Carrington, ib. t Medical Times and Gazette, May, 1871. J Medlco-Chirurgical Transactions, 1894. 872 MBDICAIi DIAGNOSIS. course of the latter affection. A chocolate-colored discoloration of the whole surface of the body has been observed in a case of psoriasis in which the patient continued to take arsenic during a period of two and a half years.* One of the confusing points connected with the diagnosis of Addison's disease is that cases occur without bronzing, or with the discoloration of the skin so slight as to be a matter of doubt. Such cases are generally in persons who die before they have had the disease any length of time. If the altered hue of the skin be wanting, the complaint is undistinguishable from per- nicious anaemia, though we may lay some stress on the compara- tive absence of febrile phenomena. Other diseases of the supra- renal capsules, such as cancer and waxy disease, are also not to be separated from the peculiar affection of the gland occasioning Addison's disease, if bronzing of the skin be not present. The malady, as Greenhow proves, is very rare except in persons employed in manual labor. In some instances it seems to arise from grief or protracted anxiety. The disorder is a chronic one, generally lasting for years ; but it almost invariably destroys life. Yet cases have been recorded in which most of the symptoms of Addison's disease existed and which recovered ; and certainly long remissions in the symptoms have been not unfrequently observed, and in these remissions the discolored skin has lightened. The disease is occasionally met with in young persons. Dyson reports a fatal case in a girl thirteen years of age.f Pyaemia. — Purulent contamination of the blood is an affection much more likely to be met with by the surgeon than by the phy- sician ; yet the physician must be familiar with its symptoms. Tliese are, great depression of the vital powers, profuse sweats, rapid pulse, and the formation of purulent deposits in different portions of the body. The symptoms may be of gradual devel- opment ; but often they set in suddenly with a chill, to which a fever of low type soon succeeds ; or the shivering is followed by copious sweating, and the febrile phenomena subsequently appear. A transient erythematous blush on the skin is not unusual. The pysemic fever rarely lasts longer than a week, and during * Carrier, Medical News, Feb. 3, 1894, p. 127. ■|- Quar. Med. Journ., vol. iii., Part I. DISEASES OF THE BLOOD. 873 its continuance it usually presents the most marked variations in temperature. Yet the disease is not always alike in this respect ; for we find, as Heubner has proved, not only cases in which the most decided increase of heat is constantly followed by an equally decided decrease, but also cases in which there are febrile attacks followed by marked intervals during which the temperature is almost normal, and cases in which continuous fever exists with striking intercurrent rises in temperature.* Still, in all the maxi- mum temperature is apt to be very high, ranging from 106° to 108°. The disorder may arise after injuries and operations ; or where sinuses or abscesses exist that have no free vent for the pus ; or in consequence of the contamination of the blood which happens in phlebitis or arteritis ; or in inflammation of the external coat of arteries, with suppuration, especially in- the periarteritis of the thoracic aorta ; or in ulcerative endocarditis ; or the pyaemia re- sults from the breaking down of coagula in the blood-vessels ; or it may supervene upon diffuse cellular inflammations, or upon puerperal fever : in fact, it will be found under many dissimilar circumstances. Micro-organisms play an important part in its production, especially the several varieties of the streptococcus pyogenes and the staphylococci. They render the pus septic, and, under conditions favorable to their development, diffuse the process. This they do by producing a suppurative infecting phlebitis or by inducing coagulation of the blood and disinte- grating thrombi. But, without stopping to explain the sources of origin of pyaemia, let us look at its diagnostic traits. Now, there arc several complaints with which pysemia is likely to be confounded, the chief of which are typhoid fever, rheuma- tism, acute glanders and farcy, and acute affections of the liver. It is liable to be mistaken for typhoid fever, on account of the adynamic character of the fever, and, it may be, the occur- rence of diarrhoea and of cerebral symptoms. But the history of the case is very dissimilar : there is no eruption, or, if there be an eruption, it consists, as Bristowe so particularly points out, of sudamina surrounded by a zone of congestion, and is therefore not the eruption of the typh-fevers ; and, on the other hand, we find in typhoid fever neither the profuse sweating nor secondary * Archiv der HeilUunde, ix., 1868. 874 MEDICAL DIAGNOSIS. deposits of pus, and the thermometry of the disease is very differ- ent. Pyaemia may, however, happen as a complication of the febrile malady. The pain in the joints and their swelling in succession, the fever, and the perspirations, resemble much at times rheumatic fever. But the difference consists in the greater severity of the constitutional phenomena caused by the poisoned blood, in the marked exhaustion, in the rigors, and in the history not being that of acute rheumatism. Moreover, the frequent signs of for- mation of abscesses in internal organs or around the joints, the development of pustules on the skin, and the striking redness of the tumid joints assist materially in the diagnosis. Acute glanders or acute farcy is a disease scarcely distinguish- able from pysemia, since it occasions, for the most part, the same manifestations. The knowledge that the patient who has appar- ently pysemic symptoms has been working among horses, the ulceration of the mucous membrane of the nose, and the fetid discharge proceeding from it, which occurs in acute glanders, and which is apt to be associated with nasal hemorrhages, with an offensive breath, with enlargement of the lymphatic glands in the vicinity of the affected mucous membrane, and with hurried breathing, or sometimes with gangrene of various parts, afford us the only means of discrimination. Then we find a peculiar tuber- culated or pustular eruption, resembling smallpox, upon the skin, and in farcy the lymphatic glands and vessels specially suffer. But more significant than all is the distinct history of the con- tagion ; for the grave coryza does not happen in all forms of equinia, — certainly not in farcy. Acute affections of the liver resemble pysemia on account of the jaundice that may attend the latter disorder ; the history of the case, the rigors, the sweats, and the purulent deposits distinguish it. Yet it must be remembered that suppurative inflammation of the portal veins and metastatic abscesses of the liver happen. In conclusion, let us inquire where and how the secondary de- posits, or metastatic or embolic abscesses, are formed. They may take place in the parenchymatous organs, particularly in the lungs and the liver; in the synovial sacs, in muscles, or in areolar tissue, especially in that under the skin. The secondary deposits are mostly due to fragments of septic thrombi filled with pus DISEASES OF THE BLOOD, 875 organisms which have become impacted in the vessels of distant parts and there become centres of suppurative change and of fresh infection. If the altered blood coagulate in the arteries, or if from disin- tegration of fibrin in the arterial system the infected masses occa- sion deposits in solid organs, as in the liver or the spleen, we may have, with the similar pathological states, symptoms arising like those of ordinary pyaemia. Indeed, in the wierial 'pyaemia, as it has been called, rigors, febrile symptoms and sweating, and pains in the joints are observable. In connection with the obscure febrile condition, the liver and the spleen are often observed to increase in size slowly.* The heart may or may not be affected ; ulcerative endocarditis is often present. Hay em has pointed out that there may be capillary embolism in pyaemia, not to be recog- nized except by the microscope. It may be one of the causes of the so-called idiopathic pyaemia in which the source of infection is not apparent. There is a form of pyaemia, called by Leubef spontaneous septico-pyeemia, which comes on without obvious cause, or is perhaps preceded by a fall or a slight skin wound, in which the symptoms of pyaemia become developed with pain and tenderness in joints and muscles, ecchymosia of the conjunctiva, vesicles in the skin containing blood, extremely high temperature, swelling of the spleen, albuminous urine, pleui'isy or perhaps signs of endocarditis or pericarditis, stupor, delirium, cramps, and finally involuntary discharges and coma. The disease, resembling typhus or ulcerative endocarditis, is to be distinguished only by the general association of the symptoms. The description of pyaemia given represents it as an acute affec- tion, and so it almost always is. Yet there are cases much slower in their course, and extending over months. These chronic or relapsing instances of the disease have been described by Paget.J The symptoms presented are the same as in the acute disorder ; but the local evidences of the complaint are more often seated in different parts of the same tissues, and less frequently in internal organs. The malady is not nearly so perilous as the acute disease. * Samuel Wilks, Guy's Hospital Eeports, vol. xv., 3d Series. ■j- Archiv fiir Klin. Med., xxii., 1878. t St. Bartholomew's Hospital Reports, vol. 1. 876 MEDICAL DIAGNOSIS. Septicsemia. — This is a poisoned state of the blood, produced especially by animal poisons, such as the bites of venomous ser- pents, or the absorption of putrid matters that have been gen- erated in the economy, or by their inoculation. It may be seen after injuries and wounds, or in the puerperal state. The con- tinued exposure to the breathing of foul air and of septic gases will also occasion septicsemia. There are no discoverable foci of suppuration, but the bacteria occasioning the sepsis are in the main the same as those of pysemia. Toxines and ptomaines have much to do with the process. The symptoms of the blood-poisoning vary somewhat with the individual poison that has occasioned it. They are, as a rule, the symptoms of pysemia, except that secondary pus-formations be- long to the former rather than to the latter ; and the same may be said of embolism and its results. . Rigors are frequently ob- served. In many instances the altered condition of the blood leads to great prostration, to hemorrhages from internal organs, to petechise, to delirium and coma, to extreme rapidity of pulse, to rapidly-developed fever with high temperature, to enlargement of the spleen, to cough and bronchial catarrh, and to gastric and intestinal disorders. The blood shows the white corpuscles almost always in marked excess, although not altered in character as they are apt to be in leuksemia; the red globules are diminished.* The bacterial types characteristic of the form of septicsemia are generally demonstrable by microscopic examination and by cul- ture experiments in the bacteriological laboratory. Malarial Septicsemia. — Since the discovery of Laveran that malaria is due to the presence in the blood of a micro-organism, the Plasmodium malariee, this well-known disorder has entered the list of infectious diseases and become recognized as a form of septicEemia. Klebs asserts that he has found flagellate protozoa in the febrile stage of influenza, but this observation has not been confirmed. Typhoid Septicsemia. — Several observers, especially in Italy,t have reported cases of typhoid septicsemia without the accustomed * See the valuable report of the Committee of the Pathological Society of London, Transactions, 1879. t See Guido Bariti, Eiforma Medica, 1887. DISEASES OF THE BLOOD. 877 alterations in the intestinal tract. The diagnosis was based upon the bacteriological examination of the organs and the characters of the bacilli. Dogliotti also reported a case which had fever, enlarged spleen, and copious eruption of typhoid roseola extending over the entire body. There was profuse diarrhoea. Cultures of blood from the finger and from a vein in the arm remained sterile ; but cultures taken from the blood of the papules developed bacilli which corresponded with all the characters of the typhoid- bacilli. At the post-mortem examination no ulcers or cicatrices were found in the intestine. The conclusion is that, besides the familiar form of abdominal typhoid, there is another, identical in every way except that it has no intestinal or lymphatic localization. The bacilli select the skin in preference to the mucous membrane or the lymph cells. Septictemic typhoid then presents the fol- lowing characters : an irregular fever, not typical as that of ileo-typhoid ; the absence through the entire illness of visceral complications and of symptoms pertaining to the digestive sys- tem ; the presence in the circulating blood, and in the blood extracted from the rash, of a bacillus presenting the characters of the typhoid-bacillus.* Pyaemia and septicaemia have shifted much from their old sig- nificance. We know much more of direct infection and how foci of suppuration are set up in various parts of the body. Another set of symptoms is occasioned when the products of the micro- organisms only, the so-called toxines, are absorbed by the blood ; here fever, prostration, and various nervous phenomena are caused. This condition has been termed saprsemia, to distinguish it from septicaemia, in which the infective agent is actually present in the blood. Occasionally pathogenic micrococci may be present in the body without giving rise to either suppuration or septic disease. The tissue-cells, especially those of the spleen and the kidney, play a very important part in the destruction, Bnd the leucocytes are also active in the warfare. Thrombosis and Embolism. — Although in connection with endocarditis, with obstruction of the cerebral arteries, and with diseases of the kidney, the phenomena of embolism have been de- * Translation in the Pacific Medical Journal, vol. xxxviii. p. 203 ; also Dogliotti, Gaz. Med. di Torino, 1894. 55 878 MEDICAL DIAaNOSIS.. scribed, it may serve a useful purpose to view here connectedly, though chiefly in their diagnostic bearing, some of the results of the formation of the clots in large vessels or in the heart, and of their being carried along with the cun-ent of the blood and driven into remote vessels, — the results, therefore, of thrombosis and of embolism. Of these embolism is the subject which more particu- larly concerns the physician in its immediate practical bearing. The embolus may produce manifestations in the venous system, either in the peripheral veins, or in the venous trunks of the great internal cavities of the body ; or a portion of the clot may have been washed into the pulmonary artery from the right side of the heart ; or it may have become impacted in the arteries of the general circulation, in the lai'ger arteries, or in those of fine calibre ; or it may have been propelled into the very structure of organs through these arteries, as into the liver-structure through the hepatic artery, into the splenic parenchyma through the splenic artery. Let us examine a little more closely some of the symptoms thus occasioned, premising that arterial embolism is of much more frequent occurrence than the other forms. In the veins thrombi may form, which, so long as they do not produce obstruction of the canal, give rise to no marked signs. A slight hardening and pain on pressure if the coagulum be in one of the more superficial veins, their enlargement if the clot be in a deeper vein, are apt to be the only evidences of the disordered condition. But when the occlusion is considerable, and especially when the collateral circulation is insufficient, oedema is developed which may be attended with very great tenderness of the swollen part, and, if the impediment be of long duration, with changes in the nutrition of the structures sufficient to produce phlegmo- nous inflammation. These phenomena are encountered in phlebi- tis, or milk-leg, phlegmasia alba dolens. This condition, occurring after parturition, is now regarded as an evidence of puerperal septicaemia due to infection of the system through the uterus. In some cases profuse hemorrhages happen as a consequence of the stoppage in the vein, — as cerebral hemorrhages produced by thrombosis of the sinus, or, as in a case referred to by Virchow,* as enormous hemorrhagic infiltration of the subperitoneal and sub- * Patliologie und Therapie, p. 172. DISEASES OP THE BLOOD. 879 cutaneous tissues, as well as of portions of the muscles of the abdominal walls, the result of a coagulum in the external iliac vein, the epigastric, and the crural vein. Thrombosis may also occur in the cerebral sinuses, without causing hemorrhage, but giving rise to pressure symptoms, pain, prominence of the eyes, and oedema ; it may be followed by complete recovery. In exhausting and wasting diseases, blood may clot in the veins, or even in the heart, without any clearly- marked cause. Trous- seau called atteution to the occurrence of milk-leg as a symptom of gastric cancer. Gout may cause phlebitis and clotting in the veins of the body, as Sir James Paget has pointed out. Again, we may have chlorosis give rise to thrombosis in the cavities of the heart and the larger veins, such as the femorals, without phlebitis preceding the morbid condition.* Now, portions of the clot, situated in any part of the venous system, however remote from the heart, may become, by being broken off and driven onward with the circulation, sources of great danger. When the blood clots in veins connected with the portal system, the detached fragments may be washed into the liver, and there lead to secondary abscesses. But when coagula occur in the venous system and are wholly or in part carried away with the circulating blood, if we exclude those which, from their situation, could only reach the liver, we generally find the mani- festations of disturbance arising in the heart or the lungs. Ar- riving at the right side of the heart, the concretion, if at all large, or if it become so by serving as a nucleus for a larger clot, oc- casions symptoms of exhaustion and collapse ; an intermitting, feeble pulse ; irregular and confused beating of the heart, and cardiac sounds enfeebled or lost over the right side of the organ ; rapidly-developed distress in breathing, referred, by the sufferer, to the heart,t and signs of asphyxia, though all. the time the patient is taking deep inspirations ; great agitation ; and a swollen state of the veins of the body. Death may then take place suddenly if a portion of the clot separate and obstruct the pulmonary artery.;); But the mode of death, and the symptoms preceding it, in * Tuckwell, St. Barthiilomew's Hospital Keports, vol. x., 1874. t B. "W. Eichardson, Medical Times and Gazette, Nov. 1868. J As in a case recorded by Druitt, Med. Times and Gaz., July, 1862. 880 MEDICAL DIAGNOSIS. embolism of the pulmonary artery, are not always tne same, and depend much upon the size of the embolus and where it is arrested. A large-sized clot, whether it be merely part of one occupying the right heart, or be washed at once into the pulmo- nary artery, will occasion the same signs as those mentioned as in- dicative of a large clot in the right side of the heart ; the craving for air is particularly intense, and this craving is increased by every movement of the body ; the muscular debility, the lowered temperature, the cyanosed look, the turgid veins of the neck and their undulations, the increased, irregular cardiac impulse, though the heart's action is not sufficiently deranged to account for the disturbed respiration and disordered general circulation, are also noticed ; and in some cases a systolic blowing sound, and, where the case is at all protracted, vertigo, albuminutia, and oedema of the limbs, may be observable. The intellect remains clear. As regards the pulmonary phenomena proper, collapse of the lung, hemorrhagic effusions or so-called infarctations, oedema, or capil- lary bronchitis are likely to happen, except in those instances in which the principal trunks of the pulmonary artery are blocked up and almost instantaneously asphyxia ensues. If the fragments be very small, the amount of dyspnoea is not of necessity great, nor are the symptoms of asphyxia marked ; and inflammations of the parenchyma of the lungs may take place, occasioning often secondary obstructions and metastatic abscesses in the lungs. These forms of metastatic abscesses are observed in pysemia, and are not unusual in puerperal fever. Blood coagulates in the arteries as a consequence chiefly of gan- grene and of ulceration. Again, inflammation or atheromatous disease of the coats of the arteries may lead to the local develop- ment of thrombi ; so may feeble action of the heart and increased coagulability of the blood.* Still, the most important phenomena connected with obstruction of arteries are those of coagula being washed into them; the phe- nomena of embolism, therefore, rather than those of thrombosis. The manifestations of embolism are distinguished from those of the mere formation of clots by what is always the most significant sign of either arterial or venous embolism, — the suddenness of the * Liddell, Amer. Journ. Med. Sci., July, 1873. DISEASES OF THE BLOOD. 881 manifestation of the abnormal state. And in point of fact the symptoms arise less often as the result of any of the conditions alluded to that occasion coagulation, than in consequence of de- posits, fibrinous concretions, and excrescences which are seated on the valves of the left side of the heart, portions of which deposits are carried away by the circulating blood into remote parts. When these bodies become impacted in a vessel the calibre of which is such that it does not permit them to pass on, we find rapid changes taking place in the portions of the body supplied by the obstructed artery, — coldness, pallor of the parts, a diminished functional activity, a shrinking ; and if the first obstruction be followed by others, and the collateral circulation cannot be estab- lished, local death and gangrene ensue.* All these changes are, of course, discernible only in external parts, especially in the extremities ; the disturbances of function are the most obvious signs where the internal organs are the suf- ferers. If the emboli be driven to the brain, we have often, as has been mentioned, softening as the final result, and this may be preceded by disorder of intellect, without motor disturbances, and by severe attacks of vertigo, in cases in which merely the smaller arteries supplying the surface of the cerebral hemispheres are obstructed. But where, as is indeed the most common seat of emboli, the arteries of the fissure of Sylvius are clogged, the phe- nomena are those of apoplectic hemiplegia, and the palsy affects the whole of one side of the body. The brain may also suffer from the seat of the obstruction being in the carotids ; indeed, of all organs the effects of embolism are most plainly perceptible in the brain. The presence of emboli in the splenic, renal, hepatic, and mesenteric arteries is generally only to be inferred from the history of the case, and does not occasion any clearly-discernible signs. But tenderness, enlargement of the spleen, and pain in the splenic region in splenic embolism, or disordered secretion of urine and pain in the loins in embolism of the renal artery, or jaundice in embolism of the vessels of the liver, may be very marked. The occurrence of pain in these cases of internal embolism must not be overlooked ; and in embolism of the arteries of the * As regards the anatomical lesions, see Litten, Zeitscli. f. Klin. Med., 1880; and Colinlieim, Allg. Path., 2d edit., Berlin, 1882. 882 MEDICAL DIAGNOSIS. extremities pain is a symptom of still greater prominence. It may be like a violent neuralgia, or so constant that it is mistaken for rheumatism ; and, as happened in a case of embolism of the right iliac artery, under the charge of Dr. James H. Hutchin- son,* which I saw, it may recur in paroxysms of intense severity, and be referred to the foot, though this be already in a condition of sjahacelufi. Besides the pain, we are apt to find extreme hyperes- thesia in some parts of the aifected limb ; and pricking sensations, formication, and loss of tactile sense, followed by complete anaes- thesia, in others. Then painful spasms of the muscles, and a more or less perfect paralysis of motion, may occur. If we join to these symptoms an absence of pulsation in the arteries below the occlusion until the collateral circulation is decidedly estab- lished, a strong beat of the vessel on the cardiac- side of the ob- struction, the coldness of the limb below this obstruction, and the signs of defective supply of blood, we have a group of phenomena which, taken in connection with the history of the case, render the diagnosis a positive one. In reviewing the history of the case the state of the heart and the cardiac symptoms must always be carefully examined into ; and a close inquiry often shows that the sudden manifestations of arterial obstruction were preceded by an attack of palpitation and of irregular action of the heart. A change in the physical signs of the, diseased organ, as of its murmurs, may not be evident; but, should it be evident, it is a sign of utmost moment. Indeed, any change in what may be viewed as the centre from which the embolus may be detached is of great significance. And this holds good quite as much for venous as for arterial emboli. Thus, in a case of coagulum in a vein, a sudden disappearing of swelling and oedema of the affected limb, with the supervention of signs of embarrassed circulation and respiration, would at once tell what had taken place. In regard also to tlie diagnosis of embolism we must always bear in mind the causes which are likely to give rise to it. Several of the causes of arterial embolism have already been mentioned ; those of venous embolism are the same as of venous thrombosis, or, to speak more explicitly, the breaking up of the clots and their transportation may occur in any of the conditions which have oc- * Amer. Joum. Med. Soi., Oct. 1863. DISEASES OF THE BLOOD. 883 casioned them. Now, these conditions, too, will produce arterial clots, and indeed some are more apt to lead to coagulation in the arteries than in the veins. Prominent among them are a narrow- ing of the calibre of the vessel, as by pressure ; dilatation of the vessels and of the heart ; failure or great diminution of cardiac power, with consequent retardation of the blood-stream, — a state which is more likely to occasion venous than arterial thrombosis ; a breakage in the continuity of the vessel, as when it is torn or cut; changes which take place in the coats of the vessels, especially in- flammatory changes ; and contact of the blood within the vessels with foreign bodies. Then it is very likely that special states of the blood also, by altering the cohesion of the globules, predispose to, if they do not absolutely cause, the clotting. Another cause of embolism is that due to accumulations of pig- ment in the blood, the result of malarial fever. The pigment may obstruct the capillaries in the brain and thus occasion capillary apoplexies ; or be driven to the liver and there produce signs of disturbance of its circulation, and abscesses. As in all forms of capillary embolism, the symptoms are obscure : the suddenness of their development, generally so characteristic of the other forms of embolisin, is wanting ; and the diagnosis, as throughout in capil- lary embolia,- is always nothing more than a matter of conject- ure, based on a close study of the general phenomena, including the microscopic examination of the blood, and on the history of the case. Similar symptoms occurring after fractures of bone point to emboli derived from the marrow, to fat embolism. The blood in malignant disease undergoes changes indicative of denutrition and wasting. It has been asserted that sporozoa can be found in the tissues invaded by carcinoma, and that these parasitic organisms are also present in the blood, but these state- ments are not yet fully established. With regard to other forms of malignant disease, observations of this character have also been made. Motz's researches concerning the blood of sarcoma- tous subjects reveal in the cultures obtained a very small micro- coccus, simple or double, anaerobic, and staining with difficulty. The sarcomatous aifection localizes itself in the venous walls or the capillaries, and causes a thrombosis of the affected vessels. This infection of the blood may serve as a diagnostic sign in doubtful cases. 884 MEDICAL DIAGNOSIS. Acute endarteritis may be the cause of embolism as well as of pyaemia. Air in the blood produces great disturbance of the cir- culation, which may be thought to be due to embolism. The air may be the result of decomposition, and get into the venous system and thence into the general circulation. Jurgensen * has reported a case in which the air passed into the circulation through the splenic vein. Irregular conti'action of the heart, pallor of the face, a peculiar systolic cardiac murmur, faintness and the signs of cerebral antemia, and slow breathing, are the common symptoms. In conclusion, the subsequent changes of the thrombus must be adverted to. It may organize and be converted into connective tissue and yield an impaired passage to the blood ; and perhaps the collateral circulation may be freely established ; or, what is not so favorable a result, it may soften and undergo fatty metamor- phosis. But even when larger portions are not detached and occa- sion the marked symptoms of embolism, small ones of an infected thrombus may be wafted into capillaries and there lay the foun- dation of abscesses. It is thus that in a case of thrombus or embolus we may have the secondary results of pyaemia to deal with, — metastatic abscesses caused in the manner described, and attended with a blood profoundly altered and vitiated by the de- composing products circulating in it. Scurvy. — This disease is not often met with in civil practice ; but it is one familiar to the military and the naval surgeon. It consists in a deterioration of the blood, produced by living for a long period upon the same kind of food, and especially upon salted meats, without the requisite supply of fresh vegetables being taken. Now, the potent influence of vegetables is attributed to the large quantity of potassium they contain ; and, as there is a deficiency of the salts of potassium in scorbutic blood, it was concluded that this deficiency is the real cause of scurvy. But this theory has not been positively proved. Another cause of scurvy is the want of proper assimilation of food, as in prison scurvy, f The existence of scurvy in childhood is now recognized as of not infrequent occurrence, and it is probably frequently mistaken for rachitis, acute rheumatism, or possibly for purpura. The * Archiv. f. Klin. Med., Bd xxxi., 1882. f See Medical Memoirs of the U. S. Sanitary Commission, p. 278. DISEASES OP THE BLOOD. 885 concurrence of marked anaemia with joint-swellings in a bottle- fed infant, or in older children, should suggest the possibility of scurvy being present. Northrup and Crandall * found, in over sixty-three per cent, of the cases of infantile scurvy they inves- tigated, that the diet consisted of proprietary foods and con- densed milk. The evidence also indicates that milk sterilized for a long time is capable of causing scurvy when used as an ex- clusive diet. Babes,t in studying three cases of scurvy bacteriologically, found a thin, long, wavy bacillus, prone to occur in clusters, in the gums, the lungs, and other viscera. There were also strepto- cocci in the gums. Scurvy is usually slow in its development. The patient be- comes low-spirited, easily fatigued, and is loath to exert himself. The appetite is impaired ; there is a craving for acids and for vegetable food ; the tongue is flabby ; the breath fetid ; the pulse feeble ; the skin dry. The bowels are usually constipated ; but a tendency to diarrhoea may exist, and indeed generally occurs as the disease advances. Neuralgic pains, referred chiefly to the lower extremities, to the bones, and to the back or thorax, are common. The face is pale, or has a yellowish tinge ; the eyes are surrounded by a dark ring. During the progress of the ailment, or in severe cases almost from the onset, we find swollen, spongy gums, bleed- ing on the slightest touch; hurried breathing; a rapid pulse; weakened eyesight, sometimes night-blindness ; epistaxis ; painful swelling and hardness about the joints of the extremities and in the calves of the legs ; and purple spots and bruise-like stains on the skin. Should the malady remain unchecked, the symptoms heighten in severity, ulcers form which have a fungoid look and a great tendency to bleed, hemorrhages take place from internal organs, old sores and wounds reopen, well-knit fractures become disunited, there is a constant tendency to swoon, and the patient perishes miserably exhausted, and with his blood in a state of dissolution. Scurvy may be the cause of epidemics of pericar- ditis.J In some cases death takes place from diarrhoea or dropsy, which may be suddenly developed. Recovery from scurvy is slow. * Proceedings of New York Academy of Medicine, Feb. 1894. t Quoted in Sajous' Annual, vol. 1., 1895. J Von Dusch, Herzkrankhelten. 886 MEDICAL DIAGNOSIS, Purpura. — Scurvy is not a disease difficult to recognize ; only one affection resembles it at all closely, — purpura. In this dis- order also red or purple spots or livid blotches, uninfluenced by pressure, and passive hemorrhages from the mucous membranes, happen. But there is this difference between the two complaints : purpura is common in fruit seasons, and often attacks persons who have not been in any way deprived of vegetable food. The gums are not soft and spongy as in scurvy, nor do we find the same weak- ness of mind and body. Then, the stain of the skin in purpiu-a is apt to be more generally diffused, and the purple blotches are smaller, or, at all events, the large patches of discoloration consist clearly of an aggregation of very many small spots. Moreover, the disorder is not controlled, like scurvy, by fresh vegetables, and by lemon-juice, — in fact, by decided antiscorbutics. From a clinical point of view we find several forms of purpura. In the mildest, the purpurous spots are apt to appear only on the legs. They come in crops, which fade, and there are no constitu- tional symptoms, except a little lassitude, and perhaps aching of the limbs and pain in the back. In the graver cases, " purpura hsemorrhagica," we find, in addition to the cutaneous hemorrhage, epistaxis, hsematemesis, hsematuria, or other internal hemorrhages, and extravasations of blood may happen into the substance of the muscles. The amount of pain attending the malady is very dif- ferent. There may be none, or it may be trifling ; or deep-seated pains in the cavities of the body, or extended neuralgic pains, may accompany the purpurous complaint. In some instances the pains are chiefly felt in and around the joints, and the apparently rheu- matic aches subside in a few days, and spots of extravasated blood become visible. This " purpura rheumatica," a variety particu- larly described by Schonlein, is usually met with in the strong and healthy. It is, indeed, one of the peculiarities of any kind of purpura, that it may come on in the midst of seemingly excellent health ; for while it is true that the disorder may be preceded for some time by general debility, or occur in the course of disease of the liver, of Bright's disease, or as a sequel to the exanthemata and rheumatic fever, it most often happens where, from the pre- vious history, we should least expect it. Its jiroduction as the result of a sudden shock to the nervous system, such as fright, and its occasional intermittent character, have been repeatedly noticed. DISEASES OF THE BLOOD. 887 It has appeared after the administration of quinine, as first ob- served by Vepau,* and since by Gauchet f and by Woodbury.J The duration of the malady is very variable : only a week may elapse, or several months may pass, before the sjjots disappear. Its pathology is unknown. It is clearly, however, not merely a disease of the blood ; the capillaries lose their retentiveness and allow the. corpuscles to migrate. In some cases purpura presents an acute form. It is ushered in by a chill, and by intense pain in the back and limbs, but is generally unattended with fever or severe constitutional disturbance. The purple spots usually first appear on the legs, and are wholly uninfluenced by pressure. They last five or six days, or somewhat longer, then gradually change their color and fade. The patient feels languid, but, unless from loss of blood, his strength is not materially im- paired. The effusion of blood happens in some cases into the loose connective tissues of the body, or blood is lost from the lungs, and still more frequently from the bowels or the urinary organs. Under these circumstances the pulse, which is apt to preserve its normal frequency, becomes very rapid ; but until ex- haustion begins to tell on the nervous system — not, as a rule, long before dissolution — the mind remains clear, and cerebral or spinal symptoms are absent. It is thus that we are able to distinguish severe cases of acute purpura, which may indeed prove fatal in forty-eight hours,§ from cerebro-spinal meningitis. Some of these acute or fulminating cases occur in young children, and it is a question whether or not they were previously subjects of infan- tile scurvy. The distinction between hsemophilia and purpura is generally simple. It is true that the bleeding in a member of a bleeder's family may happen into the skin, or from any of the parts from which it may take place in purpura ; but the family history, the congenital proneness to frequent hemorrhages from the slightest cause, their danger and protraction, the functional excitement of the heart, followed perhaps even by cardiac hypertrophy, the at- tacks of rheumatoid joint-inflammations, especially after exposure * Gazette Med. de Strasbourg, 1865. f Bulletin de Therapeutique, vol. cl. t Philadelphia Medical Times, 1886. ^ Harrison Allen, Amer. Journ. Med. Sci., Jan. 1865. 888 MEDICAL DIAGNOSIS. to cold and damp, associated witli hemorrhage, and the hemor- rhagic diathesis exhibited, stamp haemophilia M'ith distinctive features. There is in this disease diminished coagulability of the blood ; in rheumatism the coagulability is increased. Microscopic examination of the blood of a case of hsemophilia showed a very largely increased number of very small corpuscles or microcytes, with no marked increase of the leucocytes, but the percentage of haemoglobin was reduced, and also the red blood- corpuscles, proving the presence of both quantitative and quali- tative anaemia.* Henry has directed attention to the changes occurring in the arterioles, consisting mainly in wasting or ab- sence of the middle muscular tunic of the vessel. Vaso-motor influences undoubtedly play their part in bringing about an attack. This is shown by the flushing of the face which so often precedes an attack, and also by the fact that the attack may follow emo- tional excitement. Leuhsemia may be accompanied by subcuta- neous extravasation of blood, but it cannot be mistaken for either hsemophilia or purpura, if an examination of the blood be made. Hsemophilia is almost exclusively restricted to the male sex. It may be associated with arthritis. * Daland, College of Physicians of Phila., Jan. 9, 1894. CHAPTEE XI. EHEUMATISM AND GOUT. Rheumatism and Gout are affections having a strong ten- dency to change their seat, and are dependent upon the presence in the blood of some poisonous material which probably accumulates there in consequence of malassimilation. The rheumatic poison has a singular predilection for the fibrous, serous, and muscular textures. Hence we find it attacking principally the joints, the fasciae, the endocardium and pericardium, and the muscles in various parts of the body. According to its main forms, it is sometimes divided into articular and muscular; but the more usual division into acute and chronic is simpler, and will answer our purpose best. Acute Rheumatism. — Here the poison gives rise to the symptoms of an acute, active disease, and attacks especially the larger joints. These swell, become hot, red, tense, tender, and the seat of pain aggravated by the slightest movement ; an effusion also takes place into the surrounding structures, or into them and the synovial membranes of the joint itself. The rheumatic inflam- mation may either remain confined to the joints first affected until the disease is over, or, what is more common, it shifts from joint to joint, implicating most of the large ones in succession, yet often invading fresh joints before the swelling has subsided in the parts first attacked. The articular disorder is ushered in and accom- panied by high fever, soon attended with a full, bounding pulse, profuse, sour perspirations, a deeply-coated tongue, a scanty, turbid, highly-acid urine, and a countenance expressive of suffer- ing. The fever is generally in proportion to the number of joints involved. The temperature runs up to about 102° or 103° Fahr. very soon after the outbreak of the malady, and remains steady, with slight evening exacerbations and morning remissions when the joint-affection is yielding, but with renewed rises when fresh 890 MEDICAL DIAGNOSIS. joints are being implicated. As the disease disappears, the fever temperature gradually subsides. There is little difficulty in recognizing the complaint. The pains in the joints, their tumefaction and tenderness, the shifting character of the disorder, the fever, the acid sweats, form a group of phenomena eminently characteristic. In truth, excluding acute gout, the only affections at all likely to be confounded with acute articular rheumatism are pyaemia and glanders, acute synovitis, and milk-leg. The diagnosis of the former has been discussed in connection with, diseases of the blood; it only remains to point out the marks of similitude and contrast between acute articular rheumatism and the other maladies mentioned. Acute synovitis resulting from an injury, or from cold, occasions, like articular rheumatism, pain and heat in the joint, with disten- tion. But the disorder, except, perhaps, if it happen in a rheu- matic constitution, does not affect more than one joint; and, as there is scarcely any or no effusion into the surrounding tissues, the outline of the joint can be distinctly discerned, and fluctuation is readily detected. Often, too, the accumulation of fluid reaches an extent far greater than in rheumatic inflammation ; moreover, the febrile and constitutional derangement is not so severe as in acute rheunjatism, and the affection has no tendency to change its seat. Still, acute synovitis may be rheumatic* Milhrleg, or phlegmasia alba dolens, occurs most usually in women after delivery, or as a sequel of continued fevers, and is commonly a phlebitis of septic origin in which a thrombus forms. Generally, only one leg swells, and this becomes throughout, or sometimes only around tire calf, pretematurally white, firm, hot, and shining. The tumefaction is uniform, and very painful, especially so when touched. It does not pit, or pits but slightly, upon pressure, except at the lower part. There is in some cases tenderness with a sense of hardness in the course of the femoral vein, though this is by no means constant ; and we are apt to find signs of much debility and of altered blood, and febrile symptoms. The history of the case and the local signs are very different from acute rheumatism. Among the latter, two giving rise to striking dissimilarity may be mentioned : the almost * See Adams, Medical Times and Gazette, Feb. 1869. EHEUMATISM AND GOUT. 891 entire loss of power in the affected limb in phlegmasia alba dolens, and the much higher temperature it shows by the ther- mometer than the other members. And, while alluding to its heat, we may remark that an increase of general temperature corresponds to an increase of pain and swelling in the limb, and of constitutional distress.* Phlegmasia dolens has been noted in association with chlorosis, f Rheumatism may be modified in its manifestations by happen- ing in connection with, or consequent upon', other disorders. For instance, the febrile phenomena may be of an adynamic type when the disease occurs consecutively to typhoid or typhus fever; or we may find the local signs of acute rheumatism strangely mixed with the symptoms of puerperal fever, and in some of these cases pus may fill the tumid joints ; or the presence of the syphilitic poison or of gonorrhoea may imprint peculiar features upon the com- plaint ; and in most of the instances mentioned the rheumatism is probably of different blood-origin. In gonorrhceal rheumatism there is usually less febrile distress ; the articular pain is not so severe or acute ; the integument cover- ing the affected joint is apt to retain its normal color ; there may be but one joint — and there are not generally many — implicated ; the inflammation is confined to the synovial membrane, and a copious sero-fibrinous exudation occurs ; the joint-affection, which is pre-eminently an affection of one knee, shows a tendency to shift, and resembles rather an acute or a subacute rheumatoid ar- thritis than acute rheumatism ; the eye, too, unlike what happens in ordinary acute rheumatic fever, is often attacked. There is no copious sweating, and no disturbance of the heart ; and often there has been a running from the urethra, which diminishes when the gonorrhceal rheumatism sets in, but which does not cease. The disorder does not come on eai'ly in a case of gonoi-rhoea ; and the joint-affection appears really to be of pysemic origin. It disap- pears only very slowly, and is uninfluenced by salicylic acid.J It is by all these signs that we judge of the malady with much more certainty than by the mere presence of gonorrhoea with the symp- toms of rheumatism, for the former may be a mere coincidence. * Elliott Eichardson, Pennsylvania Hospital Keports, vol. ii. f Ferret, Lyon Medical, 1888. J German edition of this work. 892 MEDICAL DIAGNOSIS. Gonorrhoeal rheumatism may run an acute course.* Purulent effusions into joints may be mistaken for acute rheumatism. The history of the case, the frequent association with an infec- tious malady, and the location of the swelling, distinguish these pysemic joints. The traits of an attack of acute rheumatism are frequently altered by certain complications in internal organs which the con- taminated blood is apt to occasion. Prominent among them are the cardiac disorders, which are in fact so common that they may be looked upon as forming part of the rheumatic manifestation. Their signs we have investigated already, while examining endo- carditis and pericarditis. Certain cardiac phenomena, such as extreme pain without evidence of recent valvular affection, pain which may shoot to the neck and shoulder and be associated with signs of great irritability of the heart or of heart-failure, have been by some observers, as by Peter and Letalle,t attributed either to rheumatic myocarditis, or to an abnormal excitement of the cardiac plexus, of rheumatic origin. Other complications are inflammations of the lung, of the bronchial tubes, and particularly of the pleura ; an affection of the kidney which is generally a parenchymatous nephritis with some albumin and tube-casts, but which may be due to pysemic or embolic infarction ;f and — though not often — cerebro-spinal disturbances, exhibiting themselves by headache, violent delirium, convulsions, and coma, and occurring either in connection with a thoracic disorder, or solely in consequence of the action of the vitiated blood on the nervous centres, or in consequence of Bright's disease or of multiple capillary embolism, or of the sudden exhaustion of the nervous centres. This explanation § has been more particularly applied to the cases in which an ex- cessive temperature attends the rapidly-developed signs of cere- bral disturbance, a temperature of 107° or more. But, speaking from a bedside point of view, we must remember that such cases are comparatively rare, and that rheumatic delirium is far from * Davies-Colley, Q-uy'a Hospital Eeports, 1883. t Archives Generales de Medecine, June, 1880. X Chomel, Eecherches sur les Eeins dans le Ehumatisme, Paris, 1868; also Schmidt's Jahrb., No. 2, 1871. § Weber, Transactions of the Clinical Society of London, vol. i. RHEUMATISM AND GOUT. 893 ■always of the same nature. It may be of the kind just men- tioned. It may develop itself with or without the signs of cardiac complaint. It may come on early in the disorder during the violence of the fever ; or late, and clearly from debility aud im- poverished blood, yielding to nourishment and stimulants. It is rarely the result of meningitis. The delirium which attends aere- bral rheumatism may be marked by great talkativeness, or, on the other hand, the patient may be extremely taciturn.* Insanity may follow the brain symptoms of acute rheumatism. In some instances, whether due to rheumatic inflammation or to mere disturbance of the medulla and lower half of the pons, we find in rheumatic hyperpyrexia nervous symptoms that simulate multiple sclerosis, — exaggerated knee-jerks, ankle clonus, scanning speech, nystagmus, and tremor. Foxwell f has reported such a case in which the temperature reached 111°. The occurrence of nodules in connection with rheumatism, especially among children, has attracted a good deal of atten- tion. They are met with chiefly in the neighborhood of joints, especially of the elbow. These fibrous nodules may appear at once in any form of rheumatism, or come out in crops. They are not tender. They most often occur in cases of rheumatic endocarditis or pericarditis. In a few instances of rheumatism we find acute arteritis arising, and especially inflammation of the fibrous structures of the aorta. This condition may be suspected should we observe intense gen- eral uneasiness and distress, with pain, increased pulsation, a dis- tinct murmur in the course of the vessel, and tumultuous action of the heart without there being obvious signs of disease of that organ present. Still, the diagnosis is never a positive one. Acute rheumatism rarely ends fatally ; its cardiac consequences are more to be feared than the acute attack. Cases occur not unfre- quently in which the inflammation in the joints is lingering, and in which the febrile symptoms are not intense. These cases form an intermediate grade between acute and chronic rheumatism, and are spoken of as subacute. The disorder is more apt than the acute variety to affect the muscles as well as the joints ; nay, the * Some of these points are more fully detailed in my paper on Cerebral Rheumatism published in the Amer. Journ. Med. Sci., Jan. 1875. t Lancet, May, 1886. 56 894 MEDICAL DIAGNOSIS. former may be alone attacked. It may be witnessed in the joints of one extremity, or in one joint, and might then be mis- taken for synovitis. But the dissimilar history of the complaint will guard against error: no accident has happened to account for the swelling of the joint, and often the patient will tell us that he has had previously an attack of rheumatism. The subacute form of rheumatism is more likely to be confounded with rheumatic arthritis : we shall presently refer to their dis- tinction. Chronic Rheumatism. — This may either be a sequel of the acute disease, or the disorder may from the onset assume a linger- ing form, the constitutional symptoms being slight. The aifection may show itself in the joints, giving rise to stiffness, dull aching, pain produced by motion, but without heat or very obvious swelling, tenderness, and febrile excitement, or marked svveating ; or it may implicate the muscles in various parts of the body, occasioning stiff- ness, as well as pain when they are moved ; or it may attack both joints and muscles ; or it may be seated chiefly in the sheaths of nerves, leading to rheumatic neuritis, of which sciatica often affords a striking example. In any case the occurrence of the pain fur- nishes the starting-point in diagnosis ; and we must ascertain, by careful examination, whether it be augmented by motion, whether it be more or less shifting, whether it be not combined with stiflbess either of the muscles or of the joints, whether it be influenced by changes of temperature, whether it be not neuralgic, or associated with a disturbance of some viscus, such as of the liver or the kidneys, before we conclude that the complaint is really rheumatic. This is especially necessary in the most common form of chronic rheumatism, — muscular rheumatism. All kinds of pains in the muscles or their surroundings, the cause of which is not at once apparent, are apt to be pronounced rheumatic. And indeed it is not always easy to say whether they are or are not of that char- acter. We may distinguish them from the anguish of neuralgia by the pain in the latter complaint being ordinarily confined to the distribution of one nerve and not being increased by movement or by pressure, nor is it so steady, or attended with soreness, except over a few spots at some distance from one another in the course of the affected nerve. As regards the pains caused by organic structural disease, we EHEUMATISM AND GOUT. 895 can generally discriminate ttem from those of Theumatism by close attention to the history of the case, and by a careful explora- tion of the internal organs. Thus, for instance, we shall find pain radiating from the right hypochondrium to the shoulder to be dependent upon hepatic disease; or pain shooting down to the groin, thigh, and testicle to be caused by a disturbance of the kidney ; or a bearing down and an aching near the sacrum to be probably due to uterine disorder. Muscular rheumatism may affect the neck, the scalp, the mus- cles of the face, and the parietes of the chest or of the abdomen. It may be not only chronic in any of these situations, but also acute ; or, what is more frequent, when it occurs with fever and is transient, it is a sudden -acute exacerbation in persons who are rheumatic and suffer more or less persistently from rheumatism, though perhaps in a different part of the body from the one in which the acute affection has happened. Muscular rheumatism has been noticed in an epidemic form.* One of the most common seats of muscular rheumatism is in the loins. It then constitutes the disease known as lumbago. The patient is unable to stand erect, and finds it nearly impossible to stoop forward, on account of the severe pain occasioned when the muscles of the back are called into action. Unless the attack be very severe or acute, there is no constitutional disturbance ; but the disorder is often obstinate. It is easy of recognition. "We distinguish it from pain in the loins due to disease of the kid- neys, chiefly by an examination of the urine, and by the different way in which movement affects the rheumatic pain; from lumbo- abdominal neuralgia, by the two or three sore spots in the course of the affected nerve ; from rheumatism of the vertebral articula- tions, by the absence of tenderness and swelling around the spi- nous processes ; from lumbar abscess, by the want of local bulging or fulness, of fluctuation, and of fever. Then, we must be careful not to consider as lumbago the pain in the back caused by disease of the spine, or by disorder of the uterus, or by the passage of ab- normal urinary constituents, such as oxalate of lime, or consequent upon strains, or blows, or scurvy, or malaria, or anaemia, or a gen- eral or local muscular debility. * Schmidt's Jahrb., No. 12, 1872. 896 MEDICAL DIAGNOSIS. Thus there are many causes of pain in the loins, and where the case is of any duration or of any doubt we must be careful to exclude these causes from consideration before we assume the disease to be really rheumatism of the muscles and fascise of the back. This caution is very necessary in investigating the cases of "weak back" so prevalent among soldiers, which, though commonly spoken of as rheumatic, are really, for the most part, due to strains or injuries which have perhaps produced a weakness of the muscles and a persistent cutaneous hyperaes- thesia; or to an impoverished blood, to neuralgia, to scurvy; or to digestive disorders attended with the passage from the kidneys of large amounts of urates or of oxalate of lime. The remarks made with reference to this form of muscular rheumatism and the states which simulate it are also applicable to pains apparently muscular affecting other portions of the body. We may have pain and soreness of the muscles developed by strain or overwork and attended both with muscular and with cutaneous hypersesthesia, — a condition very different from rheu- matism, and designated by Inman " myalgia." This soreness of the muscles is always in direct proportion to their debility, and is chiefly caused by long-continued exertion beyond the power of the muscle, or by an ordinary amount of action when it or the individual himself is extremely debilitated. The morbid state is most rdarked during the convalescence from scarlet fever, where it may be looked upon as due to over-exertion of the weakened muscles. The soreness of the muscle is almost constantly accom- panied by heightened sensibility of the skin over it; and this coexisting cutaneous tenderness may be in any case regarded as an important diagnostic sign. Myalgia is chiefly found in the muscles of the trunk, and is very rarely general. Another form of muscular rheumatism which we may here mention is wry-neck, or torticollis. This depends chiefly upon contraction of the sterno-cleido-mastoid muscle of one side, and occasions the ungainly appearance with which most persons are familiar. But we must be careful not to consider every case as of rheumatic origin. The disorder may be spastic, or may depend upon nervous injury, and when chronic may lead to alteration in the muscular structure. Injections of atropine, hypodermically, may generally be used, not only for their good therapeutic effect, RHEUMATISM AND GOUT. 897 but also because, even in chronic cases, they may show us, by the difficulty or impossibility of relaxing the muscle, how much of it is really changed. There are forms of pain in muscles and tendons that are often mistaken for muscular rheumatism. AchiUodynia is one ; the slight swelling about the insertion of the tendo Achillis, with pain on standing or walking but without much tenderness, marks an affection that is frequently not rheumatic. In Morton's dis- ease the pain in the metatarsal phalangeal articulation occurs in seizures, yet only when the foot is moved as in walking ; there is neither heat nor swelling. Pain in the muscles and stiffness may be caused by still other conditions than those described, and be mistaken for muscular rheumatism, — the muscular pains of triohiniasls. But the marked exhaustion and the signs of gastro-intestinal catarrh are of such significance that they save us from error. A form of chronic rheumatism which also may be briefly mentioned is that affecting chiefly the fibrous membranes, such as the pe7-iosteum. This becomes thick, and tender on pressure ; its thickening may even be very perceptible to the touch as well as to the eye. This kind of rheumatism happens in those who have syphilis ; but it also occurs where no such taint exists. The pains are generally much more severe at night ; and this is sometimes assumed to be a proof of the syphilitic character of the disease, — but incorrectly so ; for many varieties of chronic rheumatism are aggravated by the warmth of bed. Indeed, the only really diagnostic signs of syphilitic rheumatism are the obvious evi- dences of constitutional syphilis, or the history of the infection. Still, to cases in which several nodes exist, and in which the pains more particularly affect the long and flat bones, and in which iodide of potassium speedily modifies the pains, we shall be rarely wrong in attributing a syphilitic origin. Chronic rheumatism is often feigned, especially by malingerers in the army and the navy, and the deception may be difficult of detection. They pretend to be scarcely able to walk, or hobble around with a cane, and complain much of the pain and stiffness in their joints. Yet there is not the least sign of deformity or real stiffness ; the pain is always stated to be the same ; and their general health is excellent. Their way of using the stick, too, is 898 MEDICAL DIAGNOSIS. characteristic : they move it each time they move the seemingly crippled leg, but, as a rule, not immediately, thus not employing it as a support. Anaesthetics are of great value in enabling us to decide as to the real amount of immovability of the limb. • Gout. — This disease may be, like rheumatism, either acute or chronic. Instead of describing its phenomena, I shall at once point out the marks of difference between the two kindred mala- dies. In gout, the small joints are chiefly or alone affected ; in rheumatism, the large. The gouty inflammation is accompanied by more local pain and redness than the rheumatic, and by oedema, enlargement of the veins, and desquamation of the cuticle, and implicates, at least at first, only one or a few joints, especially the joint of the great toe ; while rheumatism attacks the joints of the upper as well as of the lower extremities. In gout there is a tendency to disease of the kidneys, with a moderate febrile dis- tui'bance, and no profuse sweats; but we meet rarely with a cardiac complication, at least a valve affection, as constantly hap- pens in rheumatism. Gout is more decidedly hereditary than rheumatism ; its early ^ittacks are apt to recur with a certain amount of periodicity, and last about a week, — therefore a much shorter time than those of rheumatic fever. During the parox- ysm of gout the urine is scanty, and both before the attacks and during the first days the uric acid is strikingly diminished. Gout occurs genei'ally in those who live high or who drink large quantities of malt liquor, especially in men about middle age, or is seen in those whose systems have been impregnated with lead; while rheumatism is usually seen in the weak, is excited by cold and damp, is as common in females as in males, and is oftener found in the young and before middle age. Gout is frequently combined with a deposition of chalk-stones in the joints ; rheumatism never. Then, as shown by Garrod,* we possess an absolute means of diagnosis in the examination of the blood. Uric acid is always present in large excess in gout, and absent in rheumatism. This test will render easy of discrimina- tion even those cases which, with the usually employed means now at our command, are very perplexing to distinguish. Nor is the method of detecting the uric acid difficult, if we make use * Gout and Kheumatic Gout, 2d edit., London, 1863. EHEUMATISM AND GOUT. 899 of Garrod's ingenious plan. It consists in obtaining the crystals of uric acid, crystallized on a thread placed in a mixture of the serum of the blood or of the fluid from a blister with acetic acid, in the proportion of six minims of the acid to each fluid-drachm of the serum. The mixture of the serum and acid with the thread in it is placed in a shallow watch-glass and allowed to stand from twenty-four to forty-eight hours, protected from the dust. In the blood of gouty patients are many polynuclear colorless cells. The remarks just made apply more especially to the distinction between acute gout and acute rheumatism. The chronic disorders are more difficult to separate. Indeed, unless there be external deposits or chalk-stones, their discrimination may be impossible. In these obscure cases, however, the history and an examination of the blood may throw considerable light on the diagnosis. In many subjects, too, the exploration of the external ear will assist us in arriving at a correct diagnosis : we find one or several spots of deposit of urate of sodium on the helix. Gouty persons are subject to indigestion, flatulency, pains and cramps, or palpitation of the heart, — phenomena which are due to the gouty poison, and which are generally ameliorated by a fit of gout. The teeth of those of gouty diathesis are remarkably well enamelled, enduring, and free from decay ; but there is great proneness for tartar to collect upon them.* Violent fits of sneez- ing may be a most annoying synaptom,t and so are deep-seated pain in the tongue and a sense of burning. J In chronic gout there are often knotty finger-joints and tophaceous deposits in fingers and toes. Gouty endarteritis is not uncommon ; and the frequent association of contracted kidney with gout is universally recognized. The gouty inflammation of the joints may retrocede during an attack, and severe epigastric pain, nausea, vomiting, flatulence and acidity, faintness and a feeling of sinking, and a quick, feeble pulse show that the morbid action is transferred to the stomach; or it flies to the head, and apoplexy or maniacal symptoms occur; or to the heart, and there is violent palpitation, with dyspnoea, and * Dyce Duckworth, Transact. Odontol. Soc. of Great Britain, 1883. t Schmidt's Jahrbiicher, No. 8, 1881. J Dyce Duckworth on Gout, London, 1889, p 87. 900 MEDICAL DIAGJS'OSIS. intense anxiety j or it attacks the spinal cord, and a sense of con- striction around the thorax and abdomen, and piercing pains in the limbs, like those of locomotor ataxia, are encountered, and the spinal dura mater and the roots of the spinal nerves are found to be incrusted with uric acid and urate of sodium.* Closely connected with gout is lithsemia. Indeed, the excessive formation of lithates and the dyspeptic symptoms, with the heart- burn and eructations, the signs of functional derangement of the liver, the vertigo, the mental gloom or the listlessness and indis- position to exertion, the cramps in the legs and muscular twitch- ings, the neuralgic attacks, the restless nights, the palpitations of the heart and its irregular beat, are in many but the precursors, although, it may be, the long precursors, of a regular outbreak of gout ; while in many more this half-dyspeptic, half-nervous con- dition, with the faulty assimilation, the imperfect oxidation, the excessive discharge of lithates at times and their disappearance at other times, will go on for years without ever developing into an attack of gout.f Still, in years the same local lesions may follow in internal organs ; we may have the same form of contracting kidney, arterio-sclerosis, and the heart-affection with hypertrophy, and the accentuated second aortic sound of the lithsemic state. Lithsemia sometimes manifests itself in attacks of pain in the stomach and bowels. The pain is associated with tenderness, and is most common when the stomach is empty. Among the symp- toms of lithsemia that are very liable to be mistaken and mis- treated are disorders of vision. As RisleyJ has recently stated, lithsemia is both a primary and a modifying factor in many of the discomforts and more serious disorders of the eye. It stands second only to syphilis in the frequency with which it causes iritis. In adults, obstinate eonjunctivitis and episcleritis are apt to own lithsemia as a cause, and it often gives rise to pain and to photophobia. It may lead to ulceration of the cornea and errors of refraction and attendant eye-strain and headache. Rheumatic Arthritis or Rheumatic Gout. — Gout is rare in this country. But the same cannot be said of that distressing * Ollivier, Archives de Physiologie, 1878. f See paper on Lithaamia, by the author, Amer. Journ. Med. Sci., Oct. 1881 ; and University Medical Magazine, May, 1894. J Proceedings of the State Medical Society of Pennsylvania, 1895. EHteUMATISM AND GOUT. 901 disorder known as rheumatic gout, but which is neither rheuma- tism nor gout, but a distinct aifection. The disorder may be acute or chronic. It is not often the former ; many of the acute cases, indeed, being rather subacute than acute. Even in those belonging to the acute form there is little febrile disturbance; and though we observe pain and aching in the joints, and some discol- oration, we find less redness than in acute rheumatism, and cer- tainly the tongue less furred, the pulse not so bounding, much less profuse perspiration, no such heavy deposits in the urine, and an utter freedom from cardiac complication. The acute arthritic disease has rather inflammation of the pleura and of the eye as its attendants, and is often accompanied by a sallow skin, yellow- ish conjunctiva, and discolored, costive stools. It implicates the large and small joints equally, thus differing from gout, and causes very great swelling, due to an effusion, not around the joint, but into its capsule. It fastens upon several joints, and, though it may pass from joint to joint, it shows but little migratory tendency; the joints first attacked remain the seat of disease. Unlike gout, it is apt to affect the smaller joints of the hands without a previous affection of the toes, and exhibits no periodic paroxysms or exacer- bations. Moreover, an acute attack is of very much longer dura- tion. Unlike subacute i-heumatism, it does not affect the muscles, and is, both in the suffering at the time and in its ultimate results, a much graver malady. The great danger in I'heumatic arthritis is from the effects of the inflammation on the joints. The changes there produced are obvious in the chronic form, for each joint attacked is apt to be much damaged. The chronic complaint may follow the acute, or it may begin without any febrile symptoms, with pain and stiffness in the joints. These soon become much distended with fluid, which is gradually absorbed, and the structure of the joint alters, the cartilages become, sooner or later, implicated, and gradually waste, and chronic changes and permanent deformity are produced. The alterations may go on getting worse and worse in consequence of repeated attacks, until complete immobility ensues, and, the joints becoming permanently affected, the ends of the bones are dislocated and enlarged. But, though there is much swelling, no deposits of urate of sodium are found in the joints. Occasionally, especially in men, the disease is only found 902 MEDICAL DIAGNOSIS. on one side of the body, and may show itself first in a large joint, as in the hip. Among its peculiar, though less constant symp- toms, are very rapid pulse, sweating, and pigmentation of the skin, like freckles. Charcot has pointed out that in paralysis agitans, in addition to rigidity of the muscles, deformities of the fingers result resembling closely those of chronic articular rheumatism. But the likeness to the deformities caused by rheumatic arthritis is still closer, and to distinguish them we must take into account the whole history of the case, the tremor, the fixed look, the peculiar gait, the in- distinct speech, the tremulous handwriting, the sensation of exces- sive heat. Moreover, the disfigured joints are not stiff, and do not crack. The arthropathies of locomotor ataxia may be mis- taken for rheumatoid arthritis, but, irrespective of the history and of the characteristic pains, the absence of the patellar tendon reflex distinguishes them. All these joint affections following nervous diseases, and sometimes classed together as spurious arthritis, differ from joints attacked by rheumatism or by rheu- matic arthritis in the absence of marked swelling and of pain, except on forcible movement ; stiffness is the prominent feature. Rheumatic arthritis is more common in females than in males ; like rheumatism, it may be excited by cold and damp, and is veiy apt to occur in the weak and unhealthy. It generally, even in cases that recover, persists for months. Nor will it yield to the remedies usually administered in acute rheumatism ; nor to colchicum and the alkalies, so beneficial in gout. I shall here add a short description of a disease of nutrition of dissimilar character to those described, but having this in common, that it markedly affects the organs of locomotion, — rickets. Rickets. — In this country rickets is a comparatively rare affec- tion, certainly rare as compared with its prevalence in England, in Holland, in Germany, and in some other Continental States. It is a constitutional disease of early childhood connected with im- paired nutrition, and is chiefly characterized by increased growth of the epiphyses and periosteum, and imperfect ossification, pro- ducing softening of the bones with curvatures and distortions. The changes are most manifest in the long bones ; and the amount of organic matter in them is more than doubled, while the earthy matter is scarcely above one-third of the normal quantity. Be- EHEUMA.TISM AND GOUT. 903 sides the osseous changes there is evident cachexia ; and the liver and si^leen become enlarged and indurated from overgrowth of the glandular elements and interstitial development of fibroid tissue. A similar process may also happen in the kidneys and in the lymphatic glands. InsuiScient and improper food is a powerful cause of rickets. The malady may show itself as late as the seventh or eighth year ; but it most generally sets in during the first or second year of life. When it leads to death, it does so generally by gradual exhaus- tion, by impairment of the digestive functions, by thoracic com- plications, such as extensive bronchitis, pleurisy, collapse of the lungs associated with bleeding of the thoracic walls, by spasm of the glottis, by convulsions, or by chronic hydrocephalus. As a marked disease it does not usually last longer than a year, though the results of the osseous changes may long persist, and, affecting the thorax or the pelvis, prove eventually very injurious. Yet in time the bones may lose their rickety condition and become strong and dense, although some curvature and deformity remain. The beginning of the disease is insidious. The child makes no attempt at walking, or ceases to walk if it have commenced. It is languid, irritable, its face pale, its tissues flabby. The appetite fails, there are thirst and irregularity of the bowels, or the marked signs of a gastro-intestinal catarrh. Restlessness at night, a dis- position to throw oiF the bedclothes, profuse perspiration about the head, neck, and chest, while the rest of the body is hot and dry, attend an irregular febrile condition which soon shows itself; while fear of being touched, or general soreness or tenderness of the body or actual pain, bespeaks the local process that is going on in the bones and their covering. The changes in the bones now become more and more distinct. The joints appear swollen, especially at first the wrist-joints, and when these are examined the lower extremities of the radius and the ulna are found to be . enlarged ; similar changes are perceived in the tibia and fibula, and in the elbow. There is tenderness along the ribs, and, should the affection continue, nodules are felt at the junction of the ribs with their cartilages ; the sternum protrudes, a pigeon-breast re- sults ; then the limbs show contortions, the clavicles are bent, the spine may be curved, the pelvis deformed. The head is large and square, the forehead high, the anterior fontanel remains unclosed. 904 MEDICAL DIAGSOSIS. the sutures are open and thickened on the sides. A blowing sound is frequently to be perceived over the cranial sutures. Den- tition is delayed, or the teeth decay and fall out. The urine is copious, and contains lactic acid and an excess of phosphates. In advanced cases the symptoms of cachexia are very marked ; the flabby muscles, the wan, anaemic aspect, the large abdomen con- trasting with the small face, the enlarged liver and spleen, the persistent tenderness over the bones, and at times the marked fever, give sad evidence of altered nutrition and of suffering ; yet even then the little patient may recover, though most likely with part of the osseous system irretrievably damaged. Of course we have all kinds of gradations in the malady, and the general symptoms attending the morbid process may be slight, just as the rickety condition of the bones may be limited. The diagnosis will have been made apparent from the descrip- tion of the symptoms. In advanced cases there can be no doubt. The changes in the bones, the curvature, the distortions, the ap- pearance of the patient, the evidences of cachexia, clearly stamp the malady. Earlier in the disease it may be confounded with the manifestations of hereditary syphilis. But this affection comes on even sooner than rickets, almost from birth ; there are other signs of the constitutional taint, including early enlargement of the spleen, syphilitic coryza, and, at a later period, the notched teeth ; a distinctive history may perhaps be obtained ; and the enlarged bones not unfrequently suppurate, the swollen epiphyses become detached, and osteophytes form, — changes not met with in rickets. Mollities ossium produces deformities which may be mistaken for those of rickets. But the softening of the bone is the result of its disease, and not of its want of proper ossification. There is consid- erable difficulty in locomotion, and the bones bend or break, after having been affected with deep-seated pains. The malady lasts for years, and is not one of childhood, being most common between the ages of twenty-five and forty, and attacking chiefly women. The pelvic bones are often implicated ; it is douljtful if the phos- phates in the urine are increased, but, as in rickets, the urine con- tains lactic acid. But there are not the characteristic signs at the cranial bones, the open fontanel and sutures, nor the swelling of the epiphyses, which this malady so strikingly presents. RHEUMATISM AND GOUT. 905 Some of the local deformities that result and the diseases with which they may be confounded, as of the thorax and of the head, have been elsewhere discussed. Besides the alteration of the skull in chronic hydrocephalus, the condition described by Elsaesser and others as craniotabes may be mistaken for ordinary rickets. It consists in thinning of the bones of the cranium, especially of the occipital bone, which becomes perforated, allowing the mem- branes of the brain to come in contact with the under surface of the scalp, and convulsions may be induced by undue pressure over the points of perforation of the bone. The malady, though re- garded by some as a separate affection, is by others, by Virchow among them, looked upon as due to a rachitic diathesis ; we cer- tainly often find evidences of this in conjunction with the peculiar alteration of the bones of the skull. There are cases described as acute rickets which are a combina- tion of rickets and of scurvy.* They are most common in in- fancy, and generally present the spongy gums only about the teeth that have been cut. They sometimes show, in addition to peri- osteal hemorrhages, a sudden protrusion of one eyeball. In the early stages rickets may be mistaken for acute or subacute rheu- matism ; the fever, the pain, the sweats, and the swelling near the joints mislead. But the age, the size of the epiphyses, the absence of redness of the joints and of heart-lesion, the '• bead- ing" of the ribs, the signs of beginning cachexia, the faulty dentition, and the pale urine full of phosphates, tell the true meaning of the symptoms. Moreover, the apparent joint-affec- tion is apt to show itself at the wrist-joints, always a suspicious circumstance in delicate young children. * St. Louis Courier of Medicine, 1883, p. 453 ; also Barlow, British Medical Journal, 1883, i. p. 1029, and " Bradshaw Lecture," ib. 1894. CHAPTEE XII. FEVBES. Fever is either a symptom of some strictly local malady or constitutes the only obvious affection present. It is only in the latter case that the disorder merits the name of essential fever. The first step, therefore, when fever has been recognized, is to determine whether it is symptomatic or idiopathic ; whether, in other words, it is but a complement to a disease, or, as far as can be ascertained, the disease itself. This is not generally a difficult matter. The history of the case, the absence or presence of the marked peculiarities of serious local disturbances, soon determine the scale of evidence to rise on the one side or sink on the other. And it is astonishing, with the progress of medicine, how many affections have been passed over from the domain of fevers to the narrower circle of inflammatyjn of individual organs ; with what a different eye, for instance, the brain-fevers of the olden times are regarded. While thus the group of idiopathic fevers has been very considerably winnowed, some of their broad traits have been prominently brought forward. It is now well understood that, with some exceptions, they are characterized by the want of definite and invariable anatomical lesions. That in all con- stant changes occur in parts of the nervous system, or in the blood, is highly probable. But there is certainly no invariable injury perceptible in the organs of the body : sometimes one, sometimes another, suffers ; sometimes nearly all ; at times, none. When we contrast this with symptomatic fever, the difference is striking. The visceral lesions, then, of an idiopathic fever are not the starting-point of the fever, but rather secondary and un- certain complications influenced by and subordinate to the pro- found disturbance of the whole system. In idiopathic fever, the fever controls the lesions ; in symptomatic fever, the lesions con- trol the fever. 906 FEVERS. 907 Most fevers rtin a definite course, showing a strong tendency to a spontaneous termination at a given time. At their beginning, too, they are for the most part similar. There is a prodromic state, marked generally by unsound sleep, pain in the back, and . lassitude. This is followed by chills, which are succeeded by heat of skin, arrested secretions, quick pulse, and evident fatigue upon the least exertion. The fever has now reached its full develop- ment. Its precise character becomes evident ; the symptoms caused by disorders of individual organs stand forth. After a while the disturbance declines, or speedily ceases under the influence of crit- ical discharges. The functions are re-established, and a convales- cence, more or less rapid, sets in. An unfavorable termination, on the other hand, may take place at any period after the system has been fairly invaded. The marked features impressed upon the fever either by the course it runs, or by the specific nature of the symptoms, go to form what is called its type, and may be made the basis of the classification of all febrile disorders. But as opinions have been and are still singularly diversified as to what really constitute the most palpable characteristics, so the classification of fevers is as yet, to a great extent, a matter of speculation. In the following table no attempt is made at an exhaustive or strictly scientific classification. Some disorders, such as cholera, epidemic dysen- tery, and puerperal fever, considered by many eminent patholo- gists to belong to idiopathic fevers, have no place assigned to them ; while others, such as influenza and yellow fever, the claims of which to be here mentioned are undoubted, might have their positions impugned. But from a diagnostic point of view the arrangement adopted is convenient, and is sufficiently accurate to be free from grave objections. Peters. CoNTiNrED Fevers., ' Simple continued fever. Catarrhal fever,, or influenza. Typhoid fever. Typhus fever. The plague. Cerebro-spinal fever. Belapsing fever. EkUPTITE rEVEKS.. 908 MEDICAL DIAGNOSIS. Fevers. — Continued. C Intermittent fever. Periodical Fevers J Remittent fever. 1 Congestive fever. L Yellow fever. Scarlet fever. Measles. Rubella. Smallpox. Varicella. Miliaria. Dengue. . Erysipelas. Continued levers. All continued fevers are characterized by a steady progress of the febrile movement, without either decided exacerbation or relaxation, the rise and fall observable being too slight to modify the impression of a sustained action. Simple Continued Fever.— Simple fever sets in with feel- ings of lassitude and chilliness ; to these succeed hot skin, ex~ cited pulse, thirst, headache, pain in the limbs. The bowels are generally confined, the urine high-colored. The fever is soon at its height ; it then either gradually declines, or is more suddenly relieved by copious perspiration or by a critical discharge from the bowels. Generally it runs through all these stages in a few days ; but it may be protracted for upward of a week or longer. On the other hand, a day may witness both its beginning and its termination. The convalescence is almost always rapid. The exciting causes of this form of fever are fatigue, errors in diet, change in mode of life, exposure to cold and moisture, or to the sun. When brought on by mental overwork or by anxiety or grief, it is not uncommonly attended with increased sensibility of the skin, and with considerable prostration, simulating typhoid fever, but differing from it by the absence of epistaxis, of the pe- culiar abdominal symptoms, and of the eruption. More frequently the fever has the appearance of one of high action. At times, in- deed, it is so intense, and the vascular system is so wrought up, that the distemper assumes what is called an inflammatory type. It then exhibits the characteristics of the fever described by the FEVERS. 909 physicians of the last century as synocha. A temperature of 103° or upward, throbbing of the temporal arteries, severe headache, and delirium are among its symptoms. This variety of the fever is not, however, now encountered, save in tropical latitudes. In point of diagnosis, it is most apt to be confounded with internal inflammations, especially with inflammation of the brain. On the history of the case, and on the full consideration of all the symptoms before us, alone can a trustworthy opinion be based. In truth, in all the grades of what appears to be at first sight simple continued fever, we ought to examine carefully all the organs and see whether the symptoms may not be wholly ac- counted for by some visceral disturbance. And often, then, under what seems to be a very active or " ardent" fever will, on closer scrutiny, be found lurking the traits of an inflammatory lesion. Catarrhal Fever. — This epidemic malady, which belongs to the idiopathic fevers, is sometimes described as a mere variety of bronchitis, because inflammation of the bronchial mucous mem- brane constitutes one of its most prominent symptoms. But this is not a just view. With as much reason might typhoid fever be omitted from the list of febrile maladies and described as a variety of enteritis or of diarrhoea. Catarrhal fever, or influenza, is essentially an epidemic disease, and one which has visited the human race from remote antiquity. Its history is thus not confined to any particular time or to any particular nation. Its cause is believed to be a slender bacillus, with rounded extremities, two or three times as long as it is wide, which is to be found in the expectoration and nasal secretion.* But its bacillary origin, though very probable, has not been actually demonstrated. Each epidemic does not furnish precisely the same train of symptoms ; but they all agree in this : the dis- order sets in suddenly and attacks pre-eminently the mucous membranes. Generally it is the mucous membrane of the nose, eyes, and bronchial tubes that suffers most, and we find the signs of coryza and of bronchial inflammation, — a watery eye, sneezing, uneasiness about the throat, and a tormenting cough. But asso- ciated with these are great depression of spirits and usually an extraordinary amount of lassitude and impairment of strength, — * Pfeiffer, Zeitschrift fiir Hygiene und Infektionskrankheiten, March 3, 1893. 57 910 MEDICAL DIAGNOSIS.' much more than the cold in the head, or the laryngitis, or the bron- chitis, will account for. The skin is hot, at times covered with per- spiration ; the thermometric record is peculiar only in its extreme irregularity. The temperature generally ranges between 100° and 102°, or starts up suddenly to 104° or 105° and in less than a day subsides almost to normal ; the pulse is of moderate volume, the tongue coated ; the patient complains of debility, of lieadache, of aching pains in his back and limbs, and of constriction at the lower part of the chest. Often there is some dyspnoea, as well as epistaxis, hypereesthesia, especially of the neck and head, and distui'bance of the alimentary tract, evinced by loss of appetite, nausea, and vomiting, or by diarrhoea ; at times catarrhal jaundice coexists. Commonly after three or four days these symptoms begin to subside, the cough and debility outlasting the other morbid signs. With reference to the cough, we are often struck by the fact that its obstinacy and violence are not associated with adequate physical signs of disorder. It is often very dry and harassing. But all epidemics do not run precisely this course. In some, the prostration is not so evident, and the febrile signs are more active and of an inflammatory type ; in others, the pain and sore- ness in the limbs and in the joints are the most prominent symp- toms ; or we may find hemicrania, or torpor and delirium, or paro- titis with salivation, or otitis, or epistaxis, or jaundice, or capillary bronchitis, or pneumonia, or tendency to heart-failure, or menin- gitis, basilar or spinal, and irregular rashes, as complications. Many complications and sequelae of influenza haye been observed. Among these are inflammation of brain, cord, and nerves, and of the meninges, as well as various psychoses and neuroses, bulbar palsy, acute ascending paralysis, hemiplegia, diabetes, vascular occlusion, gangrene, angina pectoris, and painful and inflammatory affections of tendons, fasciae, joints, periosteum, and bones. The lung complication of influenza is striking. It is mostly an intense congestion, with bronchitis and here and there with spots of consolidation. True lobar pneumouia is much rarer. The lung affection may be of long duration, showing the record of a fever with marked rises and remissions. After declining, the temperature may become subnormal and remain so with occasional exacerbations for a long time, as seen in the accom- FEVERS. 911 a B t'^^ .^iV s f 'l 1 1 - 'W 1 es ^ 6 T , £ J n M i" 3 3 T= -- . s T -• ; : : . PI 8 ^ ,-- - ■ ■ 1 / s " -. PI :? * Sr° '-. 3 n s ^S 3 ' / 3 . n s, s s s° : S .. m to u" s° ; I "'s 00 s° s" 5 ^ , - - ' m to s" 2' . ±_ S _ .=.,, .^ s ^ I T ■-- - J / " £: is' .^ •• , z . s z-^ " J= £ X- '''' 4 / s - ^n ^9 ■S .= T / s , T m Ot .' S n •^ s° '- 3 ' > " / "' u »" :_ 2 : ,_ m ca s? J. D "M fT ' / T 2 ' X J- n ce / J ; S ^ - , CO u- i ~ 3. p\ 5 ^ J 3 ' it m = s i I T S m M JS i S , T m U 3 ft ' s n = !° s^ _/.3 ' T T «<< / s* S .:::4:::" > " X n 5 .^ ,i 1 . J J. s j_ m = «^ s" "' J. I -1 S sf 3 s 1 "^ . _ '] S ■ n s 8 s - " 2 ..II.-.. =: - - S ?■ S ii " W y 3 ' : s __s 5 s 5 s ; J _^ m CA ■■.a 2 '- 3 en K -" S n s^ p s ^3 r* J *° 3 _ n M s* .' r' 2 1 ■ ; „~ s 3 I^' S 7. " •a 3 ■ Ifi llllillllll 5 in. m g .3 3 I s t t m ^ s* ,S 5 S J; - s g° S "^ ; . m i» s? 3 T - ' T s L "1" n «) / s' S n •t> -.2 3' S , T n 91 s / £ ........ m A J -,2 3-. - s M \ 3 II 3 .. .)y J. "".!.' I I I ) I TTr I I j 1 1 I • I I I I J ri I Hrt 912 MEDICAL DIAGNOSIS. panying chart of a case in my ward at the Pennsylvania Hos- pital.* . Influenza is not ordinarily in itself a fatal disease. It is only so in the very young or the very old. It is also a grave malady in persons with weak hearts. A source of danger is the in- durated lung it may leave behind becoming the seat of tubercle. Catarrhal fever is easily discriminated from other maladies. Its peculiar epidemic character and the prostration prevent us from mistaking an ordinary cold or bronchitis for it. Occasionally the attending debility makes it look like the onset of a low continued fever. But brain-symptoms are present only in rare instances in influenza ; and, on the other hand, decided catarrhal symptoms are not common in typhoid and typhus fevers. Before long, too, the occurrence of the eruption of these diseases clears up what- ever doubt may have existed. The all but constant absence of an eruption in influenza comes also elsewhere into play : it serves to distinguish this disorder from measles and smallpox. Catarrhal fever may be mistaken for hay-fever. But the local symptoms of irritation of the nostrils, the watery eyes, and the red- dened conjunctivse are very striking, and the febrile movement is generally less than in catarrhal fever. Moreover, there are asth- matic symptoms in hay-fever or hay-asthma in a certain propor- tion of cases ; and the history of the case ; the manner in which it comes on as a rose-cold in the latter part of May or early in June, or as autumnal catarrh after the middle of August ; the hereditary idiosyncrasy so often seen ; the persistence of the attack while exposed to the peculiar vegetable emanations that give rise to it ; its almost abrupt cessation on removal to certain localities, — make up a set of features which are very distinctive. When influenza is prevailing on a large scale, it is often found masked by other diseases, and it may be difficult then to sepa- rate its manifestations from those of the malady it accompanies. Other peculiarities of influenza are the long time it takes the pa- tient to regain his strength, and the annoying sweats that attend convalescence. This was very striking in the epidemic of the early winter months of 1890 ; as was also the tendency to relapses, to irregular heart action, and to alterations of cutaneous sensibilit)-. * Por a further description of the lune complications of influenza, see my paper on the subject in the " International Clinics," Vol. I., Second Series. FEVEES. 913 Typhoid Fever. — In this country and on the continent of Europe a form of continued fever prevails, marked by great pros- tration and disturbance of the nervous system, and by constant anatomical lesions. To this disease the designations of typhoid fever, enteric fever, and abdominal typhus have been applied. The disorder either attacks single individuals or shows itself as an epidemic. It occurs at all seasons of the year, but, in this country at least, is most frequent in autumn. In some localities it is thoroughly at Iiome ; in others it is only occasionally seen. It avoids both extremes of age, seizing mainly on young adults for its victims. The distemper may set in suddenly, but more generally it has an insidious beginning. For some days pi'cceding the access of the fever the patient feels weak. He is without animation, and his countenance fully expresses his languor. He complains of soreness and fatigue, of dull pain in the head, of loss of appetite. His sleep is unsound ; all exertion is wearisome ; something is evidently weakening his nervous energies. A fever now appears, preceded mostly by a chill, or, at all events, by chilly sensations, which alternate with flushes of heat. The muscular prostration accompanying the febrile movement is so great that the patient is obliged to seek his bed. His appetite is entirely gone, the tongue is coated, the bowels are loose, the abdomen is somewhat swollen and tender to the touch. On close inspection, a few reddish spots, resembling flea-bites, are found on its surface. The malady has now completed its first week. It enters on the second week with "fever unabated, and with the signs of disturb- ance of the alimentary tract and of the nervous system more and more unmistakable. There is sometimes nausea or epigastric dis- tress, often pain in the right iliac fossa, increased by pressure and tympanites. The tongue dries and becomes reddish or brownish ; it is often glazed and covered with a light coat ; sometimes it has deep fissures ; very frequently I have noticed at the tip a wedge of brownish or reddish surface free from coat, but which begins to be covered over as the disease declines ; the gums and teeth are lined with dark crusts. The mind is dull and wandering ; cough and great restlessness exist ; the debility is extreme. The disease now begins to draw to its close. It has reached the third week, and a change, for better or for worse, may be 914 MEDICAL DIAGNOSIS. looked for. Slowly recovery sets in, marked by a brightening of the countenance and by a gradual increase in consciousness and strength ; or deepening insensibility, jerking of the tendons, feeble pulse, and cold, clammy sweats indicate that dissolution is fast approaching. Thus, in one way or the other, the fever itself is apt to ter- minate by the beginning or the middle of the fourth week. Yet such is not always the case. Death may take place at an earlier period ; or, on the other hand, the malady, by troublesome com- plications, may be lengthened beyond the second month. Under any circumstances, convalescence is protracted. The nervous system rallies but gradually from the shock it has received. Among the symptoms enumerated, some tend clearly to charac- terize the disease. And, first, of the more purely febrile symptoms. The heat of the skin is especially perceptible in the evening ex- acerbations of the fever. Frequently the surface is covered with an acid perspiration, very manifest during the whole course of the disorder, and also encountered long after convalescence has set in. The pulse is accelerated, and remains so after the heat of the skin has left ; it is very compressible, and even in intercurrent acute in- flammations it seldom loses its compressibility. A jerking, irreg- ular beat, or very great rapidity, is an unfavorable sign. Dicrotism of the pulse is not unusual. Associated with the diminished strength of the pulse is a decided faintness of the first sound of the heart. The temperature is peculiar ; in the first five or six days of the disease it pursues an ascending line ; that is to say, starting at the normal 98.6°, there is apt to be a daily evening rise of about 2°, with a morning remission of about 1°. From the fifth or the sixth day to the twelfth or a little later, — roughly speaking, we may say from the end of the first week to the end of the second, — the fever is continuous, with a morning remission rarely ex- ceeding 1°. From that time on, let us say from the twelfth day, although the evening temperature may remain for a day or two quite or nearly as high, there is an abatement of from 1° to 2° in the morning. These changes between morning and evening become very evident at the end of the week, and are still more evident in the third week, when the morning and evening tem- peratures may vary as much as from 4° to 6°. During this week, too, the evening temperature gradually decreases ; but in severe FEVERS. 915 cases it remains liigh, and there are no decided remissions, either in the second or the third week. The morning temperature is high, 104° or more, and there may be still greater heat of skin in the evening, or else it diiFers but little from that of the morning. The peripheral temperature, as measured, for instance, in the palm of the hand, becomes during the fever as high as the axillary temperature, but their equalization ceases prior to defervescence.* In exceptional instances, it is stated, the temperature may be normal throughout ; f in still rarer instances it is subnormal.^ I have never seen a case of either kind. Occasionally the curve may resemble that of intermittent fever. § The urine is acid, high-colored, scanty, — the urine of fever. In severe cases it contaius variable amounts of albumin, particu- larly in the cases with high temperature ; hsematuria is very rare. Ehrlich has stated that the urine of typhoid fever gives a special reaction. This test consists in taking forty parts of a saturated solution of sulphanilic acid in hydrochloric acid, one to twenty, and one part of a one-half per cent, solution of sodium nitrite, and adding them to an equal bulk of urine rendered alkaline by strong ammonia. Normal urine is colored brownish by the test liquid, typhoid-fever urine pink or ruby, with slight frothing. . The reaction has not been found in all cases of typhoid fever, and has been obtained in a variety of other morbid conditions, such as tuberculosis, measles, scarlatina, enteritis, malaria, pneu- monia, meningitis, septicaemia, uremia. || It has been thought to be due to the presence of bacterial products. Among the abdominal symptoms, diarrhoea is the most promi- nent. It is never absent, except when the disease is unusually * Couty, Archives de Physiol 'gie, No. 2, 1 880. f Finlayson, American Journal of the Medical Sciences, March, 1891, p. 225; "Wendland, Deutsche medicinische "Wochenschrift, Aug. 29, 1892; Dreschfeld, Practitioner, No. 298, vol. 50, p. 272 ; Fisk, Medical News, Nov. 3, 1894, p. 479; MacDougall, Lancet, April 15, 1«93. i Eaimondi, Gazette des Hopitaux, 1894, No. 109; Centralblatt fiir Innere Medicin, 1895, No. 6, p. 152. § MacDougall, Lancet, April 15, 1893. II Taylor, Lancet, May 4, 1889 ; Edwards, Medical News, April 2, 1892 : Dawson, Dublin Medical Journal, 1894, No. 2-58; American Journal of the Medical Sciences, April, 1894, p. 448 ; Nissen, Jahrb. fiir Kinderheilk., B. 38 ; Fortsohritte der Medicin, 1895, No. 5, p. 192. 916 MEDICAL DIAGNOSIS. mild. Generally it is a very early symptom ; at times it is even seen among the prodromes. The clue to its cause is found in the state of the intestinal glands, — in the enlargement and ulceration of the glands of Peyer and of the solitary glands, with the tume- faction of the mesenteric glands. And in these morbid alterations we find an explanation not only of the occurrence of the diar- FEVERS. 917 rhoea, but also of its frequency. The stools are thin, of a yellow or dark-brown color, and of offensive smell. When the affection is at its height, from three to four evacuations occur during the twenty- four hours ; but the passages may become much more numerous, and with their number the danger rises. If they take place without the knowledge of the patient, his situ- ation is precarious. Sometimes the stools contain blood. Should this be present in considerable quantity, it is a very unfavorable circumstance. Yet intestinal hemorrhage is by no means neces- sarily fatal. In rare instances there is hsematemesis.* Dickinson f has reported a case in which profuse haemoptysis occurred, in the absence of any pulmonary lesion. Pig. 78. EbertU-Gaffky'a typlioid-fever bacillus, from a potato culture. Tlie broad ones are really two bacilli lyiug iu juxiaposiiiou. ZeUs j^, homo, im.^ Oc. 5. The poison of typhoid fever is conveyed chiefly through drinking water or defective sewerage. It is now generally thought to be the bacillus described by Eberth and by Gaffky as present in the intestinal lesions (Fig. 78) and found in the * Weiss, Wien. med. Presse, 1887. f Lancet, Feb. 17, 1894, p. 421. 918 MEDICAL DIAGNOSIS. stools. This is a rather plump organism, from two to three /^ long, with rounded extremities, and staining with the ordinary aniline colors. While there is a close resemblance between the bacillus of typhoid fever and the bacillus coli communis, there are certain points of distinction. Thus, the movement of the former is more active and more extensive than that of the latter. The typhoid- bacillus manifests a greater tendency to form threads of two or more than does the colon-bacillus. Colonies of the former grow much more slowly on gelatin and on agar than do those of the latter. Potato cultures of the typhoid-bacillus are scarcely visi- ble, while those of the colon-bacillus appear as distinct, broad, orange streaks. The colon-bacillus is capable of inducing fer- mentation and of curdling milk, while the typhoid-bacillus is not. Flagella are more readily demonstrable on typhoid-bacilli than on colon-bacilli. Finally, the typhoid-bacillus yields the indol reaction with potassium nitrite, while the colon-bacillus does not.* Enlargement of the .spleen is a very constant attendant upon the fever. In fact, whenever we can be certain that the evident in- crease in size is not due to some previous malady or to malaria, the extended percussion to dulness in the splenic region becomes an element of importance in our diagnosis. The tympany that often exists interferes with the recognition of the enlargement. Another abdominal symptom of significance is pain. It varies much in severity and character, and is, indeed, not always present. It is often a heavy, aching feeling. In some patients it is of a griping kind, preceding the. loose discharges ; in others it seems to be called into existence only by pressure. Its most common seat is in the iliac fossae ; yet the testimony of the sick man him- self as to its exact situation must be received cautiously. He is too ill to answer intelligently. Still, the expression of suffering on his face when pressed on either side at the lower part of the abdomen is indicative of the pain corresponding, for the most part, to the seat of the irritation. In rare instances the pain is really in the muscles, which may, indeed, suppurate.f Often, while the hand is exploring the abdominal regions, a movement * Archiv fiir Hygiene, vol. xix., fasc. 3. f Ebing, Archiv fiir klin. Med., viii. PEVEES. 9 1 9 of the fluid and gas in the distended bowel, attended with a gurgling noise, becomes appreciable. This sign is best elicited near the ileo-csecal valve. Attention has been called to a yellowish discoloration of the palms of the hands and soles of the feet in cases of typhoid fever, and not, as a rule, observed under other conditions.* During convalescence, griping pains are not infrequently com- plained of They are colicky pains, produced generally by errors in diet, and may be followed by a return of the diarrhoea or by a relapse of all the other symptoms of the malady. Occasionally during the latter period of the fever a sudden pain sets in, of great intensity, unremitting, and attended by spreading tender- ness. Such a pain shows that peritoneal inflammation has been lighted up in consequence of perforation. This complication is not necessarily fatal, as the morbid process may be limited by inflammatory adhesions. In a number of instances the abdomen has been opened, the perforation found and closed, and recovery has ensued.f The peritonitis and intestinal adhesions that fol- low perforation may be attended with symptoms of obstruction of the bowel.| Hardly inferior to the abdominal symptoms in import are the signs of dkturbance of the nervous system. The fever is, as its old name implies, pre-eminently a " nervous" fever : the nervous symptoms are, in truth, never absent ; but, though always present, they are less extensive in some cases than in others, and not the same throughout all the stages of the disease. Thus, early in the disorder, dull headache, mental languor, wakefulness, and a perverted state of the senses, such as ringing in the ears and dul- ness of hearing, are encountered ; while later, great restlessness, delirium, somnolence, or coma, and jerking of the tendons are phenomena more likely to be met with. Occasionally the disease is ushered in by acute mania. § * Klipovitch, Lancet, Aug. 19, 1893. See also Medical News, Oct. 4, 1893, p. 444. t Van Hook, Medical News, Nov. 21, 1891, p. 591 ; Sifton, Chicago Clinical Keview, vol. iv.. No. 7, p. 368. X Blaikie Smith, International Clinics, vol. i., 2d Series, 1892, p. 79. § Hare and Patek, Medical News, June 20, 1891, p. 681 ; MacDougall, Lancet, April 15, 22, 1893. 920 MEDICAL DIAGNOSIS. The delirium sets in generally during the second week, for the most part at night, and terminates with convalescence or ends in coma. It is not a wild delirium, but a confusion of mind associated with rambling thoughts. If the patient's attention be strongly engaged, he may be almost always roused, and does for a time as he is told ; but after a short interval his muttering lips indicate that some curious fancy has again taken possession of him. In some cases, not in many, the delirium is attended with great restlessness and agitation, and the sick man, if not pre- vented, attempts to walk about the room. This kind of frenzy often ends in fatal coma. Equally unpromising is early or unre- mitting delirium. When contrasted with the mental wandering in other acute disorders, the delirium of typhoid fever exhibits peculiar traits. It is ordinarily more active than that of typhus; far less demonstrative or talkative than the mania of drunkards ; as aimless as, but less continued than, the ravings of inflamma- tion of the brain. Great restlessness and tremors, associated with a clear mind, and at times with copious perspirations, have a very significant meaning : they point to deep and extending ulceration. Other symptoms of grave disturbance of the nervous system show themselves in violent general conimlsions. These are more common in children than in adults, in whom they may be a late symptom ; they may or may not be of ursemic origin. As a rule, the knee-jerks are present, unless peripheral neuritis exists. In severe cases both the reflexes and the muscular irritability are said to be increased.* On the other hand, it has been observed that in children the tendon-reflexes are often enfeebled during the acute stage of the disease and exaggerated during convales- cence, f In some cases of typhoid fever symptoms not only of cerebral but also of spinal origin appear, and they may, indeed, assume a high degree of intensity. We find extensive cutaneous hyperses- thesia, spinal pain and tenderness, with a sense of prickuig along the vertebral column, and, in some instances, cutaneous and mus- cular anaesthesia, numbness of the extremities, partial paralysis or convulsive contractions of the respiratory muscles, convulsive » Angel Money, Lancet, Nov. 7, 1885, p. 842. f Albouze, Journal de Medecine et de Chirurgie Pratiques, Sept. 10, 1892. FEVERS. 921 eough, paralysis of the sphinctei's, contractions of the extremities, and even rigidity of the muscles of the neck.* These spinal symptoms are more common when the disease is epidemic than when it is sporadic, and are always indicative of a very serious form of the disorder. They sometimes persist after the fever has left, or indeed — and this is especially true of paralysis — may not appear until convalescence. The palsy, the most common form of which is paraplegia, mostly begins gradually and disappears gradually. It may be preceded by trembling movements, sug- gesting the idea of disseminated sclerosis ; but the tremor is rather the result of general debility, and, unlike sclerosis, it occurs be- fore, and does not attend or follow, the loss of muscular power in the limbs, and is not associated with difficulty of enunciation. Hawkins f has reported a fatal case of typhoid fever complicated by intestinal hemorrhage and purpuric spots and the develop- ment of right hemiplegia and aphasia due to occlusion of the left middle cerebral artery. He has collected seventeen cases of typhoid fever complicated by hemiplegia. Most often the palsy was right-sided and associated with aphasia. Usually there was recovery from the paralysis, but in three cases this was persistent. The complication was most common at the end of the attack or during convalescence. There is much evidence that the paralysis after typhoid fever is due to neuritis.J Two other prominent symptoms of the malady must still be inquired into : one is epistaxis ; theother, the cutaneous eruption. Epistaxis is not often absent in grave cases. It may happen at any period of the complaint ; but it generally takes place before the disorder is far advanced. The quantity of blood lost is rarely considerable : and for this reason the occurrence of the hemorrhao-e is frequently overlooked. The eruption peculiar to the disease is the rose-colored rash. It appears on or shortly after the seventh day, but occasionally not until the end of the second week. It can hardly be called a papular eruption, as it consists rather of small, red spots, only * Fritz, Etude clinique sur divers Symptomes spinaux observes dans la Fievre typhoide, referred to in Arch. Gen. de Med., June, 1864. t Transactions of the Clinical Society of London, vol. xxvi., 1893, p. 50. I Pitres and Vaillard, Eev. de Med., 1885, t. v. ; Boss, Amer. Journ. Med. Sci., Jan. 1889; Bury, Medical Chronicle, June, 1892. 922 MEDICAL DIAGNOSIS. very slightly elevated above the skin, somewhat similar to flea- bites, yet diiFering from them in lacking the central mark and in their finer, paler color and less obvious outline. The spots are seen upon the abdomen and chest, rarely upon the extremities, almost never upon the face. They disappear totally on strong pressure, yet return immediately when the pressure ceases. They are generally few in number, and not persistent. Each spot does not last for more than three or four days ; then it fades, and a fresh one near by replaces it, and runs the same course. Spots thus appear and pass away for more than a week, after which, in most cases, they entirely vanish. During convalescence not a trace of them can be found ; but should a relapse take place, they reappear with the other symptoms of the malady. This eruption, although very common, is not invariably present ; at all events, it is not in- variably found. Beyond doubt, too, it is in some epidemics more constant and marked than in others. Late in the disease another eruption appears, consisting of minute transparent vesicles, scattered plentifully over the body. These sudamina are not so frequently encountered as the rose-rash, and are certainly not so characteristic. After convalescence has set in, we may have a return of fever. It may be either a transitory and slight return, due to fatigue or to some indiscretion in diet, or a more protracted state, in which most or all of the symptoms peculiar to the disease reap- pear. Thus, typhoid fever relapses usually come on in the second week of assured convalescence, and, according to my experience,* occur suddenly ; soon diarrhcea, furred tongue, and enlargement of the spleen are manifest, and on the fourth or fifth day reappears the characteristic rose-rash, which is often somewhat coarser than in the first attack, and does not show the same disposition to ap- pear in successive crops. With the eruption delirium is apt to come back. The temperature is unlike that of the original attack in quickly reaching a high point of fever-heat ; after the first day or two it remains more or less stationary, with a slight morning fall, for five or seven days usually, and then shows the well-known remissions and rises of the zigzag decline. The pulse is often noted to be dicrotic, t The relapse is in its duration usually much * See article on Eelapses of Typhoid Fever, Transactions of the College of Physicians of Philadelphia, 1877. t Steinthal, Arch. f. klin. Med., Feh. 1884. FEVEKS. 923 shorter than the original attack, and generally, notwithstanding the threatening appearance of the symptoms, ends in conva- lescence. During its progress intestinal hemorrhage may hap- pen; and after return to apparent health a second relapse or more may occur. Each relapse occasions characteristic mark- ings on the nails, from impaired nutrition, which Longstreth has very fully described.* Ziemssen specifies the fifth, seventh, and fourteenth days after the cessation of the original fever attack as the days on which a relapse is likely to happen.f The tempera- ture sometimes keeps up a degree or two, while the patient is in every other respect fully convalescent, yet will come speedily to the norm if he be made to leave his bed. Both during the height of the fever and in convalescence, but more especially during the latter, certain complications or sequelae may arise, some of which are medical, such as parotitis, erysipelas, noma, laryngeal ulceration or stenosis, milk-leg, thrombosis of the femoral artery, the result of arteritis,^ cirrhosis of the liver, peri- ostitis, osteomyelitis, and transitory aphasia ;§ while others, as dislocations, caries, necrosis of bones, epididymitis,!! abscess, and gangrene, come within the domain of surgery.^f Sometimes sequelse appear long after the primary disease has come to an end. Orlow** has reported a case in which five and one-half months afterwards typhoid-bacilli were found in a granuloma of the tibia. Pean and Cornilff observed a case in which five months after an attack of typhoid fever typhoid- bacilli were found in the lesions of a suppurative periostitis. Sudden death may take place in the course of typhoid fever as a result of disturbances in the circulation, from the formation of blood-clots, from inflammatory and degenerative changes in the muscular wall or in the nervous supply of the heart, or from * Eelapses of Typhoid Fever, Transact. Coll. of Phys. of Phila., 1877. t Arch. f. klin. Med., Feb. 1884. t Lucas-Championniere, Journ. de Med. et de Chip. Pratiques, 1888. ? Arch. f. klin. Med., Bd. xxxiv., 1, 1883. II Girode, Archives Gen. de Medecine, Jan. 1892, p. 43. T[ See an elaborate discussion of these surgical complications, by Dr. W. W. Keen, Fifth Toner Lecture, "Washington, 1877. ** Deutsche medicin. Woohenschrift, Nov. 27, 1890. •(■■f- Bull, de I'Academie de Medecine de Paris, Apr. 14, 1891. 924 MEDICAL DIAGNOSIS. the poisoning of the system that is an essential part of the dis- ease.* Death has also resulted from profuse sweating.f After this analysis of the symptoms of typhoid fever, it would be useless repetition to discuss at length how the disease differs from all other idiopathic fevers. The attempt will rather be made to explain its diagnosis from those maladies, whether essentially febrile or not, to which it bears the closest resemblance. And here we find that the disorders with which typhoid fever may be confounded are not the same at all the stages of the complaint. Early in the aifection it is most likely to be mistaken for simple continued fever, or for one of the exanthemata. But diarrhoea is not present in these, nor are there marked prodromata ; and what- ever doubt may exist with reference to simple continued fever is cleared up in a few days, as the temperature-record is different and as the symptoms come to an end at a time at which in ty- phoid fever they begin to be more and more developed. Still, the exanthematous fevers cannot, before their eruptions appear, be distinguished with absolute certainty ; though we may suspect measles- by the attending coryza, scarlatina by the sore throat, and smallpox by the lumbar pains and high fever. At a more advanced period, typhoid fever may be confounded with typhus, and with these morbid states : General Debility; Typhoid Conditions ; Enteritis ; Peritonitis ; Meningitis ; Ulcerative Endocarditis ; Acute Pulmonary Affections. General Debility. — It does not seem likely that so acute and dangerous a malady as typhoid fever could be mistaken for mere debility ; yet such an error may occur when the disease is latent, or so light as not to confine the patient to his bed. In these so- called " walking cases" the debility, however, sets in suddenly, and not gradually, as in weakness from general constitutional causes. * Dewevre, Archives Generales de Medecine, Oct., Dec. 1887; Galliard, ih., May, June, 1891. f Juhel-Eenoy, Archives Generales de Medecine, 1886, vol. i. p 274. FEVERS. 925 Moreover, the abdominal symptoms are rarely wanting, and there is more or less confusion of mind. Due attention to these circum- stances will prevent mistake ; but the greatest safeguard against error is to be aware that the disease assumes at times a latent form, and to examine every case of sudden debility, to see if under its mask are hidden the features of typhoid fever. Typhoid Conditions. — No blunder is more common than to mis- construe into typhoid fever a typhoid condition of the system. We may iind this condition in many different complaints, both acute and chronic; but more especially are purulent infection, some forms of pneumonia, dysentery, and erysipelas attended with delirium, drowsiness, dry, brown tongue, and extreme prostration, — in one word, with a typhoid state. Yet a typhoid state is not typhoid fever; it is simply a low condition of the system which may be present in many dissimilar maladies, and which is present in its most perfect form in typhoid fever. But in this complaint we have other signs than those of vital depression : we find joined to it diarrhoea, tympanites, epis- taxis, an eruption, and special manifestations of disturbance of the nervous system, — all symptoms bearing no direct relation to the adynamia, and thus serving as valuable distinctive marks. An examination of the urine, too, is often of signal service ; though we must not forget that in grave cases albuminuria to a moderate degree is present. And there are cases of Bright's disease and of abscess of the kidney in which the poisoning of the blood that happens occasions a deceptive likeness to typhoid fever, so deceptive that only a minute examination of the urine can fully explain the true meaning of the symptoms. The following case well illustrates this : A man, about forty-five years of age, was admitted into tho Philadelphia Hospital in January, 1863. He was very prostratCj and hardly able to give an account of himself. It was ascer- tained that he was not a person of intemperate habits, and that he had been attending to his work until within two weeks. He was evidently stupid, and, when questioned about himself, seemed to have great difficulty in remembering, and in collecting his thoughts. He had fever ; a pulse above 100; a dry, brown tongue. The heart-sounds were feeble, the heart increased in size. The urine was at times turbid, and contained a slight, whitish sediment, 58 926 MEDICAL DIAGNOSIS. which was not, however, examined with the microscope. His mind wandered at night; the abdomen was distended and in parts slightly tender ; several doubtful red spots were detected on its surface. In fact, he appeared to have almost every one of the more constant symptoms of typhoid fever, except the diarrhoea. A few days after his admission he became comatose, and sank. The intestinal glands were found in a healthy condition ; but both kidneys were thoroughly disorganized and filled with pus. What exactly produces the typhoid state it is difficult to say. Milner Fothergill* connects it with tissue-waste without in- creased renal activity, and with the accumulation in the blood of the products of the tissue-waste. Enteritis. — The great difference between enteritis and typhoid fever consists in this : in enteritis the in-flammation of the intes- tine constitutes the disease; there are no symptoms other than those referable to the inflamed intestine. We find no great prostra- tion ; no mental wandering ; no enlargement of the spleen ; no rose- spots ; no signs of abnormal processes due to a typhoid dyscrasia. The disorder, too, gives rise to much more abdominal pain, and is of shorter duration. In certain rare cases the follicles of the intestines are inflamed and swollen, and the attending fiebrile malady may closely simulate typhoid fever, without, however, its characteristic intestinal lesions, or eruption, though with consider- able diarrhoea and swelling of the spleen, f Again, I have known ffflcal accumulations in the intestine to produce and keep up diar- rhoea and continued fever of several weeks' duration similar to that of typhoid, and ceasing only when the large fascal masses were voided. The absence of eruption, of cerebral symptoms, and of enlargement of the spleen proved the points on which the correct diagnosis of the non-existence of typhoid fever was based. Peritonitis. — The same remarks apply to peritoneal inflamma- tion. Here, moreover, the expression of the face, the constipation, and the great abdominal tenderness serve as marks of discrimina- tion. But we must not forget that acute peritonitis may appear in the course of typhoid fever. Generally this untoward event happens at a late period of the disease, and after the patient has * Edinburgh Medical Journal, September, 1873. f Cazalis and Renaut, Archives de Physiologie, 1873. FEVERS. 927 been under observation for some time ; we are then at no loss to understand the meaning of the spreading tenderness, the rapid, small pulse, the mai'ked tympanitic distention, the sweats, the nausea and vomiting, the collapse, and. the pinched features. But the accident may occur in cases, that we have not previously seen, or in which the affection has run so latent a course as hardly to have attracted even the patient's attention. The cause of the peritonitis is then commonly first revealed by the autopsy, which shows actual perforation of the intestinal walls, in consequence of ulceration of a solitary or an agminated gland. Whenever, indeed, in typhoid fever the signs of peritonitis can be clearly traced, the exciting cause of the inflammation may be announced to be perforation ; for the evidence on which it has been assumed that peritoneal inflammation may take place without the giving way of the intestine is not so positive as to cause us to abandon this diagnostic rule. Meningitis. — Typhoid" fever has some symptoms in common with inflammation of the brain ; but the signs of difference have been fully discussed in connection with acute meningitis, and need not here be examined. And in rare cases we really have menin- gitis as a complication of typhoid, showing small pupils, vomit- ing, and rigid neck. The distinction from epidemic cerebro- spinal meningitis we shall presently trace. Ulcerative Endocarditis. — In some cases the differential diag- nosis between this and typhoid fever becomes of great difficulty, especially if the case be not seen until the endocarditis has led to delirium and the symptoms of collapse. Recurring "chills, with high temperature and sweats, as in malarial fever, great rapidity of pulse, with sudden changes and marked irregularity, a gen- erally-diffused roseolous eruption, and the signs of the cardiac lesion, form the most trustworthy points of distinction. Acute Pulmonary Affections. — In the majority of cases of typhoid fever we find cough, dependent upon an affection of the bronchial tubes. The bronchial affection gives rise to extreme loudness of the rales, with a cough disproportionately slight ; sometimes, too, owing to the blood gravitating to the most dependent portions of the lungs, the resonance over the posterior part of the chest is impaired. From these phenomena, added to the abdominal and cerebral symptoms of the fever, and the vital depression, there is 928 MEDICAL DIAGNOSIS. no difficulty in discriminating between idiopathic bronchitis and typhoid fever. Not infrequently we find a dry pkurisy combined with the bronchitis, and in some cases, not in many, the cough is asso- ciated with exudation into the pulmonary structure. Now, it may be extremely difficult to distinguish a pneumonia of this kind from inflammation of the lung setting in amid signs of prostra- tion, until the eruption and the abdominal symptoms solve the difficulty. Generally, however, it is not a matter of much doubt, as the condensation of the lung in typhoid fever does not occur early in the disease, — not, in fact, until the symptoms of the fever are clearly developed. Occasionally a cough remains after the febrile symptoms have begun to decline and the mind is regaining its clearness. The cough increases in severity, and the patient soon loses the strength he may have acquired. On listening to the chest, we find scattered over both lungs many fine, dry and moist sounds. The percussion-note is here and there dull ; the expectoration is profuse ; there are dyspnoea and excessive sweat- ing. Here is a group of signs bespeaking acute phthisis. We may also observe acute phthisis with most of the symptoms of typhoid fever; even the delirium, the stupor, and the enlarge- ment of the spleen may be present ; but the eruption never is, ' and the diarrhoea rarely. In general acute miliary tuberculosis the similarity is even greater, and diarrhoea is not uncommon ; the disease is, as- a rule, longer. Tubercle-bacilli may or may not be present in the sputum ; they have been detected in the urine and in the blood ; when present they enable us to make a positive diagnosis. In rare instances the two diseases have coexisted. In concluding the subject of typhoid fever it will be proper to notice those forms of the affection which run their course in a different manner from that ordinarily pursued by the malady, — ^the mild typhoid and the abortive typhoid. The former has usually a gradual beginning, and the disease throughout remains mild ; its duration may be, however, the same as, or even longer tlian, that of ordinary typhoid, or it may be considerably shorter, — in fact, an abortive typhoid, the variety of typhoid to which of late years Jiirgensen especially has directed attention.* Yet the * Saminlung klinischer Vortrage, No. 61, 1873. See also paper by Johns- ton, Amer. Journ. Med. Sci., Oct. 1875. FEVEES. 929 abortive type is not always mild : cases are mentioned * in which the temperature rose to 106°, but in Avhich the duration of the* fever was only from seven to twelve days. Indeed, it is the short duration that is characteristic of abortive typhoid. As a rule, it begins suddenly, and the temperature reaches its highest point on the second or third day. It often does not exceed 104°, and it stays at, or near, the height it has so speedily attained for the greater part of the duration of the fever, and then remissions show themselves, and there is a gradual return to a healthy standard, much in the same way as at the end of ordinary typhoid fever ; or the changes are so marked and rapid that the deferves- cence is accomplished in a few days. The symptoms of typhoid fever are all met with in the abortive malady, though they are not present with the same constancy ; tenderness in the right iliac fossa is the most frequent; enlargement of the spleen and the rose-colored spots are very usual ; diarrhoea is often \vanting. The disease terminates in sixteen days or less ; but there is great proneness to relapses. It is not apt to be a fatal affection. Typhus Fever. — This is a highly-contagious malady, almost always met with in an epidemic form, and generally among those whose systems are depressed. It prevails in jails and camps, among crowded populations, or in badly- ventilated localities, and has no constant structural lesion. In this country it is a rare disease. It is either preceded by a brief stage of lassitude and dejection, or is ushered in with a chill and pain in the head and back. The skin soon becomes dry and of pungent heat ; the pulse rises much in frequency, and is at first full, sometimes even tense. The patient lies in a state of half-consciousness, dull, drowsy, weak, with evident signs of his nervous and muscular system being overwhelmed by the influence of some fearfully- depressing poison. The face is flushed ; the odor from the body extremely unpleasant. By the fifth day all these symptoms are plainly marked, and about this time a coarse, red, cutaneous eruption makes its appear- ance. But it occasions no change in the gravity of the symptoms. On the contrary, the confusion of mind and the stupor increase ; the patient wanders, picks at his bedclothes, and ceases to com- * Liebermeister, in Ziemssen's Cyclopsedia. 930 MEDICAI, DIAGNOSIS. plain of the pain in the head or limbs. The pulse is frequent and ' feeble ; the tongue dry and dark ; sordes collect on the gums and teeth. The bowels remain as they were at the onset, — constipated. The urine often comes away drop by drop, or, as the bladder loses the power of contracting, is retained. The case has now reached its height ; the signs of a prostrated nervous system, of deteriorated blood, and of utter loss of muscular strength either begib to pass away, or deepen from hour to hour and clearly show the doom that awaits the fever-stricken patient. From the beginning of the distemper until the unfortunate issue is rarely over thirteen days. If the sick man can withstand the poison until the third week, he is apt to throw it off and recover ; but it may be so virulent as to overpower him almost at the onset. Micro-organisms have been found in the blood in cases of typhus fever. Thus, Brannan and Cheesman * describe a club- shaped bacillus from 0.5 to 0.8 ij- in diameter, and from 1 to 2.5 /* long. Dubief and Bruhl f have found an organism that they designate " diplococcus exanthematicus." Lewaschew % describes cocci from 0.2 to 0.5 i^ in diameter. Let us examine some of the symptoms of this pestilential dis- ease in detail. The -physiognomy of typhus is peculiar. The expression is stupid, and coarser than in health. The face shows a deep flush of a dusky-red hue. The eye is injected, the pupil often con- tracted. The skin is covered with a characteristic eruption, from which the disease takes its name of " spotted" or " maculated" or " exanthematic" typhus. The rash is at first slightly elevated and much like that of measles. It is of a dark tint, a " mul- berry rash," and fades but does not vanish on pressure. It makes its appearance from the fifth to the seventh day, and is perma- nent, consisting not of successive eruptions, but of the same spots, which deepen or lighten with the changes in the disease, and do not pass away before the fourteenth day. Each spot thus lasts until recovery or until death, and no new ones show themselves after the second or third day of the rash. They are numerous on * Medical Record, June 25, 1892. ■f- Universal Medical Journal, May, 1893. X Deutsche medicin. 'Woclienschrift, Nos. 13, 34, 1892. FEVERS. 931 the trunk and the extremities, but are rarely observed upon the face. Some are much lighter than others, and thus a mottled aspect of the skin is produced, on which Sir William Jenner * lays great stress. Sometunes the spots are of purple color and uninfluenced by pressure. These petechise are the attendants of the worst forms. The skin of a typhus-fever patient is often sensitive, and, as already stated, generally very hot. In some cases the ther- mometer indicates a temperature of 107°, or more ; commonly it ranges above 104°. The heat is sustained : it does not show the decided differences between morning and evening that are ob- served in typhoid fever, the daily variations to the middle of the second week being rarely 1° ; and from that time onward the morning abatement does not amount to more than about 1.5°, until the defervescence is reached. The passing away of the high temperature occurs, however,, not, as in enteric fever, by more and more evident remissions, but suddenly. Early in or towards the middle of the third week the temperature falls quickly, and in twenty-four or thirty-six hours a normal standard is reached. In rare instances, it is asserted, the temperature may not rise above the normal, or it may even be subnormal. f The cerebral symptoms of typhus fever are never absent. In some epidemics they constitute the prominent feature of many cases, and dangerous and fatal these cases are apt to be. One of the most frequent proofs of the disturbance of the brain is seen in stupor. The patient lies in a heavy slumber, occasionally mut- tering some incoherent words ; or he is sleepless, his eyes remain wide open, he has coma-vigil, he takes no notice of anything going on around him. Either of these states may deepen into coma. In other cases delirium is the most conspicuous symptom. This delirium rarely sets in before the end of the first week. In type it is low and muttering, and unaccompanied by great rest- lessness ; or it may be associated with constant movements and trembling of the limbs, or jerking of the tendons, — in fact, with symptoms resembling those designated as hysterical. Sometimes * Identity or Non-Identity of Typhoid and Typhus Fevers, London, 1850 ; and Medico-Chirurgical Transactions, vol. xxxiii. t Comtemale, Gazette hebdom. de Medecine at ds Chirurgie, 1893, No. 30, p. 352. 932 MEDICAL DIAGNOSIS. the mental wandering is active and very persistent. The patient tosses about, is constantly talking, and can hardly be restrained from getting out of bed. He has illusions of hearing and of sight ; his eyes are injected, the pupils often contracted ; there is headache, with intolerance of light. Here we have the true brain typhus, with its formidable cerebral symptoms simulating closely those of acute meningitis, and differing only by their union with a cutaneous eruption, by the dissimilar aspect of the tongue, and by the beat of the pulse, which is rarely full, and never so tense as that of meningitis. Then, the nervous excitement is accompanied, or, at all events, soon succeeded, by greater and more rapid pros- tration of strength, and is often exchanged far more suddenly for coma than is observed in the meningeal disorder. The headache which has just been mentioned is a very constant symptom: usually it is most severe during the first week, and abates with the appearance of the mental wandering. Often it is accompanied by more or less giddiness, which increases with the progress of the disease. These head-symptoms of typhus are, like those of enteric fever, sometimes connected with a noisy, shallow, and irregular respira- tion. This kind of breathing can be cleiirly traced to the abnormal state of the nervous system, as no signs of alteration in the lungs coexist. Often, as Flint* has pointed out, it is a forerunner of fatal coma. In one case I found the strange phenomenon associ- ated with great distention of the bladder, and subsiding materially after the introduction of a catheter. The remarks with reference to the cerebral phenomena of typhus apply to those instances in which there is no inflammatory disorder within the cranium. But we must not overlook the fact that this may ensue. Such cases are difficult of recognition. The pulse, as a rule, is slow and irregular, the pupils are contracted, there is a frown on the forehead, and intense headache, sometimes scream- ing. Vomiting is not always encountered. We may find with these symptoms acute meningitis, and the morbid appearances may be confined chiefly to the base of the brain, f There are other symptoms referable to the nervous system that are occa- * Clinical Reports on Continued Fever. ^ Kennedy, Dublin Quarterly Journal, Feb. 1867. FEVEES. 933 sionally very marked, such as great agitation, rigidity of certain muscles, and convulsions. But as regards the latter, the nervous system is for the most part only secondarily disturbed, for the convulsions are generally of ursemic origin. The puhe, after the disease is fully developed, is generally rapid, and of moderate volume or feeble. As the disorder ad- vances the pulse rises in frequency, while it diminishes in force. As convalescence is established, it falls ; if it remain frequent, this is generally indicative of some concealed visceral disorder, often of a disease of the lungs. It does not always correspond closely with the condition of the heart, which is in a state of granular degeneration. The beat may be excited and violent, while the pulse is very weak. Often the cardiac impulse undergoes a sin- gular diminution, and with its change the first sound becomes enfeebled; in fact, it is sometimes almost lost, and only very gradually regains its natural tone. Occasionally, at the height of the disease, it is replaced by a soft, systolic murmur of blood origin. The urine is generally high-colored at first, and deposits an abundance of urates and phosphates. There is an absence of the chlorides, or they are reduced to a trace. The urea, as ascer- tained by an analysis of Parkes * in a case in which no medicine was given, is increased, and its augmented excretion is remarkably regular during the height of the malady. During convalescence the urea sinks below the normal standard. The water passed is lessened ; the urine is apt to contain a large amount of uric acid, and to preserve its acidity. In eight out of twenty-one cases that I examined during an epidemic,t it contained albumin, but this ingredient was present only in the severer cases. In some instances the microscope exhibits in the deposit, besides the salts of the urine, renal as well as vesical epithelium, and tube-casts, either finely granular or hyaline, or epithelial. Much the same condition of urine is also found in typhoid fever. But the pig- ment that in typhus fever was detected by Parkes throughout only in small amounts has in typhoid fever been found to be immensely increased. * The Urine In Disease, p. 258. f Amer. Journ. Med. Sci. , Jan. 1866. 934 MEDICAL DIAGNOSIS. The oomplicatiom encountered during the course of the fever, or during convalescence, are much the same as those of typhoid fever, although they do not in the two diseases occur with equal frequency. We meet with abscesses, with large sloughs on the trunk and extremities, or with gangrene of the extremities,* with milk-leg, with erysipelas, with inflammation of the parotid gland, with cedema of the glottis, and with pulmonary complaints. The latter are very common, and mostly very alarming. Sometimes they consist merely in affections of the larger or the smaller bron- chial tubes, and rales of varying size are heard all over the chest At times, instead of these signs, or associated with them, may be noticed dulness on percussion and bronchial respiration over the lower lobes of the lungs, depending upon congestion, with con- solidation, more or less perfect, of the pulmonary tissue. Here is one of the worst of all the complications, — a low form of pneu- monia, often of the broncho-pneumonic type. This must, how- ever, not be confounded with the so-called pneumotyphuSj^ in which the manifestations of pneumonia appear early and become later complicated with those of a typh- fever, though generally of typhoid and not of typhus. During the last stages of typhus fever, or after convalescence has set in, acute tuberculous deposits occasionally develop themselves in the lungs, with the same symp- toms as during or subsequent to typhoid fever. To discuss now the differential diagnosis of typhus fever. We find various maladies resembling it, but none so closely as typhoid fever. The subjoined table shows both their similarities and their differences : Typhoid. Typhus. Age generally from eighteen to thirty- At all ages ; often in persons beyond five. middle life. Not contagious ; mostly sporadic. Highly contagious ; usually epidemic. Attack generally insidious. Attack generally sudden. Duration fully three weeks ; fre- Duration somewhat shorter ; often not quently much longer. prolonged beyond second week. Death hardly ever before end of sec- Death not infrequently at end of first ond week ; more generally in, or week, and often before conclusion after, third week. of second. * Estlander, quoted in Amer. Journ. Med. Soi., July, 1871. t Wagner, Archiv fiir klin. Med., Aug. 1884. PEVEES. 935 Typhoid. Cerebral symptoms come on gradu- ally I last longer. Great emaciation. Face pale, or flush confined to cheeks. Skin hot, sometimes covered with acid perspiration. Characteristic temperature-record, chiefly influenced by the changes in the intestinal glandular lesion. Abdominal symptoms, such as diar- rhoea, tympanites ; stools contain characteristic bacilli ; intestinal hem- orrhage not unusual. Epistaxis common. Bronchitis and pleurisy. Eruption light red, and not on ex- tremities or face. Post-mortem appearances are : mor- bid state of Peyer's patches ; en- largement of mesenteric glands ; ulceration of mucous coat of intes- tine ; enlargement and softening of spleen ; ulceration of pharynx. Typhus. Delirium or decided stupor comes on soon, sometimes almost from the onset; headache has appeared and disappeared by about the tenth day. Less emaciation ; greater prostration. Pace deeply flushed ; eye injected. Skin of pungent heat ; sometimes emitting an ammoniaoal odor. Temperature-record more that of a continuous fever ; for the most part sudden and rapid defervescence. No abdominal symptoms ; bowels con- stipated ; meteorism rare ; intes- tinal hemorrhage of extreme rarity ; sometimes acute dysentery during convalescence or as a sequel. No epistaxis. Intense pulmonary congestion ; some- times bronchitis of finer tubes ; broncho-pneumonia. Eruption darker in color, and all over body ; very seldom on face. No constant post-mortem appear- ances ; the most frequent are the dark-colored, liquid state of the blood, and enlargement of spleen. Softening of the heart common. There are no intestinal lesions. The points of contrast between the two affections are here so manifest that it would seem impossible to confound them. Yet it cannot be denied that in sporadic cases of typhus it may be very difficult to come to a conclusion; occasionally, also, the symptoms of the two diseases are strangely blended or inter- changed. Thus, we may have constipation in typhoid, and diar- rhoea in typhus, or the eruption may be curiously mixed. For instance : A boy, sixteen years of age, was received into the Philadelphia Hospital, with evident signs of a beginning fever of a low type. A day or two after his admission, and corresponding, as nearly as could be ascertained, to the fifth day of the disease, an eruption showed itself all over the body. It was dark-colored, petechial in its aspect, and did not disappear on pressure. Associated with 936 MEDICAL DIAGKOSIS. it were drowsiness and constipation. In a few days more, how- ever, the symptoms changed. The dark eruption faded, and rose- colored spots were perceptible on the chest and abdomen ; diarrhoea set in, and the fever ran its course to a favorable termination with the character of typhoid, just as at the onset it had assumed the character of typhus. Besides typhoid fever, typhus may be confounded with menin- gitis, with inflammation of the lungs, with measles, with small- pox, and with the plague. The distinctive marks between the first two and typhus fever have been rendered apparent while discussing the cerebral and pulmonary complications of the latter malady. I shall here only dwell again upon the great value of the eruption from a diagnostic point of view. The symptoms that approximate measles, smallpox, and yellow fever to typhus will be analyzed in connection with these afPections. One word here as to its difference from the plague. This pestilent disease, which during several centuries left almost annually its deep indent upon the human race, is hardly known to any but Russian physicians at present, save by description. And the descriptions leave on the mind the impression of an exposition of a familiar malady ; for the authors who have most carefully de- lineated its traits have produced a picture which, with very slight changes, may be suited to a representation of epidemics of typhus fever. Thus, we read of a highly-contagious feyer setting in sud- denly, attended with constipation, with a rapid, feeble pulse, with dizziness and delirium, with injected eyes, with a dry tongue, with noises in the ears and deafness, with defective urinary secretion, with starting of the tendons, with watchfulness or stupor, and with red patches and purple spots scattered over the surface of the body. The features that the plague does not share with typhus are nausea and vomiting, pale face, an alarmed, despairing look of the countenance, hsemoptysis, and, above all, the buboes and carbuncles in different parts of the body, and the clearing mind when they happen. Moreover, the disease is of much shorter duration. Death generally takes place between the third and the fifth day, or convalescence sets in on the sixth or the seventh day, or early in the second week. It may, however, be protracted by the long-continuing suppuration of the buboes. In very severe cases death takes place in forty-eight hours. FEVEES. 937 These cases are apt to be associated with but slight fever and with clear intelligence.* The relations of typhus fever to cerebro-spinal fever will be best discussed with the latter disease. Cerebro-spinal Fever. — This disease is also known as cere- bro-spinal typhus, as epidemic meningitis, and as epidemic cerebro- spinal meningitis, and is the affection which has been called in this country spotted fever. It was formerly very prevalent in portions of the United States, but the present generation of physicians had little knowledge of it until about simultaneously with the severe epidemic in Germany in 1863 and 1864 it invaded this country and committed great ravages, especially in some of the New-England States, in New York, and in Pennsylvania. Since that time it has become naturalized here, as Ziemssen states to be also the case in Germany. f Cerebro-spinal meningitis does not always present exactly the same symptoms. These vary somewhat according to the struc- tures which bear the brunt of the disease. Usually, however, marked cerebro-spinal phenomena preponderate; in some in- stances the evidences of pulmonary embarrassment or of blood deterioration are very prominent. Again, the signs of spinal disturbance may prevail over those of the cerebral, or the reverse. The disease may be gradual in its approach, feelings of chil- liness, succeeded by headache, by tenderness at the nape of the neck, by nausea, and by pain in the back and joints, preceding its full development. Generally its onset is sudden ; a violent chill is quickly followed by intense headache, vomiting, and extreme prostration. However the beginning, the disease usually soon reaches its full development. The excruciating headache is as- sociated with vertigo, and often with delirium and stupor. The headache may remit, but does not cease during the attack. An- other symptom of the fully-developed disease is stiffness of the deep muscles of the neck, so that the patient cannot bend the head forward ; and the stiffness may pass into marked contraction, and the head be thrown backward and rigidly fixed. The contraction * Hirsch and Sommerbrodt's report on the epidemic in Astraohan in the winter of 1878-79, Berlin, 1880. t CyclopEBdia of the Practice of Medicine, vol. ii., 1875. 938 MEDICAL DIAGNOSIS. of the muscles may extend along the spine, which frequently is painful, not specially to the touch, but on movement of any kind ; sometimes, moreover, severe spontaneous pain occurs. There are also pain at the nape of the neck, and in the loins and shooting to the lower extremities, and pain at the epigastrium, and a feel- ing of contraction of the chest. The face has a fixed or suifering expression ; the patient is extremely restless ; he trembles ; talks incoherently; when spoken to, does not appear to hear ; his pupils are generally dilated, and there may be dimness of sight, or double vision. The skin is dry, generally very sensitive, or in some parts the sensibility is increased, in others diminished, and the cutaneous surface is frequently spotted with a red eruption, erythematous and roseolous, — an eruption which often becomes brownish, and then for the most part rapidly petechial, and wholly uninfluenced by pressure ; or the purple spots may be seen from the start. Vesi- cles, too, are apt to appear on the lips. They show themselves from the third to the sixth day of the disease, while the eruption is seen on the first day, or may at all events be detected by the third day. The pulse at first is natural or slow ; but it becomes rather fre- quent and irregular, and commonly remains accelerated throughout the disease, showing extraordinary variations in a few hours ; the impulse of the heart is at times much augmented. The tongue is moist or dry, and brown ; the breathing often hurried and shal- low ; and the urine I have often noticed to contain large quanti- ties of urates and to be slightly albuminous ; hyaline and granular tube-casts have been also found in the urine in severe cases attended with high fever.* In the malignant cases there may be hsematuria. The bowels are at the outset constipated, but as the malady advances they become relaxed ; in some cases dysentery has been observed, with lanceolate micrococci in the stools.f There are usually persistent irritability of the stomach with great thirst and spasmodic contractions or convulsive movements in the muscles of the extremitities. The spleen, early in the aifection, is apt to enlarge, but does not continue tumefied. With these symptoms, to which those of exhaustion become plainly added, the disorder progresses to its close, presenting now and then * Flexner and Barker, loc. cit. f Ibid. PEVEES. 939 strange and delusive remissions, soon followed by distinct exacer- bations. In fortunate instances the morbid phenomena gradually lose their violence, and the patient, greatly emaciated, enters upon a tedious convalescence. But though these are the symptoms which frequently recur in epidemics, yet, as already indicated, they cannot always be taken as the standard expression of the disease. Most of them were observed in the formidable examples of the malady which have of late years been encountered in this country ; and they have also been met with in the epidemic cerebro-spinal meningitis prev- alent in Germany. The temperature is most variable ; it may be scarcely above the norm, or may reach between 106° and 108°, or even higher, without there being a proportionate rise in the pulse. The irregularity of the temperature was a common feature in our epidemics. High temperature may be interrupted by long-continued normal temperature.* In a recent epidemic in a mining centre in the State of Mary- land, carefully investigated by Flexner and Barker,t symptoms referable to the cranial nerves were observed, particularly loss of smell, strabismus, nystagmus, inequality of the pupils, photo- phobia, ptosis, impairment of vision, rigidity of the face, trismus, retarded respiration, Cheyne-Stokes breathing, deafness, and dis- turbances of speech. The strabismus was almost always diver- gent, and in many cases affected especially the right eye. The nystagmus was, as a rule, horizontal or vertical, but in one case it was rotatory. A considerable number presented engorge- ment and fortuosity of the retinal veins ; some, optic neuritis ; and one each, retinitis and thrombosis of the central vein. The pupils were variable, — sometimes contracted, sometimes dilated, often unequal. The tendon-reflexes were not uniform, but were in many cases diminished. General cyanosis was not uncommon, and epistaxis was frequent. In addition to herpes and purpuric and petechial spots, a common form of cutaneous eruption was an indistinct purplish mottling of the surface. Nearly twenty per cent, of the cases presented articular complications, principally * Wunderlicli, Archiv der Heilkunde, No. III., 1865. + American Journal of the Medical Sciences, February, March, 1894. For a report of the ocular findings, see, also, Eandolph, Bulletin of the Johns Hop- kins Hospital, 1893, ToL iv.. No. 32, p. 59. 940 MEDICAL DIAGNOSIS. effusions into and around the joints, with redness and swelling, "Well-marked leukocytosis was a constant feature at the height of the disease ; the red blood-corpuscles were little, if at all, changed in number, while the haemoglobin was somewhat diminished. No micro-organisms were found in the blood. The duration of the malady is very various. Patients may become rapidly comatose, and die within twelve hours, before any distinctly febrile action has begun ; or may sink in a few days ; or, on the other hand, the complaint may pursue a very chronic course, lasting for weeks, and during this time deafness and blind- ness, convulsions, retention of urine, and local palsies — though these are unusual — may be prominent phenomena. Of the cause of the formidable disease we know little. It is not a malarial disease ; for, though occasionally there is a singu- lar intermission or remission in the symptoms, there is no regu- larity in this respect. The temperature-record, even of these apparently malarial cases, is different, being irregular; and the affection is unyielding to quinine. Many look upon the disorder as modified typhus ; and certainly it occurs epidemically under much the same circumstances as typhus. But, though kindred to typhus, it is a fever due to a different poison, and differs broadly from typhus by being far less contagious, if indeed it can be regarded as contagious at all, and in the inflammatory lesions found in the brain and spinal cord. Bacteriological examinations have in many instances resulted in the isolation from the menin- geal exudation of the diplococcus of pneumonia, which, there is reason to believe, bears an etiological relation to cerebro-spinal fever.* Cerebro-spinal meningitis attacks children very frequently. It is more common in winter and in spring than in summer ; though I have seen it in summer. It is an affection very familiar to military surgeons ; it seizes on recruits who have been subjected to unaccustomed fatigue or have been huddled together in unhealthy barracks or camps. To determine the diagnosis is ordinarily not difficult : the sud- den onset of the malady and its epidemic character are safeguards against error. The protracted cases simulate typhoid fever. They * !Flexner and Barker, loc. cii. FEVERS. 941 resemble it in its long duration, in several of the cerebral symp- toms, and in the occurrence of an eruption, and sometimes of diarrhoea. They diifer from it in the more abrupt invasion, or rather in the short time in which the disease reaches an alarming aspect ; and in the early stages the violent headache, the constipa- tion, the constant vomiting, the slow or normal pulse, and the cool or but slightly heated skin, are unlike the signs of enteric fever. In those cases in which an eruption appears, it is noticed, at latest, by the third or fourth day, not at the end of a week, as in typhoid fever; nor is the rash, save in extremely rare instances, rose- colored. Later in the malady the traits of distinction become broader and broader. The prominence of the abdominal symp- toms in the one disorder; the continued violent headache, the fixed spinal pain, the hypersesthesia, the facial herpes, the severe twitchings or the tetanic rigidity of the muscles, and the . absence of marked enlargement of the spleen, in the other, — are signs the import of which is not easily overlooked. The suddenness with which the morbid phenomena occasionally develop themselves, and the. lulls that take place in the course of the affection, may cause it to be mistaken for the cerebral variety of congestive fever. But the remissions are not so marked as in this pernicious malady, nor are the exacerbations preceded by a long, violent chill. Moreover, the temperature-record is different, and congestive fever does not begin with congestive symptoms, but the first attack is like that of an ordinary intermittent or remittent : hence we have the history of the case to instruct us. Finally the detection of hsematozoa in the blood establishes the diagnosis of the malarial affection. From tetanus cerebro-spinal meningitis may be distinguished by its epidemic prevalence, and by the signs of mental disturbance, which are very slight or wholly wanting in the former disorder. Trismus is common and early in tetanus ; rare, if ever present, in cerebro-spinal fever. Generally, too, the sudden and painful spasms, aggravating the tetanoid contractions, and the cognizance of the exciting cause of the tetanic convulsions, such as their fol- lowing wounds or punctures, aid in interpreting their meaning. How can we discriminate between inflammation of the meninges of the cord and epidemic cerebro-spinal meningitis ? Thus : in pure spinal meningitis, as in myelitis, mental symptoms are ab- 59 942 MEDICAL DIAGNOSIS. sent ; their presence in cerebro-spinal fever constitutes one of the marked features of the disease. The history of the case in the former malady points to cold and exposure, or to syphilis. Clonic spasms of the extremities are more common ; persistent rigidity of the muscles is a less striking peculiarity. We find no eruption. Tubercular meningitis is distinguished by the much more in- sidious beginning, the much more protracted course, the absence of eruption, and usually of marked stiffness of the neck, the va- riations in the pulse according to the stage of the disease, the irregular breathing, and the history of a tubercular taint. Idiopathio or sporadic cerebro-spinal meningitis is a very rare disease. It runs a much slower course than the epidemic malady generally does, and its spinal symptoms are less marked. But it cannot be distinguished with any certainty from isolated cases of cerebrorspinal fever. The absence of an eruption and of the striking variations of temperature presented by the latter is of •significance. There are other diseases with which cerebro-spinal meningitis has been confounded; for instance, owing to the eruption and to the sore throat that may attend it, with scarlatina. But the onset and the neck-symptoms are very different ; and so is the eruption ; certainly it is different in its course. Still, as regards the onset, we must bear in mind that both may be ushered in by convulsions. An extremely rapid pulse would be in favor of scarlatina. Cerebro-spinal fever also resembles at times the onset of malignant measles ; but the catarrhal symptoms and presently the eruption guide us. I have known more than once the disease, on account of the congestion of the lungs or the broncho-pneumonia which may accompany it, — and in some epidemics the lung-affection is very marked, — to be mistaken for pneumonia. In truth, the diagnosis is sometimes far from easy. The mental symptoms, the intense headache, the variations in the pulse, the hypersesthesia, the vomiting, the stiffness and retraction of the muscles of the neck, the eruption, are distinguishing traits of value ; but when these important symptoms are ill defined, much doubt may exist. So there may if epidemic cerebro-spinal meningitis become inter- current, as it sometimes does in pneumonia as well as in other acute affections. Supervention of the severe headache, and ap- ^FEVERS. 943 pearance of rigidity of the neck, of great restlessness, of hyper- esthesia, and of coma, are the symptoms of most importance. In some instances of cerebro-spinal fever there is great pain, with some swelling of the joints, and the disorder is thought to be acute rheumatism. But the head-symptoms, the state of the muscles of the neck, and the dissimilar course of the malady soon clear up the diagnosis. The poison may produce so light a case that the stiffness of the neck may be mistaken for rheumatism of the cervical muscles. There is, however, even in these instances, an unusual amount of headache, and in a case in which I was consulted it became a permanent condition for several years, and then yielded. Uraemia with contracted kidneys may give us most of the same symptoms as cerebro-spinal fever, especially headache, vomiting, and retraction of the head ; the differentiation will depend upon the previous history, the existence or non-existence of similar cases, and the presence or absence of febrile phenomena and of cutaneous eruptions. Lastly, let us look at the clinical features separating cerebro- spinal fever from the disease it is most like, — typhus ; let us con- trast its phenomena with those of this affection, which in many respects it so clossly resembles. Both diseases are apt to prevail at the same time ; both attack all classes and ages ; both are evi- dently attended with dissolution of the blood, — but this alteration in the blood occurs much more rapidly and is much more marked in epidemic cerebro-spinal fever than in ordinary cases of typhus;* the eruption is different from that of the common form of typhus ; we find less delirium ; a less intense, though more irregular, fever ; the affection is generally of much shorter duration ; the counte- nance is not of a dusky hue and stupid, but pale or of a sallow color, and dull or expressive of suffering ; and there is the stiff- ness of the muscles of the neck, with the fixed spinal pain, and muscular contractions and other signs of spinal or cerebro-spinal * The deterioration of the blood occurs, indeed, very soon in cerebro-spinal fever. In an autopsy of a child that died in twenty-four hours, I found the blood diffluent and black ; in an adult patient who had been ill but two days, I detected blowing sounds in the heart, evidently of blood-origin. The poisoned blood unquestionably gives rise to many of the nervous symptoms, and it is on the blood and the nervous centres that the poison mainly acts. 944 MEDICAL DIAGNOSIS. lesion ; and the herpetic eruption on the face. Certainly, there- fore, the clinical manifestations of cerebro-spinal fever are very dissimilar to those of the usual varieties of typhus. But they are not so dissimilar to those occurring in some epidemics of malignant cerebral typhus.* Cerebro-spinal fever may, during an epidemic, complicate other acute maladies, and mix its symptoms curiously with them. With the attack the difficulty does not pass off, for it may leave all kinds of want of power and local palsies, besides derangement of vision, permanent deafness, impaired intelligence, epilepsy, per- sistent headache, chronic meningitis, which may be indeed the cause of the headache, and chronic hydrocephalus. In one instance I have known an extraordinary swelling of the whole body to follow ; the skin is hard, tense, and greatly thickened, pits very little on pressure, except around the ankles, and is tightly drawn over the face; this swelling and thickening, very much like a general sclerema, has now lasted for upward of twenty years, and has been attended with a feeling of numbness in the skin and a moderate amount of anaemia. There is no palsy or albuminuria ; the patient suffers little inconvenience, except from her size. She has a waxy countenance, and looks like a very fat woman. Relapsing Fever. — This is a form of fever characterized by its rapid course and its proneness to relapse. Epidemics of this disease — and it occurs only in epidemics — are frequently encoun- tered in Ireland and in Scotland. In this country it was until of late years almost unknown. The disorder is decidedly acute. Its invasion is sudden, and marked by rigors, pain in the back and limbs, vertigo, severe headache, and nausea and vomiting. Fever is soon developed, and rises high, it may be to between 107° and 109°. There are severe muscular pains, particularly in the muscles of the extremi- ties ; the pulse is very rapid ; the temporal arteries throb ; the tongue is covered with a thick white fur. The bowels, as a rule, are constipated. In many cases there is engorgement of the liver, with yellowness of skin ; and in nearly all there are epi- * An extraordinary case, bearing on the relationship of the complaints under discussion, was under my charge in 1865 at the Pennsylvania Hospital. See Case XII. of a series of typhus fever cases published in Amer. Journ. Med. Soi , Jan. 1866. FEVERS. 945 gastric tenderness and marked enlargement of the spleen. The matter ejected from the stomach is greenish, or sometimes black and like coffee-grounds. Minute points of extravasated blood are not uncommonly seen upon the integument. The urine is scant}', and contains usually bile-pigment, some albumin, and hyaline casts. On the fifth or the seventh day, though some- times not until the tenth, the symptoms subside as speedily as they set in, a profuse perspiration preceding their decided abatement, and the temperature falls to the norm or even below. Convales- cence is now apt to be rapid, and seemingly complete, the patient being up and going about ; but the apparent return to health does not last long. Ordinarily after a week, therefore on the twelfth or fourteenth day from the first beginning, — sometimes sooner, rarely later, — the attack, preceded perhaps by a slight rise in tem- perature for an evening or two, returns, presenting again the same signs, and again terminating by a critical sweat in convalescence. This second attack may be short and mild ; but it may be both longer and of graver character than the first. It is, at times, fol- lowed by another, and yet another, relapse. When the patient finally throws off the disease, he is very weak, and his blood is much impoverished. He shows a tendency to dropsy of the ex- tremities; and blowing murmurs, evidently not organic, are per- ceptible while listening to the heart. These murmurs, however, may also be heard during the paroxysms. The patient is not really well during the intermission ; his spleen remains enlarged, the pulse is slow, the action of the heart is weak, and the muscu- lar and arthritic pains do not entirely disappeai*. Relapsing fever has an intimate connection with destitution. It is a contagious but far from a fatal disorder, except, perhaps, in the negro. In fatal cases death sometimes happens during the first paroxysm as the result of syncope, of hemorrhage into the brain or from the lungs; or it may occur suddenly during the intermission from paralysis of the heart. But the most common termination of the cases having an unfavorable issue is in conse- quence of complications or of states which have been induced by the malady, such as lobular or lobar inflammation of the lung, hemorrhagic pachymeningitis, abscess of the spleen or of the kid- ney leading to pyaemia, chronic diarrhoea, Bright's disease, dropsy, parotitis, palsies. At times the patient jjcrishes in a condition 946 MEDICAL DIAGNOSIS. similar to the collapse of cholera, though the collapse is more protracted and the pulse can be felt, and discharges from the bowels are by no means a constant accompaniment. The ex- treme prostration, attended with great coldness of the skin, may last for days. It is more particularly met with in the " bilious" or " bilious typhoid" form of the malady, — a dangei'ous variety, in which severe vomiting, jaundice, and delirium are encountered, and the paroxysm is not followed by a distinct intermission or remission, but often by the signs of collapse alluded to, in which ursemic symptoms have been more particularly noticed.* The collapse, however, may happen not only at the close of the par- oxysm, but in the remission, whether this be distinct or not, or in a subsequent paroxysm ; and this may be the case no matter what variety of the disorder we have to deal with, and whether or not the grave symptoms be due to uraemia. Yet the state of the kidneys and of the urinary secretion has commonly a great deal to do with the graver phenomena of the malady. Acute renal disease with albumin and tube-casts in the urine was discerned by Obermeier f in two-thirds of his cases. It was also, with or without tube-casts, met with in a number of Pepper's cases. J The urea, Reisenfeld § found, was during the first paroxysm always increased, and this increase continued beyond the crisis. The products of the heightened tissuermetamorphosis may be retained, and thus grave symptoms arise. Leucine and tyrosine have been also found. There is no constant obvious lesion in relapsing fever, unless it be the lesion in the spleen. Tliis organ is greatly enlarged, and presents numerous round or irregularly-shaped bodies, of white or yellowish-white color.|| But myriads of minute organisms, spirilla, are found in the blood just prior to the outbreak of the paroxysm, and at its height. Indeed, since Obermeier's discov- ery of the spirilla in relapsing fever, there is no doubt that they are the cause of the malady, and their detection in the blood re- * Hermann, Account of St. Petersburg Epidemic, Schmidt's Jahrb. , No. 6, 1865. See also further observations in Meissner's article, ib., No. 2, 1870. f Virchow's Archiv, 1869, Bd. xlvii. J American System of Medicine, article " Relapsing Fever." J Virchow's Archiv, 1869, Bd. xlvii. II Pastau, lb. FEVERS. 947 Fig. 79. moves all doubt in the diagnosis. In a single field of the micro- scope we may see but a few or from twenty to thirty spirilla. The diagnosis of the malady cannot be made positively during the primary seizure. Yet the presence of the fever, while an epidemic prevails, may be sus- pected from the sudden fierce beginning of the attack ; from the fact of the high fever-heat of 104° to 107° showing itself in less than twenty-four hours, and exhibiting either a morning remission of one to two degrees and the maximum of tempera- ture in the early afternoon or evening, or but little difference between morning and evening, until the rapid and great fall which takes place at the crisis ; and from the character of the gastric symptoms. Then the microscopical examination of the blood is of great importance. Eelapsing fever resembles yellow fever in its short duration and in some of its manifestations. But there is this evident differ- ence : in yellow fever the paroxysm or febrile stage is usually much shorter ; the symptoms in the remission do not subside nearly so completely ; this stage is a very brief one as compared with the decided intermission of relapsing fever ; the black vomit of yellow fever does not come on until the stage of collapse is reached ; and this far more fatal malady presents lesions in the liver and heart which are not found in relapsing fever, while it does not show the extraordinary enlargement of the spleen. From typhoid and typhus fevers, relapsing fever may be dis- tinguished by the shorter prodromata, by the presence of jaundice, by the absence of the characteristic eruptions, and by the short period during which the symptoms last. Again, critical sweats with the rapid cessation of the fever are not likely to be seen in these disorders, certainly not in typhoid fever ; and the very high • Spirilla of I'elapsing fi-ver {from Ileyden- reich). a, siiigltj epirilliini; 6, Btar-eiiaped bundle ; c, nidus of spirilla, with blood-cor- puscles. 948 MEDICAT. DIAGNOSIS. temperature, the severe muscular and arthritic pains, the tender- ness over the liver and the spleen, the vertigo, and in some cases the early collapse without apparent cause, are characteristic ; while, on the other hand, delirium and stupor are rarely en- countered in relapsing fever. After the relapse has taken place, the diagnosis is easy, if the case have been watched during the first attack. But, should it not have been under notice before, it may be at times very difficult, without an examination of the blood for spirilla, to say whether we are dealing with re- lapsing fever or with a relapse of typhoid or typhus fever. And this difficulty is enhanced by the want of uniformity of the symptoms in the second onset of the strangely recurring malady, and the close similarity they occasionally show to those of typhoid or of typhus fever. Another difficulty is presented by the fact that relapsing fever may exhaust itself in the first paroxysm. But this is an unusual occurrence, and the abortive cases are light. In them too the spirilla may be detected in the blood. Periodical Fevers. These fevers are characterized by the distinct periodicity of their phenomena : they exhibit intervals during which the patient is wholly or nearly free from febrile disturbance. With the ex- ception of one, — and its place here is, indeed, doubtful, — they are all owing to marsh miasm, or malaria. This noxious agent gives rise to a group of fevers ever betraying their common origin by their strong family resemblance : alike in occurring in low, swampy localities ; alike in most of their symptoms, and in the difficulty of eradication from the system ; alike in the secondary lesions, in the enlargement of the spleen and of the liver, and in the altered condition of the blood, which they leave behind them ; and also alike in being under the control, absolute and immediate, of cinchona and its various preparations. Along with the forms of miasmatic fever I shall describe yellow fever ; not because it is of identical nature, but on account of the similarity of the prominent symptoms. Intermittent Fever. — The paroxysm comes on with a chill : the face becomes pale, the lips bluish ; the teeth chatter ; the skin is cold ; there is a feeling of uneasiness and fatigue. After FEVERS. 949 a period varying commonly from half an hour to an hour, this cold stage passes off. Now we find decided heat of the surface, with restlessness, thirst, a full, rapid pulse, muscular pains, a scanty secretion of urine; in other words, active febrile symptoms. These continue for hours, for a period always much longer than the first stage : then a sweat breaks out all over the body; the pulse becomes softer and less frequent; the secre- tions are fully re-established; and this sweating stage terminates the paroxysm. The patient is now, for the time being, well ; but the disease soon recurs : in from twenty-four to seventy hours the paroxysm repeats itself. In the former case we call the fever a quotidian; in the latter, a quartan. The tertian type is before us when the paroxysm sets in again in about forty-eight hours ; the double tertian, when we find a daily attack, but those of alternate days alone corresponding in time and severity. Even a quintan ague may happen.* The period between the ending of one attack and the beginning of another is spoken of as the intermission, or apyrexia; while the time between the beginning of the two paroxysms, including the first with its succeeding intermission, is called the interval. The varied types of the fever present marked differences in the character and duration of the several stages. The tertian has generally tlie longest hot stage, the quartan the longest cold stage. In the quotidian there is a short cold stage, followed by a hot stage which may last for upward of fifteen hours. Occasionally the stages are very irregular and anomalous. Thus, the sweating stage may precede the cold stage, or it may be the only one which shows itself; or, again, the rigor may be altogether wanting. Sometimes there are no distinct stages, but the patient has a " dumb ague," which manifests itself at definite periods by a feel- ing of great depression, or of a severe pain at some portion of the body, or by chilly sensations, or by headache, or by nausea and vomiting, or, as I have seen, by excruciating pain over the kidneys, and almost entire suppression of urine, or by spasmodic obstruction of the intestine.f * Case of Henry, Brit. Med. Journ., Feb. 18, 1888. ■f- Cases of Hoyt, Atlanta Med. and Surg. Journ., Sept. 1875. 950 MEDICAL DIAGNOSIS. Now, cases of this kind are difficult to distinguish from organic disease. We can do so only by laying stress on their strictly peri- odical nature; by noting that the curious manifestations cease entirely to recur with intensity. This does not happen when the symptoms ai'e not caused by a lurking malarial poison ; for idio- pathic disorders exhibit the phenomena of structural change or of deranged function at all times, — not merely on certain days or at certain hours. It is true that among the inhabitants of miasmatic districts some complaints, and particularly those of the nervous system, display a well-defined periodicity ; but here, too, are found the significant traits of organic or functional disturbance between the decided exacerbations of the symptoms. Then, again, we must remember that diseases may assume an apparently intermittent character, being worse every second day, and yet not be malarial at all. Even mania, as Schroeder van der Kolk tells us, may take this type. The whole aspect of the symptoms, and a tentative treatment with quinine, will help to inform us as to the true nature of the malady. The temperature in intermittent fever shows a peculiar record, and one which, in doubtful cases, may be turned to great advan- tage. Notwithstanding the marked sense of chilliness, the ther- mometer rises suddenly and rapidly to a high degree ; there may be a slight elevation of temperature for an hour befoi'e a chill, but the striking rise begins with the chill. Even during the decided chill of the beginning of the paroxysm it indicates 106° or more in the axilla. The temperature remains stationary, or continues to rise, though not much, during the hot stage, and during the sweating stage falls at first slowly, then rapidly, until it comes down to about the normal heat. During the chill the peripheral temperature is decidedly lowered ; during the hot stage it is increased. But with the ending of the paroxysm it is found that the fall has been equally rapid. In the intermission the thermometer in the axilla marks a natural temperature, or one somewhat lower than in health. It rises again quickly with each paroxysm. No other malady presents these variations. In some cases of intermittent fever a peculiar intermitting mur- mur is heard over the spleen. This is ascribed to the movement of the blood in the splenic arteries with the systole, in conse- quence of the soft, enlarged, and overfilled condition of the spleen. FEVERS. 951 Fig. 80. It is usually detected most distinctly during the febrile period ; ceases with the paroxysms;* and is not heard in chronic malaria. The diagnosis of an ordinary and regular intermittent is easy. Leav- ing the other malarial fevers out of consideration, only two morbid states are likely to present recurring rigors and febrile excitement, and are, therefore, apt to be confounded with it : hectic fever, and chills at- tending upon suppuration in deep- seated parts. Now, hectic fever dif- fers in this from an intermittent : it is simply a fever of irritation, the cause of which a careful scru- tiny will generally detect. We find it accompanying many chronic dis- eases in which destruction of tissue occurs, especially phthisis ; and the chronic affection has its own signs, which exist at all times, whether the symptomatic fever be present or not. Then its outbreaks are ir- regular. Several often take place within the twenty -four hours ; their intermissions are incomplete; the temperature does not fall as in in- termittent fever, for there is not complete defervescence; and al- though the paroxysms may begin with chilliness, they are not ushered in by a well-defined rigor. Further, they are apt to be morning paroxysms, and are not modified by antiperiodics. Whenever, indeed, we find an intermitting fever not influenced by these agents, it ought to arouse suspicion, and all the internal organs, particularly the lungs, should be carefully explored. Thus only can serious errors in diagnosis be guarded against. When j3MS forms, and especially when it forms in internal cavi- Temperatnre-record of a tertian inter- mitteot. * Maissurianz, St. Petersburger medicin. Woclienschr. , 1882, 12. 952 MEDICAL DIAGNOSIS. ties, it betrays its presence by rigors, followed by more or less fever. But these, unlike the chills of ague, do not repeat them- selves at definite periods. Moreover, in the midst of the apparent intermission, febrile signs or other manifestations of a seriously disordered system may be discovered. The chills of ordinary pyaemia are distinguished by the same phenomena; then the rigors, unlike the malarial malady, are often characterized by the profuse sweating which immediately follows them, rather than by an active development of the fever. But there are other causes which may occasion attacks of fever happening in paroxysms and simulating ague. They may occur in disease of the heart, as in ulcerative endocarditis and in valvular affections.* Gall-stones which form in the radicles of the hepatic duct in the interior of the liver may, as Frerichs shows, give rise to at- tacks of chills, followed by heat and by sweating, easily mistaken for ague. The fact that these febrile phenomena are preceded in many instances of intra-hepatio concretion by dull pain in the hepatic region, and by sudden sharp seizures of pain at the lower part of the thorax on the right side, is very significant. Even gall-stones passing along the gall-duct and the common duct may occasion febrile symptoms like those of an intermittent, and the paroxysms may extend over mouths, and then the patient recover. Jaundice is apt to be a symptom of this hepatic fever, the attacks of which are more likely to be repeated in the afternoon and evening, while the malarial paroxysm more commonly occurs in the morning. "We have already pointed out that hepatic fever may occur without the impaction of gall-stones, and have seen how far these different forms can be told apart. An affection which on account of the chill succeeded by fever might be mistaken for the malarial disorder is the curious so- called urethral fever which sometimes arises after the passage of a bougie, and which may even terminate in death. f Our knowledge of the introduction of the instrument, and the non-recurrence at a fixed time of the rigor and febrile phenomena, furnish the points of distinction. *Ord, St. Thomas's Hospital Keports, 1882; Osier, Practitioner, vol. 1., No. 3, p. 181. t Roser, quoted in Brit, and For. Med.-Chir. Rev., Oct. 1867. FEVEES. 953 Yet another affection liable to be mistaken for intermittent fever is syphilitic fever. The fever may occur in attacks consisting of a chill, followed by a hot stage and sweating, and be so similar to the malarial disorder as to lead to error.* The apparent ague-fits happen, however, toward evening, and are succeeded or accom- panied by severe headache and pains in the bones, — in fact, by the same symptoms as the more ordinary form of syphilitic fever. In the form in which the febrile symptoms are continuous, these generally precede the eruption for a week or more, and may continue after this appears. We may also find this syphilitic fever with symptoms like those of malaria in cerebral syphilis.f This, it is well known, may occur, is indeed apt to occur, years after the early manifes- tations of syphilis, though the brain affection may happen within six months : thus the paroxysmal pyrexias may be met with at very varying times after the infection. The history of cerebral syphilis must often be considered, to understand their meaning. "VVe must bear in mind that disease of the membranes of the brain may exist which may disclose itself with great suddenness or gradually, and which does not unusually appear with apoplectic seizures ; that headache is a very marked symptom : that irregular motor palsies and epileptic attacks frequently happen, as well as mental failure and perversion, and symptoms similar to general paralysis, though wanting in the tremulousness. The aphasia which may be met with is said to be very commonly associated with left-sided hemiplegia. In the puerperal- state a malarial outbreak may happen which, as Manson and Fordyce Barker J have shown, may be mistaken for puerperal fever. Unlike the latter, however, the puerperal malarial fever is attended with pain in the. head, back, and limbs, and does not generally appear so. soon after parturition, — not, therefore, between the first and fifth days after delivery. More- over, it has at the beginning a great temperature-rise, and marked * See oases of Bassereau, referred to by Bumstead in his Treatise on Venereal Diseases ; Ord, loc. eii. t Wood, Transactions of the College of Physicians of Philadelphia, Feb. 1884; also in Medical News, Philadelphia, March, 1881; Janowsky, quoted ib. I Medical Record, Feb. 1880; Virginia Med. Monthly, Nov. 1881. 954 MEDICAL DIAGNOSIS. remissions or intermissions. Puerperal malarial fever may lead, after the twelfth day, to secondary hemorrhage. Remittent Fever. — This is a fever pre-eminently of hot climates and malarial districts. It is the fever of Hungary, of the Pontine Marshes, and particularly of Africa and the southern portion of the North American continent. Occasion- ally, not often, we meet with it in winter and in early spring ; very generally, during the summer and autumn months. Remittent fever has no well-defined and constant prodromic symptoms, except, perhaps, a singular sense of gastric uneasi- ness. It is ushered in by a marked chill, soon succeeded by violent fever, which, aflxsr a varying period, decreases, and then breaks out again. By this time the symptoms of the disease are very apparent. The patient complains of pain, of fulness and of throbbing in his head. He is restless and distressed ; his limbs ache ; his tongue has become coated ; he suffers from thirst, and rejects the contents of the stomach. After continuing at their height from six to eighteen hours, these symptoms again subside : a sweat breaks out all over the body ; the irritability of the stom- ach lessens ; the patient is composed, even cheerful ; his headache has nearly ceased, and he falls into a quiet slumber. But this lull is not of long duration, not longer than some hours. Soon the active fever is rekindled : the skin is as hot and dry as before, the pulse as full, frequent^ and hard ; the spleen is observed to be swollen ; and the other symptoms return with increased intensity again to abate, again to recur, until either the exacerbations are effaced and the fever assumes a continued type and then gradu- ally lessens, or else subsequently the remissions become better and better defined, — more, indeed, like intermissions than remissions. In the progress of the disease at and afl«r its height the pulse is generally quicker and weaker than at first. The temperature rises markedly with the first chill, and con- tinues to rise during the high fever that follows. With the sweat- ing stage it declines by several degrees, to rise to a greater height than previously with the succeeding febrile phenomena ; then again there is a fall in the remission, with another quick rise in the fever, which may attain a very high point, marking from 105° to 108°. The greatest height is usually reached in the ex- acerbation of the third day. After this the remissions become FEVERS. 955 less distinct, and may, indeed, be recognizable only by the ther- mometer ; the whole fever is more like a continuous one. Sub- sequent to the ninth day usually the remissions are very marked, the difference between the heat in them and the exacerbations being three degrees or more. The exacerbations become less and less high, and soon cease, the temperature falling perhaps pre- viously to below the norm. In cases in which the fever remains for a long time continuous, irregular remissions occur, especially Fig. 81. Besp. Date. 1 2 3 4 5 ( i r I ' 10 11 12 108° 107° MEMEMEM. EMEMtMCMEMEMEMEME.! ■ 106° 105° : f^ i 104° ■ ^ \^' [^ v^ ^ A f\ \ 103° * \ V V J \l\\ 102° : /p> \ (\ ■ 1' \ i 1 \ ) \ ■/• 1 1 \ :/ i 1 I ; i j 1 1 \ / 97° '; i \ / \ i I ! M. 80 Too' 90 "UT 105 iao" J.io 120 An 120 1?,8 116 "ize J.16 PA V08 tie 90 Tbs" 80 M. 18 9.0 Z5 ..2.5. 3,6 24 !>f't a* 24 2-4r 28 20 i 6 E. z 2 4 2 5 i 6 s. 8 -T 2r 2-t al X T Pulse. -El "J-, Temperature iu a cado of remittent fever uf moderate severity, fnding in recovery on the twelfth day. The chart shows also the pulso and the respiration. toward the end, though the fever may preserve its continuous type more or less to the end. The average duration of the fever, unless protracted by com- plications, is from nine to twelve days. Its most common type is quotidian, or rather, perhaps, double tertian, the exacerba^ tions of alternate days corresponding in severity, in duration, and even in the nature of the symptoms. Sometimes there are two 956 MEDICAI, DIAGNOSIS. excerbations in twenty-four hours, — a duplicated quotidian, — or the paroxysms have a tertian form. The exacerbations may occur any time in the twenty-four hours ; in many instances morning exacerbation is noticed, and I have met with more cases in which the paroxysm comes on in the afternoon than in the evening. The urine in remittent fever presents much the same changes, though in a different degree, as those occurring in intermittent fever. During the active stages of the fever there is an increase of urea, not simply above the standard of health, but even above that in intermittent fever ; and this increase of urea is attended with a diminution of uric acid — unlike what happens during the paroxysms of ague — and of the coloring and extractive matter ; while, as convalescence sets in, the urea decreases in amount, and the other ingredients mentioned increase.* A copious deposit of urates, forming with the phosphates as it were a critical discharge, is noticed as the fever subsides, and is analogous to what takes place after the paroxysm in intermittent fever. At no stage does the urine contain albumin, as it often does in typhus, and as it generally does in yellow fever, but, as in intermittent, it may contain sugar. Remittent fever is readily recognized : the rise and fall of its febrile signs are too striking to escape observation. Its charac- teristic traits are more closely allied to those of intermittent fever than to those of any other disorder. But there are these points of contrast : in intermittent fever each paroxysm begins with a chill, which is not the case in remittent fever ; for after the first paroxysm there is rarely a marked chill, and even the chill ushering in the disease is usually not violent. After each febrile exacerbation comes an abatement, — not an intermission, for the thermometer shows that the fever does not wholly leave; the tongue remains coated, and the gastric derangement does not entirely cease; the patient is not well, as after a fit of ague. The symptoms grow and decline ; they do not appear and dis- appear. In both affections we may have herpes labialis at the decline, but it is more common in remittent than in intermittent. Owing to the jaundice in many cases of bilious remittent fever, the disease is often mistaken for acute congestion of the liver. * Joseph Jones, Observations on Malarial Fever. FEVERS. 957 Here, again, the exacerbations and remissions in the temperature serve as distinguishing marks; and so, too, in separating the gastric complications of bilious remittent fever from acute gastric inflammation. The severe headache is also a distinctive feature of value ; so is the herpes labialis. Under ordinary circumstances, there is very little likelihood of confounding with each other typhoid and remittent fevers. The lines between the two diseases are too strongly drawn : no marked periodicity exists in typhoid fever, and, on the other hand, we find no diarrhoea, no eruption, no thoracic symptoms, no deafness, and no very great prostration, in remittent fever. But instances are met with in which the diagnosis is not easy, because the symptoms of the two maladies are blended. Thus, in a typhoid fever occurring in a malarious region there are often distinct exacerbations and remissions obscuring the real ailment. The malarial influence has set its stamp on the disease, and may for several days com- pletely veil it ; but soon its real nature becomes manifest. The great weakness ; the low delirium ; the tympanitic abdomen ; the thin passages, so unlike the dark, hard stools of remittent fever, — all unfold the true character of the disease. Sometimes a cer- tain periodicity is witnessed in typhoid fever as it is approaching a favorable termination ; the afternoon or evening rise of temper- ature is most marked, the morning remission very great. Here a knowledge of the previous history of the case guards against error. We shall presently again refer to the symptoms of periodicity in fevers of low type in examining into typho-malarial fever. Further, not unfrequently, after an attack of remittent fever has lasted for ten or twelve days, these symptoms are noticed : great muscular debility, jerking of the tendons, picking at the bedclothes, dark, dry tongue, and weak pulse, perhaps diarrhoea. The fever becomes of a continued type. It is these cases which have given rise to the opinion that bilious fever often changes into typhoid fever. But in reality it is not so much the specific typhoid fever, with its enteric lesions, as a typhoid condition, that is developed. During the exacerbations of remittent fever the cerebral symp- toms are sometimes almost identical with those of an acute brain- affection. There is severe headache, with violent beating of the arteries of the neck and face, a wild eye, intolerance of light, 60 958 MEDICAL DIAGNOSIS. and even delirium. Were the patient now seen for the first time, he would be at once pronounced to be laboring under axiute men- ingitis. Suddenly the pulse loses its throbbing character, a per- spiration covers the surface, and, as if by magic, the cerebral disturbance ceases until the next paroxysm redevelops it. Cases of this kind are readily enough recognized, if we know some- thing of their history. If we are not familiar with it, we have to await the remission for their explanation ; and after the sud- den withdrawal of the signs of disorder of the brain it is hardly possible to have doubts as to the meaning of the acute nervous symptoms, should they recur. It cannot be a meningitis we are dealing with, — a steady, progressing disease, and one never exhibiting such strange freaks of intermission. But occasionally the symptoms show themselves under circumstances where a mala- rial poison is not suspected to be at work : A young gentleman of studious habits, while diligently pre- paring for a college examination, was seized with violent headache and fever. The sense of fulness in the head was unbearable, the fever was high, there was nausea with great gastric irritability. These symptoms lasted for nearly twenty-four hours, and then subsided in the forenoon, to become aggravated in the evening. Delirium followed by great drowsiness was perceived at an early hour of the third day of the disease. The case now assumed a very alarming aspect. Local blood-letting was resorted to with some relief, and in a few hours the symptoms were, fortunately, favorably modified : the headache was much less, the mind was again quite clear. Although the patient had never suffered from a malarial fever, he had spent part of his summer vacation in the marshy neighborhood of Washington ; but several months had ^elapsed, and winter was setting in. The time of the year was Jiot in favor of malaria. But the evident remission in the cere- bral symptoms, the coated state of the tongue, and the inde- scribable malarial look of the countenance, that became daily more apparent, decided me upon administering quinine. The evening exacerbation came, but was far less severe. The nature of the case was now evident : the quinine treatment was vigor- ously pursued, and the patient soon recovered. The violent headache and delirium were in this case observed to be in connection with well-defined febrile signs. Occasionally FEVERS. 959 one or both of the symptoms mentioned last during the remission, while the fever abates. I have even met with them occurring in paroxysms without fever being present, as in the following case seen a number of years ago : A young lady of delicate constitution was attacked, in Septem- ber, with remittent fever. The disease ran its course without any unusual symptoms ; a violent headache, but little if any wander- ing of the mind, being observed during the daily exacerbations. After the tenth day the fever lessened, and the disease assumed a continued type ; yet soon afterward, as convalescence seemed to be established, every evening for three days, between five and six o'clock, a boisterous delirium set in, lasting for three or four hours, and once nearly all night. It was followed by a profound sleep, from which she woke up with a clear mind. During these fits the pulse was not accelerated, and there was no fever. The third attack was not so very severe, as the patient was already in part under the influence of decided doses of quinine ; another was prevented by this drug. In both these cases the symptoms approached those of the congestive type of the disease, and the issue appeared at one time doubtful. Generally speaking, remittent fever, unless it be of the congestive variety, has a favorable prognosis. It is difficult for us, living in a century in which the remarkable effects of bark are so well understood, to believe that the complaint was once so fatal, and that so many deaths should have taken place from a disorder over which we now exercise so undoubted a control. But the long list of distinguished names that have fallen victims to it, among them Cromwell, James I., and the Emperor Charles V.,* proves the medical skill of former times to have been in- sufficient for its cure. In our day, the consequences of remittent fever are more to be dreaded than the disease itself. We often find, as its sequelae, obstinate intermittents, enlargement of the liver and spleen, dropsy, protracted anaemia, headache, and im- paired activity of mind. * Prom the record of the Emperor's illness, as given by the historian Mignet (Charles V au Monastdre de Tuste), we may learn, what fortunately now we hardly have an opportunity of observing, the features of remittent fever when left to itself. 960 MEDICAL DIAGNOSIS. It is in this malarial cachexia that, on pricking the finger and examining a drop of the blood thus obtained, we detect a large number of those particles and masses of black or dark color and irregular shape to which Frerichs has particularly called attention. Not that the pigment-matter is found merely in the cachexia following remittent fever. We observe it in the blood in the severer forms of any malarial disease; and it is very probable that the spleen is the principal seat of its forma- tion, and that it is chiefly derived from a destruction of the red Pig. 82. A drop of Mood taken from the finger of a man the snhject of malarial cachexia. The granules of pigment, as well as the larger fi-agments of irregular form, are seen among the hlood-globulps. Thp pigment waa lor the most part black ; some of the particles were reddish brown. globules. The pigment is in great part carried from the spleen to the liver, where it remains ; or it passes through this visciis to the lungs, brain, and kidneys. The clogging of the coarser frag- ments in the capillaries of the liver may, as Frerichs suggests, by interference with the portal circulation, explain the intestinal hemorrhage and diarrhoea which attend some severe cases of remittent fever ; while the cerebral phenomena, or albuminuria, hsematuria, or suppression of urine may also be caused by reten- tion of pigment, in the one case in the capillaries of the brain, in the other in those of the Malpighian bodies. Thus, then, would be solved some of the anomalous symptoms of malarial fevers. But the abundance of pigment does not occur in all ; and whether a peculiar quality or an unusual intensity of the miasm produces FEVERS. 961 it, is undetermined. In a diagnostic point of view, though from the very evident grayish or ash-colored hue of the skin, and the singular character of the symptoms, we may suspect that -we have to deal with the pathological state under discussion, we cannot be sure of it until we have examined the blood microscopically. And here, too, it seems to me that the question of the amount of pig- mentary matter present must not be overlooked. For pigment may be found in the blood of those who never, to their knowl- edge, have had intermittent fever, and who certainly present no signs of malarial poisoning.* Parasitic formations have been described by Laveran f as pres- ent in the blood of those! suifering from malarial fevers ; and these minute appearances of the blood, as regards both the free bodies and the masses of protoplasm which are found in the red corpus- cles of the blood, are of distinct diagnostic value. In the latter is reddish or black pigment, due to the action on the haemoglobin. The hsematozoa of malaria in their varied forms are represented in the accompanying drawings, made from cases mainly under my care at the Pennsylvania Hospital, and drawn by Dr. Joseph Leidy, Jr. Bodies 1, 2, and 3 were found in the blood of a case of malarial paralysis.f To the peculiar appearance of the tongue which those under the malarial influence may show, Osborn has directed particular attention.§ There is a distinct lateral boundary of the organ, an appearance of indentation transversely, and the inferior sur- face appears to have encroached upon the superior and lateral borders. In children, a fever of remittent type is observed, called in/an^ tile remittent, which is rarely a miasmatic disorder. It is often a gastro-enteritis connected with verminous irritation or produced by errors in diet ; or a typhoid fever, — an affection which now * J. F. Meigs, Pennsylvania Hospital Keports, vol. i., 1868. f Bulletin de la Societe Medicals de Paris, 1880. J Dr. Leidy called my attention to the effect of heat and of cold on ordi- nary blood-corpuscles : they are distorted, and changes are produced which might easily be taken for some of the forms of the hsematozoa of malaria. It is also very important to cleanse the part thoroughly from which the blood is taken, as epithelial cells filled with pigment or free pigment from the skin might otherwise be mistaken for malarial changes in the blood. g Transactions of the American Medical Association, vol. xx. 962 MEDICAL DIAGNOSIS. and then occurs even in very young children. What has given rise to this confusion is, that all febrile diseases in children ex- hibit a much greater periodicity than in adults, and in all cerebral symptoms are apt to be present. To distinguish the two maladies mentioned from true remittent fever, we must study particularly Pig. 83. a, a', vacuolea eontainiBj; pigment; ft, pig- mented body, outside of corpuscle. a, a, pigmented bodies, — theliaamoglobin is entirely consumed in one coipuacle ; 6, hy- aline body. a, cresceutic body ; 6, b, pigmented vacuoles. 6. ^i ^^ — ^ a, a, a, amoeboid bodies; i, pigmented vacnole. a, pigmented ciliated body, flagellated or- ganism of Laveran ; b, mass of free pigment. (From a case of pernicious malaria.) theii' manner of beginning and their probable origin^ and note the peculiarities of the abdominal symptoms. Then we may lay stress on the irregular mode and the unequal duration of the febrile ex- acerbations. Sometimes, also, by close scrutiny, the characteristic FEVEES. 963 eruption of a low continued fever may be found in an apparent remittent. But some of these cases of remittent fever are really of malarial origin ; even in very young children this may be their source. I saw, for instance, some years ago, a little girl, three years of age, who had a distinctly malarial remittent fever, which was checked by antiperiodics. During the violent exacerbations she was very delirious ; her face had a most anxious, frightened look ; her screams could be heard all over the house. In the remissions she was perfectly sensible, but there was gastric irritability, and the bowels were very constipated. I have met with a similar case in an infant of eighteen months. Congestive Fever. — This is a malignant, destructive, ma- larial fever, which may be either of the intermittent or of the remittent form. The pernicious attacks are of the tertian or of the quotidian type. While they are at their height, there is in- tense congestion of one or several internal organs, with a dangerous perversion of the function of innervation. From this state the patient may rally, but only to fall a victim to another paroxysm, unless art intervene. The temperature during the chill and sub- sequent fever ranges from 104° to 108°. Sugar is apt to be found in the urine much more commonly than in ordinary inter- mittent fever. The symptoms of this violent malady vary according to the organ more specially disturbed, and to the extent of the derange- ment of the nervous system. We have, thus, several distinct varieties, of which I shall describe the most prominent. . The gasti'o-enteric form is common in our Southwestern States. Its distinctive features are nausea and vomiting, purging of thin discharges mixed with blood, intense thirst, and an equally intense desire for air. There is little abdominal pain or tenderness, but a weak, frequent pulse, and very great restlessness. The patient complains of a sense of sinking and of weight, and of burning heat in the stomach. His breathing is deep-drawn; to each expiration succeed two short inspirations. The face, hands, and feet are pale and cold ; the features shrunken. Sometimes these symptoms continue for several days, and gradually increase in intensity, in spite of nature making efforts at reaction. More frequently reaction does take place ; the temperature is very high, 964 MEDICAL DIAGNOSIS. the pulse feeble, and the stormy symptoms subside or wholly yield, until another outbreak, which is very apt to be deadly, occurs. The usual length of the fatal paroxysm is stated by Parry,* in his short but interesting sketch of the disease, to be from three to six hours. The thoracic variety of the malady is often combined with the one just described. Its most characteristic trait is violent dyspnoea, caused by overwhelming congestion of the lungs. It is perhaps the most rapidly destructive of all the forms of the disastrous aifection. In the cerebral variety there is intense congestion of the brain ; and sometimes effusion of serum into the ventricles takes place, or even rupture of the blood-vessels. The abnormal state of the brain manifests itself either by coma or by delirium. In the former case there is usually preceding stupor with occasional delirium ; the pulse is slow and full ; the face is dull, and either flushed or livid ; indeed, some of the symptoms which are ob- served in apoplexy show themselves. When, on the other hand, delirium is marked, we have much the same morbid phenomena . as in acute meningitis : the patient is wild ; he sings, he cries. He may die in this state without coma supervening; but a coma- tose condition generally succeeds rapidly to the fierce excitement. Should recovery take place, the delirium gradually ceases. Another variety much dwelt upon is the so-called algid form. This is not often seen in this country; Maillot f noticed it in Cor- sica and Algeria. The disease is more than a mere continuation of the cold stage of a paroxysm : commonly the characteristic symptoms manifest themselves during the period of reaction. The' pulse slackens, and finally ceases ; the extremities, face, and trunk become in succession rapidly cold. There is no thirst ; the skin feels like marble ; the breath is cold ; the voice broken. The mind is clear ; the expression of the countenance impassive and like that of a dead man. There may be vomiting and chole- raic discliarges. These symptoms go on steadily toward death, unless decided reaction be brought about. In none of these forms of congestive fever is the first paroxysm * Amer. .Tourn. Med. Soi., July, 1843. f Traite des Tievres intermittentes, Paris, 1836. FEVERS. 965 apt to be of a pernicious character. In the majority of instances the disease begins as ordinary periodic fever, and it is only in the second or third paroxysm that the alarming symptoms appear. Nor is the first congestive paroxysm likely to prove mortal ; gen- erally it is not until the second or third that a fatal issue is to be apprehended. Proper watchfulness will sometimes detect, even at the onset of the attack, by the unusual prolongation of the cold stage, or by the irregularity of the pulse, or by the great sensitiveness in the splenic region and by the pain which press- ure there may occasion all over the body, or by an imperfect hot stage, or by the feeling of internal heat while the surface is really cold, the danger that is approaching, and arrest its further steps by the bold use of antiperiodics. The cause of this desperate disease is evidently a highly active malarial poison ; and once in the system, it remains for a long time. Should the patient even weather the first attack com- pletely, he is not wholly out of danger ; he may have a second seizure quite as dangerous within the same season. Dock * has recorded in detail the study of a case of pernicious malarial fever characterized by an enormous development of plasmodia in the blood, with consequent ansemia and melansemia ; parenchymatous degeneration and inflammation in liver, kidneys, and stomach ; thrombosis in various organs ; hyperplasia of the spleen and lymphatic glands. On micro-chemical examination the pigment in the malarial parasites failed to respond to tests for iron, while deposits in the tissues themselves yielded such reaction. Hemorrhagic Malarial Fever. — Closely connected with congest- ive fever, indeed in a certain sense a form of it, is that per- nicious malady which is attracting in this country more and more attefition, and is known as the yellow disease, icterode pernicious fever, malarial hsematuria, or hemorrhagic malarial fever. It is the same disease as that which some of the French writers have long described as hsematuric bilious fever, and is found in intensely malarial places, sometimes in epidemics. It usually occurs in those who have already suffered much from malarial fevers, and is almost always ushered in by a marked chill, longer usually and more intense than the patient has had in the pre- * Amer. Journ. Med. Sci., April, 1894, p. 379. 966 MEDICAL DIAGNOSIS. ceding seizure of intermittent, — for often the dangerous paroxysm is preceded by one of ordinary kind. Soon after the protracted chill, distressing nausea and vomiting are noticed, as well as headache, great restlessness, and rapidly-developed deep jaundice. The fever which follows the chill is not high, the pulse is rarely extremely rapid, the patient is very thirsty. In a few hours after the chill, pain in the right hypochondrium, in the epigastrium, and over the kidneys is encountered, and a dark-colored, bloody urine is voided. Sometimes hemorrhages occur also from the nose and bowels. The type of the fever is either intermittent or remittent ; occasionally it is continuous. The bloody urine — for I know the dark-colored urine, judging from the specimens I have examined, to be bloody or to contain large quantities of dissolved haemoglobin — is at times associated with considerable albumin and with tube-casts. If the case progress unfavorably, the pulse rises, cold sweats occur, purpuric spots appear on the skin, and the signs of ursemic poisoning are not unusual. In the intermission or remission the symptoms abate considerably, jaundice and bloody urine cease to a great extent, perhaps almost entirely, — at least this is true of the latter symptom, — but they recur in the paroxysms, which may happen every day or every ten or twelve hours. The disease may prove fatal in three days ; but generally it lasts longer. Convalescence is apt to set in slowly, and not until the urine has entirely and permanently cleared. The liver and spleen may remain for a time greatly enlarged. As regards the diagnosis of the disease, there are but two dis- eases that closely resemble it. One is intermittent hsemoglobinuria. Now, undoubtedly some of the recorded cases of this are cases of the malady under discussion ; but in those to which the nkme can be fairly given the absence of marked malarial elements, of jaundice, of red blood-disks in the urine, and the want generally of fever, supply the distinguishing traits. From yellow fever, for which hemorrhagic malarial fever may be mistaken, it differs in the speedy occurrence of marked jaundice, in the bloody urine, in the extreme rarity of black vomit, in the course of the fever with its recurring paroxysms, and in the high degree of malarial poisoning which the history of the case proves. Then, again, the malarial poison may affect the kidneys, pro- FEVEES. 967 ducing altered secretion and even transitory albuminuria, and may lead to recognizable organic change.* Before proceeding to the discussion of another subject, I shall here devote a few pages to the consideration of some of the ir- regular forms and modifications of malarial poisoning, and to its share in producing febrile disorders of blurred and uncertain type. Practically, this is of great importance, and specially of importance to American physicians. In the first place, I shall speak of the chronic malarial poison- ing so often seen among inhabitants of malarial districts. It manifests itself by lassitude, debility, torpor of the liver, and enlargement of the spleen. The stools are oft«n black, the diges- tion is impaired, the complexion sallow. Occasionally attacks of jaundice occur, which rather relieve than aggravate the unhealthy state of the system. Sometimes the noxious influence shows itself in another way : the patient is seized with nausea, and with gastric irritability so great that almost evei-ything he takes is instantly rejected. The tongue is coated, the skin dryish ; but he has little if any fever. The bowels are confined, the urine is turbid. He is restless, and as weak as if he had typhoid fever ; but he has neither an eruption nor diari-hcea. His sleep is disturbed, and he often suifers with hypersesthesia of the scalp, and neuralgic pain shooting over the forehead and causing twitching of the eyelids. After remaining from six to seven days in this condition, his nails, perhaps at a certain hour every day, are noticed to become bluish ; or he feels chilly, and a slight fever immediately after- ward sets in. The return of these febrile symptoms is checked by quinine, and the patient enters upon a slow convalescence, remaining for a long time enfeebled. Again, there may be head- * See papers on malarial changes in the kidneys in Arch, de Phys., 1882, Nos. 1, 2, 3; and on malarial hzematuria, T. P. "Wood, North Carolina Med. Journ., 1884, xiv. ; J. Cochrane, Journ. Amer. Med. Assoc, Chicago, 1885, iv. ; I. J. Newton, Jr., Transact. Louisiana Med. Soc, 1885, vii. ; K. H. Day, Therap. Gaz., 1886, 3d S., ii. ; B. H. Eiggs, Alabama Med. and Surg. Journ., 1886, i. ; W. L. Van Horn, Gaillard's Med. Journ. 1887, xliii. ; J. W. McLaughlin, New Orleans Med. and Surg. Journ., 1888-89, N. S., xvi. ; I. T. Young, South. Med. Rec, 1889, xix. ; Chamhless, Med. Brief, St. Louis, May, 1891; McHatton, Times and Register, Phila., June, 1891; Ferreira, Rev, mensuelle des maladies de I'enfance, Paris, March, 1893 ; Stephanowicz, Wien. Klin. Wochensch., No. 8, 1893. 968 MEDICAL DIAGNOSIS. ache, coming on at a certain hour, associated with rise of temper- ature. . We also encounter malarial neuralgias and malarial pal- sies. In these, as in a case under my care at the Pennsylvania Hospital in 1889, the detection of the malarial corpuscles in the blood led to the diagnosis of the affection. Typho-malarial Fever. — Fevers of hybrid character, for the most part of kindred nature to those low states of malaria just described, have long been recognized by practitioners in this country. But it is only since our civil war that, owing to the publications of Woodward, they have been set apart in a sep- arate class. Now, one of the most marked forms of " typho- malarial fever," to adopt this, from a practical point of view, convenient name, was that curious fever which so many soldiers brought with them from the swamps of the Chickahominy. The fever generally began with a decided chill, to which febrile excitement soon succeeded. This chill was sometimes, but not always, repeated. Many cases of the disorder showed at first distinct remissions ; but if the fever lasted for more than a week it became continued. Diarrhoea was a prominent symptom from, the first ; sometimes it preceded the disease by several weeks. In the cases that I saw in Philadelphia, nausea, vomiting of bile, and great thirst were often present ; the stools were very frequent and offensive ; the eye was injected. There was generally mental confusion, and not unusually wild delirium ; but no eruption, — certainly no rose-colored spots ; the spleen was always much enlarged. Dark purple spots, unchanged by pressure, showed themselves at times all over the body, and often did not appear until long after the fever had left. The diarrhoea was very ob- stinate, and remained long after the fever. The solitary glands and Peyer's patches were generally swollen, of dark color, but in a large number of instances not ulcerated. I have mentioned this fever because it presented on a large scale a striking illustration of the typho-malarial disease. According to Woodward, the fever belonged to the group which was the most frequent form of camp fever during our civil war. It con- sisted of mixed cases, in which the malarial and typhoid elements were variously combined with each other and with the scorbutic taint, now one, now the other of these elements preponderating. Prominent among the peculiarities of the malady were a decided FEVERS. 969 tendency to periodicity, hepatic tenderness, with an icteroid hue of the countenance, gastric disturbance, excessive enlargement of the spleen, a very protracted convalescence, and the appearance throughout of the signs of a scorbutic aifection. The rose-colored rash and the tympanites of typhoid fever were generally absent. Diarrhoea was ordinarily very marked, and was apt to be persistent, Now, except the scorbutic symptoms, similar cases are seen by all of us to this day throughout large portions of the United States, and the clinical manifestations are those of a malarial fever with prominent typhoid symptoms. In fact, I have already mentioned these symptoms when describing remittent fever, and I will here only add that they may come on early in the case, as well as develop late. They are cases of malarial fever complicated with a typhoid state, or more generally lapsing into it; and, while they present the symptoms of a typhoid condition, they are lacking in the eruption of enteric fever, and in the abdominal phenomena, if we except diarrhoea and some abdominal swelling, both of which may, how- ever, also be absent. It is these cases, malarial primarily, in which the typhoid condition shows itself, but in which there is not the characteristic lesion of typhoid fever, to which, in my judgment, the term typho-malarial should be restricted. Yet most cases that are now called typho-malarial fever are really typhoid fever asso- ciated with malaria. They are true typhoid cases showing un- wonted periodicity and greater enlargement of the spleen from a malarial complication, and should not, I think, be called typho- malaria. They are simply cases of typhoid fever with malaria, and, if we are to give them a name, might be distinguished as " raalario- typhoids." Thompson * has reported four cases of con- current typhoid fever and malarial fever. In three plasmodia and in one malarial pigment were found in the blood.f Yellow Fever. — This formidable malady takes its familiar appellation of yellow fever from the yellow tinge assumed during its course by the skin. It is a distemper met M-ith in hot climates in low and level localities on the sea-coast. Its source is un- known ; it is not malaria, nor has a characteristic micro-organism been detected. All we know certainly of the cause is, that the * Amer. Journ. Med. Sci., Aug. 1894, p. 158. f See, also, Johnston, Trans. Assoc. Amer. Physic'ans, 1888, vol. iii. p. 8. 970 MEDICAL DIAGNOSIS. malady is due to a specific poison which does not exist without a high temperature, and that frost is its greatest enemy. Yellow fever is an affection of short duration : it rarely lasts a week ; many die on the third or the fifth day of the disease. It has but one paroxysm, which is never repeated. This paroxysm may be divided into three stages, which are well marked in some epidemics, far less so in others. The first stage, called that of reaction, is pre-eminently the febrile stage. Its average duration is from thirty-six to forty- eight hours. It usually begins suddenly, and is frequently ushered in by a chill. In rare instances this is protracted, there is great internal congestion, and death ensues before reaction oc- curs. But much more generally a short chill is followed by marked febrile excitement. The skin is harsh and hot; the pulse quick and tense, although sometimes it is both easily compressible and not much accelerated ; indeed, as a rule, it declines before the temperature. The face is flushed ; the eye brilliantly injected, yet watery. The patient is conscious, restless, anxious, and com- plains much of the torturing pains in his forehead, loins, and legs ; and the muscles of the extremities are sore when moved. The breathing is hurried ; the stomach irritable, the epigastrium painful on pressure ; there is great thirst. The bowels are con- stipated ; the stools very dark-colored. The tongue is more or less coated and moist ; sometimes it is red, while at other times it remains natural throughout the disease. The febrile signs increase toward evening and lessen toward morning, but do not distinctly remit until after from thirty-six to forty-eight hours, when a remission does occur, or when, to speak more correctly, the whole aspect of the case changes. The disorder now appears in its second stage; the fever sub- sides ; the pulse falls and becomes easily compressible ; the head- ache is relieved ; the breathing is no longer oppressed ; the tem- perature declines to a little above the norm. But the gastric irritability does not wholly disappear, and a deep yellow or orange hue gradually tinges the eye and the whole surface of the body. The patient is cheerful, and wishes to get out of bed. His sufferings may be, indeed, over, his convalescence may have set in : after a few dark, biliary stools, the yellowness of the skin fades, and he slowly gets well. FEVERS. 971 • But it is not often that the disease relaxes its hold so easily : more generally the deceptive improvement does not last a day, and after a brief lull, the struggle for life begins. The patient grows again very uncomfortable and anxious. In truth, the symptoms of the first stage reappear with increased intensity. In addition, new signs, of the gravest import, show themselves ; some of which are clearly due to the corruption of the blood that the poison has silently effected. The pulse sinks, and be- comes slow and extremely irregular and compressible ; the skin is cool, dry, dark, and in some cases of a bronze hue, or livid, and spots may occasionally be seen on its surface. The stomach is as irritable as before, but the act of vomiting is easier ; and, without much retching, large quantities of altered blood, or " black vomit," are ejected. Blood oozes from the mouth, from the gums ; some- times from the eyes and nostrils, from the bowels, and from the vagina ;* or hemorrhage takes place into internal cavities, and the blood is retained.f The phenomena of collapse become now more and more un- mistakable : the black vomit often ceases, because the contractile power of the stomach has ceased ; a low, muttering delirium sets in, and the patient dies prostrated. Yet the mind may remain clear almost to the last, and the strength be but little impaired. Should reaction take place, recovery is only very gradual. But yellow fever does not at all times and in all localities present precisely the same degree of intensity or the same group of symptoms. Sometimes it exhibits frank, active febrile phe- nomena ; at other times there is little febrile excitement, but a disposition to internal congestions and to early prostration. This congestive form is far more dangerous than the inflammatory. Yet both are highly destructive. From 10 up to 75 per cent, are the figures representing the mortality of this fearful malady. Omitting the instances of an exceptionally mild type, the average is calculated, in the elaborate work of La Roche,J to be 1 in 2.32. The more rapidly the stages succeed one another, the more danger- * Cases in the epidemic of 1856-57 at Lisbon, reported upon hy Lyons, London, 1858 ; also by Alvarenga, Pievre jaune a Lisbonne, Paris, 1861. f In a case at the Pennsylvania Hospital the pericardium was filled with blood resembling black vomit. J Yellow Fever, Philadelphia, 1855. 972 MEDICAL DIAGNOSIS. Fig. 84. ous the case. The occurrence of black vomit, of great epigastric tenderness, of hiccough, of suppression of urine, of delirium, of early jaundice, of oppression in breathing, of convulsions, of a fiery, glistening eye, and of petechise, warrants an unfavorable prognosis. " Walking cases," or those in which the patients walk about until they suddenly eject black vomit, always ter- minate fatally. As regards the tem- perature in yellow fever, the maximum elevation is attained upon the first, second, and third days of the disease, ranging from 102° to 110°; it then falls in the stage of calm, to rise for the most part again in the stage of collapse, though it never attains the high temperature character- istic of the first stage, and never rises so lap- idly. The elevated tem- perature of the first days may, however, continue with little variation un- til the sixth day, when the remission becomes marked. A complete remission usually happens on the morning of the third day, but may not occur until the fifth day or the ninth. Whenever it takes place, the speedy defervescence is very characteristic. Even in these longer cases there is a decrease in temperature preceding a fresh rise, which occurs in paroxysms of two days each. Slight rises in temperature are neither uncommon nor grave after the marked fall in the srcond stage. But when the temperature rises rapidly in this stage of calm it is of most DDDDBBIID Q Q Q DSDBEIIIBI 19 II I I U I I I I I I § I i H I UN I Biin I HBI I ■iiinii I ■■imi mi niiiH lu Temperature of yellow fever in a caae ending in recovery recorded by Bemiss. FEVERS. 973 serious meaning. In the stage of calm the absence of fever may be complete; but generally the defervescence is only partial : a remission, therefore, rather than an intermission.* Yellow fever has rarely any complications. It may, however, seize upon those affected with other diseases. It has been spe- cially noticed that it is frequently intercurrent in surgical and obstetrical cases.f The recognition of yellow fever is, generally speaking, easy. The intense pain in the back, limbs, and forehead ; the appear- ance of the eye ; the color of the skin ; the short duration of the febrile symptoms; the nausea; the epigastric tenderness; the black vomit ; the albuminuria, — constitute a group of symptoms which unmistakably mark the disease. But let us look at the points of contrast which yellow fever presents to other affections. It differs from plague by the absence of buboes and of carbuncles, and by the much more frequent occurrence, on the other hand, of jaundice and black vomit. Then, too, the red, suffused eye and the single paroxysm are not witnessed in plague. The febrile malady may run on to a state of collapse as complete as in Asiatic cholera, ; but, unlike this destructive disease, the symptoms of entire prostration are preceded by fever, and not by vomiting or purging of rice-water. The lines of demarcation between the ordinary forms of con- tinued fever and yellow fever are very broadly drawn. It is dis- tinguished from relapsing fever by the different countenance, by the supra-orbital pain, by the soon-occurring remission, and, above all, by the extreme rarity of a relapse and the infinitely greater mortality. To typhoid fever it bears so slight a resemblance that it is scarcely possible to confound the two affections : one, a short, severe disease, with its peculiar physiognomy and gastric symp- toms ; the other, a long-continued malady, of low type, with its characteristic eruption and enteric signs. It is only when yellow * In addition to the authors quoted, see on the temperature Paget, New Orleans Med. and Surg. Journ., 1873-74; Bemiss, Amer. Journ. Med. Sci., 1880, and article ' ' Yellow Fever" in Syst. of Pract. Med. by American Authors, and the temperature charts of Naegeli, of Eio Janeiro, as given by Jaccoud, Pathologic interne. f S. M. Bemiss, Clinical Study of Yellow Pever, Amer. Journ. Med. Sol., April, 1880. 61 974 MEDICAL DIAGNOSIS. fever is protracted beyond the ninth day that the diagnosis is rendered doubtful; and then we have generally the history to guide to a correct understanding of the case. The likeness be- tween yellow fever and typhus is much closer. But one is a short fever, with distinct stages ; the other is a longer, much more con- tinued fever. One has no marked cerebral symptoms; in the other the cerebral symptoms are the most prominent feature. One has but rarely an eruption, but often hemorrhages; the other has always an eruption, and hardly ever hemorrhages. The disease most likely to be confounded with yellow fever is hilious remittent. In truth, the symptoms are very similar, and many of them differ only in intensity. The diagnosis of the milder forms of yellow fever from remittent fever is, indeed, extremely difficult, unless the epidemic influences prevailing be taken into account. Then, as is well known, the affections may be blended, and yellow fever become obviously periodical in its febrile phe- nomena. The occurrence of black vomit is not in itself a dis- tinctive sign between the two diseases ; for black vomit may be absent in yellow fever, and, on the other hand, it may, although it rarely does, occur in remittent fever, just as it has been known to occur in childbed fever, in the plague, and even in typhus.* A valuable sign is derived from an examination of the urine. Unlike what happens in bilious fever, a trace of albumin ap- pears in from twelve to fourteen hours after the fever sets in ; then the albumin increases, and the urea and the uric acid dimin- ish and gradually disappear, as does the bile -pigment, f The more obvious the suffusion of the countenance in yellow fever, the more marked and early is the albuminuria.J In children, * This statement with reference to typhus fever is made on the authority of Stokes. The occasional occurrence of hlack vomit in remittent fever is admitted hy many authors. Some winters ago, a physician of this city brought to me, for examination, a specimen of hlack vomit which had the same mi- croscopical characters that I have repeatedly found in the hlack vomit of yellow fever. The patient undoubtedly had remittent fever, from which he recovered. f Ballot, Arch. G6n. de Med., Nov. 1869; see, also, Joseph Jones, New Orleans Med. and Surg. Journ., Jan. 1874; Holland, American Practitioner, Sept. 1879; Sternberg, New Orleans Med. and Surg. Journ., 1880-81, N. S., viii. J Bemiss, loc. cit. FEVERS. 975 albumin may be present only in the evening urine.* An addi- tional valuable sign is finding the plasmodium of malaria in the blood in cases of remittent fever. When yellow fever is well marked, it differs in this way from bilious remittent : Yellow Fever. Of short duration, ending commonly in from three to seven days. Period of incuhation from five to nine days. A disease of one paroxysm, termi- nating in recovery or in collapse. Very severe nausea and vomiting throughout; early and decided epi- gastric tenderness ; black vomit. Hemorrhages from gums and various parts of the body. Tongue clean, or but slightly coated ; pulse very variable, frequently be- comes slow in last stages. Highly -injected, humid eyes; often fierce or ajaxious expression of face. Supra^orbital pain, and pain in back and in calves of the legs. Very rarely delirium ; mind usually clear. Urine acid, generally contains albu- min, also epithelial and granular casts and blood casts ; suppression of urine common ; no micro-organ- ism in blood. Little muscular prostration ; often rapid convalescence ; no sequelae. Almost certain immunity after one attack. Very high mortality; disease is epi- demic. Treatment unsatisfactory. BiLiotrs Ebmittbnt. Lasts nine days or upward. Period of incubation very variable ; may extend to months. A disease of several paroxysms, with intervening remissions. Nausea and vomiting not so severe, and rarely as marked at the onset ; neither as early nor as constant and decided epigastric tenderness; vomiting of bile and of the con- tents of the stomach. No hemorrhagic tendency. Tongue heavily coated ; pulse varies less, is always quick until convales- cence sets in. Eye not peculiar; different physiog- nomy. Headache ; sense of fulness in head ; often no pain in loins or in legs. Delirium frequent; mind always dull. No albumin in urine ; suppression of urine rare ; plasmodium of malaria in blood. Much greater muscular prostration ; slow convalescence and tedious se- quelaa. One attack seems rather to predispose to others. Slight mortality ; disease more en- demic in its nature. Very amenable to treatment. * Guiteras, article eases of Children. ' Yellow Fever," in Keating's Cyclopaedia of the Dis- 976 MEDICAL DIAGNOSIS. Tkllow Fever. Bilious Eemittknt. Autopsy shows inflammation or very Autopsy shows congestion of stom- great congestion of stomach, and ach ; more rarely inflammation, sometimes ulceration or softening. Liver of an olive or bronze hue, Liver enlarged, of a yellowish color, not fatty ; accumulation of animal its secreting cells filled with oil- starch in liver of malarial fever, no globules. Kidneys swollen, in- grape-sugar.* Kidneys unchanged, flamed. Heart often exhibits disin- or simply congested, tesration of muscular fibres. Eruptive Fevers. The eruptive or exanthematous fevers form a group having numerous features in common. They are all characterized by a period of incubation, during which the poison lies dormant in the system ; by a fever of more or less intensity preceding the eruption ; by an eruption which presents a distinct aspect in each disease, and which pursues a definite, clearly-defined course until it, and with it the febrile malady, disappears. Moreover, they are all very prone to occasion serious sequelae; are all, in the main, disorders of childhood ; rarely attack the same person twice ; and are contagious. These remarks apply particularly to the three chief exanthematous fevers : scarlet fever, measles, and smallpox. In great part, too, they hold good in regard to erysipelas, described here in connection with the eruptive fevers. Scarlet Fever. — Scarlatina affects both children and adults, and is marked by great heat of skin, frequent pulse, sore throat, and an early scarlet eruption. These symptoms are preceded by an uncertain, generally a short, period of incubation, but soon exhibit their striking features. The febrile excitement is charac- teristic ; the skin is very hot and generally dry, and the rapidity of the pulse so great that often by this sign alone we may, espe- cially in the midst of an epidemic, predict the coming eruption. Vomiting, too, is a frequent symptom at the beginning of the ill- ness. The temperature, which may reach between 105° and 107°, does not fall with the appearance of the eruption. The highest temperature occurs on the second or the third day.f The * Joseph Jones, Medical and Surgical Memoirs, vol. ii.. New Orleans, 1887. f Hatfield, article "Scarlet Fever," in Amer. Text-Book of Diseases of Children, 1894. FEVERS. 977 temperature continues high until the eruption is completed and at its height. It slowly declines as this fades, and with the occurrence of desquamation attains the norm ; but it may persist, with marked morning remissions and . evening exacerba- tions, when the eruption has gone and during the earlier stages of desquamation. The rash appears on the second day of the disease. It comes out almost simultaneously all over the body, although, on close scrutiny, it may be soonest perceived on the neck and the breast. At first the surface exhibits an almost uniform red blush, which disappears momentarily on pressure, or rather pressure leaves a white stain on the skin, which quickly again reddens from the periphery to the centre. Soon, however, the eruption presents an unequal aspect : it is of more vivid scarlet hue in some parts of the body, as in and around the flexures of the joints, and is not everywhere smooth. Here and there are seen elevated rough points of darker tint, edged by the red integument, and not unfrequently vesicles containing a thin fluid. The skin is very hot and itchy, and tumefied, especially on the hands and feet. The eruption declines on the fourth or the fifth day ; by the seventh or eighth, the cuticle begins to come away in large flakes. Sometimes the rash, when at its height, recedes and then appears again. In malignant cases it comes out late, and is either pale and indistinct or dark and livid. In some instances it is want- ing. Some years ago, I saw this " scarlatina sine exanthemate" in a lady, who, watching over the sick-bed of her daughter, contracted the disease and went regularly through it, even to its sequelse of disorder of the kidneys and swelling of the salivary glands, but in whom not a trace of an eruption could be detected. The sore throat of scarlatina is almost as constant and as char- acteristic as the scarlet rash. It shows itself early, sometimes before the eruption, and rarely waits until the third day of the complaint. At first the throat-affection consists in a diffused redness extending over the tonsils, palate, and half-arches, and in a swelling of the tonsils : the patient complains of pain in his throat, augmented by pressure and by swallowing, and of stiffness of the muscles of the neck. After a few days, if the disorder be severe, irritating discharges occur from the inflamed surfaces, and patches of false membrane and superficial ulcerations are 978 MEDICAL DIAGNOSIS. seen in the fauces. The glands of the angle of the jaw become much tumefied, and, by pressing on the cervical vessels, produce a tendency to drowsiness and stupor. These are grave symptoms ; their occurrence, indeed, is indicative of one of the main dangers in these " anginose" cases of the disease. The false membranes which are developed last about five or six days ; they form as well as reform in patches, and are very easily removed. Sometimes they extend to the larynx ; but this does not often happen, and, even when it does, the symptoms of croup, in the opinion of Barthez and Rilliet, do not arise. The acid discharges and the decomposing membranes often occasion a most fetid breath, and, by being swallowed, a persistent diarrhoea. The tongue has a peculiar look. At first it is thickly coated, and its borders only are red ; but soon the fur is cast off, and the whole organ becomes very red and its papillse prominent. After it has presented this appearance for six or eight days, it returns to its normal condition. In bad cases it is extremely dry and of a brownish hue. In children the disease frequently sets in with convulsions. In truth, cerebral symptoms of one kind or another are not uncommon at all stages of the malady ; yet great differences are observed, in this respect, in different epidemics. In some cases of malignant character, the vomiting, the screams, the grinding of the teeth, the occurrence of delirium and insomnia, make the attack look, at the onset, like one of acute meningitis ; but the eruption soon sets all doubt at rest, and, even before it is noticed, the great heat of the skin and the extreme rapidity of the pulse point to the source of the mischief. The nervous symptoms in these dan- gerous instances of the affection do not, however, cease with the eruption ; they may last to the end of the malady. Sometimes they are not noticed until late in the disorder, and after the period of desquamation has fully begun ; but the convulsions and stupor — for these are the morbid manifestations then more specially encountered — are owing rather to a diseased state of the kidneys that has been induced, than to the immediate effect of the fever poison. Occasionally some of the larger joints swell up, and present the appearance of subacute rheumatism. The joints are not, however, very painful on pressure, and generally only two or FEVEES. 979 three are enlarged. This form of rheumatism is evidently owing to the retention in the blood of some morbid material, and simu- lates ordinary acute articular rheumatism in presenting endocar- ditis and pericarditis as complications. Endocarditis and peri- carditis occur also irrespective of articular involvement. Further complications of the disease are dropsies, renal hema- turia, pleurisy, local gangrene, oedema of the glottis, neuritis, diphtheria,* and a very low state of the system. These compli- cations are hot apt to arise until at or soon after the period of desquamation; sometimes they lead to long-continued disorder, and become thus the most hazardous of the sequelae. Other con- sequences of the affection, lasting, it may be, for years after the febrile attack, are a tendency to boils, swelling of the parotid and of the lymphatic glands of the neck, nasal catarrh, diarrhcea, chronic inflammation of the eyelids, and deafness from inflamma- tion extending up the Eustachian tube to the membrane of the tympanum, or from suppurative destruction of portions of the ear. Epilepsy is also a sequel of scarlet fever, more cases being consecutive to it than to all other acute diseases combined-f Optic neuritis may follow scarlet fever, without organic change in the brain. Of all these morbid states, dropsy is the most common. The effusion of fluid may be caused by the altered state of the blood ; but much more generally it is owing to the poison producing an acute desquamative nephritis : albumin, tube-casts, epithelial cells, and sometimes blood, are found in the scanty urine ; and we meet with severe headache, great restlessness, and oedema of the face and extremities, as the attending symptoms. Still, notwithstanding these grave phenomena, the majority of the cases recover, and the kidneys are rarely permanently injured. The dropsy is apt to show itself between the tenth and the twen- tieth day of the malady. The albuminous condition of the urine may precede it by several days ; yet dropsy may happen without albuminuria,! especially in some epidemics, and albumin in the * Trousseau, Clinique Medicale, tome i. ; see, also, article " Scarlet Fever" in Ziemssen's Cyclopaedia and in Amer. Syst. of Pract. Med. t Gowers, Diseases of the Nervous System. X Gee, in Kussell Eeynolds's System of Medicine ; also Quincke, Berlin. Klin. Woch., 1882, No. 27; Dyce Duckworth, St. Earth. Hosp. Eep., 1883. 980 MEDICAL t>lAGNOSIS, . urine is not always associated with dropsy. In most cases of scar- latina it is found at some period of the disease for a short time and in small quantities; but this transitory albuminuria is not, like the albuminuria coexisting with marked anasarca, connected with many tube-casts in the urine and numerous epithelial cells. The state of exhaustion noticeable at the close of the fever and while desquamation is still going on is at times great, — so great that, in young persons especially, the case wears the look of typhoid fever. And the resemblance is heightened by the occur- rence of diarrhoea associated with a swelling of the solitary and agminated glands. But the signs of desquamation, the sore throat, the enlargement of the cervical glands, and the history of the affection furnish distinctive marks of the utmost value. The statements that have just been made concerning the diverse complications of the malady are mainly of interest on account of their exhibiting the intricate diagnostic questions which may arise. Of the I'ecognition of the disorder during the febrile stage it is not necessary to say much, as ordinarily it is not difficult. The distinction between it and the other exanthematous fevers may be seen by glancing at the table, to which a place is elsewhere assigned. I shall only here mention, as bearing upon the differ- ences between scarlet fever and measles, that cases are occasionally encountered in which the eruption alone is too ill defined to be- come the sole basis of an opinion, and that then we have to lay the greatest stress on the presence or absence of catarrhal symp- toms and sore throat, and on the march of the symptoms. So, too, with reference to smallpox. The rash preceding the forma- tion of the pustules may have so strong a resemblance to that of scarlet fever that a scrutiny of all the attending circumstances, and a careful watching of the eruption for at least a day, are requisite for the detection of the true nature of the case.* An erythematous rash, appearing in blotches everywhere except on the face, has been noticed in membranous croup and in laryngeal diphtheria after the operation of tracheotomy.f But it is very ir- regular, runs a rapid course, and is not followed by desquamation ; a point, it may be here mentioned, distinguishing all the forms * The disorders may also be combined. See the oases of Marson, Medioo- Chirurg. Transact., vol. xxx. f Bericht des k. k. Krankenhauses, Weiden, 1865. FEVEES. 981 of irregular rashes happening at times — though very rarely — in diphtheria, from the scarlet fever eruption. As the result of gon- orrhoea we may have symptoms of a low fever associated with a cutaneous rash like that of scarlet fever. The history and progress of the case chiefly distinguish this pseudo-scarlatina.* The same is true with reference to the so-called surgical scarlet fever. It shows an eruption that may be like that of scarlet fever, though the throat symptoms and the sequelae are lacking. Like measles, scarlatina may be mistaken for that curious form of eruptive fever called rubella or rubeola. But this really re- sembles measles more closely, and in examining it presently the differences between it and scarlet fever will become apparent. An affection with several features like scarlatina is breakbone fever, or dengue. The points of dissimilarity may be learned by referring to the description of the malady given farther on. Scarlet fever may go on concurrently with other fevers. It has been observed with typhoid fever, and with varicella.f Eding- ton and Shakespeare have described a special bacillus to which they beheve the disease to be due. Measles. — The symptoms precursory to the specific eruption of this affection are fever, watery eyes, frequent sneezing, flow from the nose, and cough ; in fact, all the manifestations of an acute coryza or catarrh. To these diarrhoea is in many instances added, indicating a simultaneous irritation of the intestinal mucous membrane. On the fourth day after the beginning of the morbid signs, a rash is perceived on the face and neck ; thence it con- tinues to extend, until, in the course of two or three days, the whole body is covered. The temperature during the first day of the disease is generally from 102° to 103° ; if higher, the attack is likely to be severe. On the second or third day — usually on the second, when it may be but 98.6° or 99° — it is markedly lower, and it rises again on the evening of the third or on the fourth day to decided fever heat. The temperature does not at once decline with the rash. Indeed, it is apt to go on rising for twenty-four to thirty-six hours ; the occurrence of the eruption does not alle- * Ballot, Arch. Gen. de Med., Sept. 1882. The same author calls attention to a puerperal pseudo-rubeola, a false measles, from blood-infection, t Church, St. Barthol. Hosp. Bep., 1881; Lond. Med. Record, Nov. 1883. 982 MEDICAL DIAGNOSIS, viate the febrile symptoms ; on the contrary, while it is spreading to the trunk and the lower extremities, the constitutional disturb- ance lasts, or more generally increases. But as soon as the rash has fully reached its height, the defervescence is rapid ; and from the fifth to the seventh day of the disease the temperature sinks until it is but little above the norm. By the ninth day of the disease both fever and rash have left. Frequently then the cuti- cle comes away in fine scales, and this desquamation is attended with very annoying itching. The patient, now that he is conva- lescent, shows his illness: he is pale and somewhat emaciated. Often he still coughs, and his eyes are slightly inflamed. These signs are not unusually the last to disappear. Paralysis, of cerebral, spinal, or peripheral origin, may occur in the sequence of measles.* Of all the symptoms mentioned, two are, in a diagnostic sense, of pre-eminent importance : the catarrh and the eruption. The catarrh is nearly constant. It is true that a variety of measles is recognized, — " rubeola sine catarrho ;" but this is very rare. Generally speaking, the coryza and catarrh decline with the eruption ; occasionally, however, they remain for some time after the rash has left. The feature which distinguishes these catarrhal symptoms from those of influenza consists in the erup- tion : before this happens, the diagnosis is uncertain, though we may often suspect measles by the look of the face, the greater intensity of the febrile signs, and the knowledge that the disease is prevailing in the community. The eruption is peculiar : it consists of slightly-raised red spots, which coalesce and form blotches of an irregular, crescentic shape ; between these blotches the skin is of natural color. The erup- tion disappears first from the face ; in other words, it disappears in the same order in which it appeared. As it fades, which it does on the third or fourth day of its appearance, it becomes brownish, and subsequently of a yellowish tint. In its earliest stages it is similar to the papulae of smallpox ; and this similarity may be heightened by its being mixed, as it sometimes is, with a few miliary vesicles. But after the first day of the rash there is * Allyn, Medical News, Nov. 28, 1891, p. 617; Carpenter, Medical News Feb. 13, 1892, p. 183. FEVERS. 983 little room for doubt. In the one case the spots remain as they were ; in the other, they change into pustules. . A question may sometimes arise as to whether the eruption be that of typhus fever or of measles. Both are coarse, both often not unlike in color, and both may be developed about the same time. Generally speaking, however, the eruption of typhus fever shows itself several days later tlian the rash of measles ; and, although coarse, it is not crescentic, and is found on the trunk and extremities rather than upon the face. Moreover, the physi- ognomy, the excessive prostration of strength, and the marked cerebral symptoms of the low fever are such as to render a dif- ferential diagnosis seldom difficult. Measles is usually met with in children ; but it may be en- countered in adults, especially among soldiers, and is in adults a much more severe complaint than in children. In the latter it is not an alarming disease. Only occasionally does it occur in epidemics which present a malignant character. Its greatest danger commonly consists in the eruption disappearing prema- turely or appearing but partially, and in the severity of the tho- racic complications. These are either acute bronchitis or acute pneumonia. Acute bronchitis may occur at any period of the disorder, and involve the finer tubes. But it does not generally set in with severity until the eruption has reached its height or is beginning to fade. In young children, symptoms of inflammation of the larynx, or of croup, are at the same period apt to manifest them- selves. Acute pneumonia, too, either croupous or broncho- pneumonia, the latter most often, is met with at this stage of the malady, or sometimes even after convalescence has apparently begun. We may suspect that mischief is going on within the chest, if the breathing be very oppressed and the pulse continue to be rapid ; but to detect early the hazardous and insidious complication we have to depend chiefly on physical exploration. Occasionally the thoracic affection leaves a chronic bronchial disease, or a persistent cough and night^sweats point to the de- velopment of tubercles. It may, in individual cases, be ex- tremely difficult to decide with which of these morbid states we have to deal. Emaciation and a chronic cough are found in both chronic bronchitis and phthisis ; and the physical signs of 984" MEDICAL DIAGNOSIS. tubercular consumption are, in children, notoriously ill defined and untrustworthy. We may be obliged, therefore, to depend upon finding the tubercle-bacillus before coming to a definite conclusion. The pneumonia of measles has been attributed to the bacteria which are detected in the nasal mucus in measles penetrating in large numbers into the lung, and there setting up inflammation.* At times we meet with anomalous forms of measles. Such was the " rubeola notha" that prevailed extensively in London about thirty years since,t and in which there was a papular erup- tion like that of ordinary measles, but distinguished from it by its dusky hue, and by the papulae not being arranged in ores- . centic clusters, being less obvious, or not appearing at all, on the limbs. A similar anomalous exanthem was common in Philadel- phia during the winter of 1865-66, occurring at a time when both measles and scarlatina were frequent, and particularly the former. The eruption, which occurred in patches of dark hue, was principally confined to the face ; there was no sore throat. Perhaps these anomalous forms of measles are rather varie- ties of rubella than of measles. An aifection formerly very common, miliary fever, would be also a source of much confusion were it in our day often encountered. But epidemics of miliaria are now extremely rare. Yet we know that it is a disorder with a prodromal stage of two or three days, during which great irrita- tion of the skin, debility, and a feeling of suifocation are usual. The marked disease begins with profuse sweating and with severe fever, and prsecordial and epigastric distress. These symptoms last until the appearance of the i-ash, generally on the third or the fourth day, though sometimes not until much later, and then, as a rule, slowly subside. The rash appears first upon the neck and the breast, and consists of numerous round or irregular spots, in the centre of which vesicles arise that finally bui'st and form crusts. The disease ends with desquamation and generally in a slow convalescence. The sweating, the oppression and prsecordial pain, and the peculiar eruption distinguish chiefly this epidemic disease from measles. * Cornil et Babes, Arch, de Phys., Aug. 1883. f Babington, Lancet, May 7, 1864. FEVEES. 985 Rubella. — The most striking resemblance to measles is fur- nished by rubella. This, called by the Germans Motheln, and often spoken of as " German measles," is not a hybrid of measles and of scarlet fever, but a special exanthem, which occurs in epi- demics. It displays a red eruption, ushered in by a chill, followed by slight fever, which is accompanied by coryza, cough, and sore throat. The fever prior to the eruptiou lasts for two or three days, but this is far from constant ; indeed, it often does not last more than half a day, or it may be of a week's duration.* The tem- perature rarely exceeds 102.5°. The rash may come out all over at once, or spread in a day or two over the body ; it generally appears first on the face and neck. It is most distinct on the face, the scalp, the neck, and the trunk, being more scattered on the extremities ; it is specially distinct about the mouth. It first . resembles measles, but the spots are round or oval, and smaller and paler, and they soon run together in irregular patches, unlike the well-defined crescentic emption of measles ; they show no tendency, however, to become generally confluent. The patches are of vari- able size, and, unlike the rash of scarlatina, are surrounded by healthy skin; small spots range themselves around the large ones. They are of deepest color in the centre, but not bright-colored as in measles, nor of the dark red of severe scarlatina, are elevated, and very much influenced by pressure. The eruption lasts ordi- narily four or five days, but in severe cases eight or ten. It gradually fades, but it may happen that it fades on the face before it has fairly come out on the legs, and desquamation may ensue, though the scales are small, and never in size like those of scarlet fever. During the continuance of the rash, which is attended with much itching, the general symptoms are much aggravated, except the fever, which indeed may be perceptible only at the beginning of the aifection ; the sore throat and catarrh may be severe, and attended with hoarseness and with inability to swallow J there are congestion of the conjunctivae and pain in the eyes. Osbom has called attention to enlargement of the small glands at the edge of the hair on the postero-lateral sides of the neck as a pathognomonic sign.f As tlje rash fades, the other * Edwards, article " Bubella," in Keating's Oycl. of Diseases of Children. t "Weekly Med. Eev., Dec. 24, 1887. 986 MEDICAL DIAGNOSIS. symptoms subside. Swelling and even suppuration of the cer- vical glands are not uncommon sequelae. The disease may be very difficult to distinguish from measles, except when it is epidemic and affects those who have already had measles. The more sudden onset, often almost feverless, the milder course of the complaint, and the peculiarities of the erup- tion already spoken of, are guides in separating individual cases. But the appearance of the rash may be ill defined and very misleading. The following table exhibits the differences between well-marked cases of rubella, measles, and scarlet fever : EUBKLLA. Premonitory symptoms often wanting, but frequent sore throat. If attack severe, there are loss of appetite and drowsiness for twenty-four hours be- fore eruption. ' Incubation from nine to twenty-one days ; usually eighteen days. Eruption is mostly the first noticeable symp- tom ; dots, rosy-red, with well - defined edges, first behind the ears, on scalp and face, around mouth ; extends to neck and chest; gradually cov- ers entire body. Dots become larger, coa- lesce, and form patches. Fauces look dry, with a dark mottled red hue ; little relation of appearance of fauces to extent of rash. Sore throat may dis- appear, to recur in last stages of the dis- ease. Measles. Premonitory symptoms common, such as las- situde, loss of appe- tite, headache, vom- iting, watery eyes, catarrh, cough. From seven to fourteen days. Appears on fourth day ; first behind ears, then on scalp and fore- head ; gradually spreads all over, face, body, and limbs, forming orescentic blotches. Eruption is papular in charac- ter and dark red in color; never bright rose-red. Fauces red and swollen throughout activity of the disease. Scarlet Peter. Premonitory symptoms ; usually feeling of lassi- tude for a few hours, fre- quently vomiting. If at- tack slight, patient feels tired, but complains only of sore throat. From a few hours to seven days ; rarely beyond five days. Diffuse, dusky red ; papu- lar ; just behind ears ; presents goose-flesh ap- pearance ; appears early about clavicles and on chest, and on covered parts of the body ; in- tensely hot to touch. Fauces vary in appearance from slight to intense dusky redness, with marked swelling, and sometimes with white spots of inspissated secre- tion ; intensity bears di- rect relation to skin- eruption. Sore throat throughout disease. FEVERS. ■987 EUBBLLA. Eyes pink-red and suf- fused. Lymphatic glands gen- erally enlarged, ten- der, hard, notably the posterior cervical, the axillar}', and the in- guinal. Catarrhal symptoms and cough wanting ; there may be a little flaky desquamation ; frequently none. Measles. Eyes red and watery ; photophobia. Not usually aflfected ; the posterior cervical rarely and slightly ; bronchial glands al- ways enlarged. Catarrhal symptoms and cough constant ; a little flaky shed- ding of the epitheli- um, varying accord- ing to the intensity of the rash. Kidneys rarely affected ; may be transient trace of albumin. Diarrhoea none. Patient, as a rule, does not feel ill. Tongue clean or slight- ly furred. Pulse normal or slightly accelerated ; main- tains ratio to tempera- ture. Temperature varies be- tween 103° and 104°. Duration short; a few days. Kidneys not affected. Diarrhoea frequent. Usually feels illness much. Tongue slightly furred. Usually accelerated ; maintains ratio to temperature. Temperature usually from 101° to 104°. Convalescence more protracted ; often pa- tient very weak. Scarlet Eever. Eyes unaffected. Lymphatic glands of throat and neck scarcely dis- cernible during first few days, but subsequently may be enlarged in pro- portion to the severity of the faucial affection. Catarrhal symptoms and cough absent, or slight throat cough, unless a pulmonary complication. Desquamation in propor- tion to the extent of the eruption ; continues for many weeks ; begins , as a peeling of the tongue, extending to lips, face, and ears ; free about hands and feet. Kidneys often implicated; albuminuria ; acute ne- phritis common. Diarrhoea not uncommon. In slight cases light ill- ness ; in severe cases grave illness. Coated with a thick, white fur, peeling off from the tip and edges on the fourth day, leaving the "strawberry" tongue. Pulse accelerated out of proportion to tempera- ture. Ranges from 99° to 106°; proportionate to rash, but not to pulse. Gradually subsides in from four to seven days ; des- quamation begins as eruption fades, and may continue for seven or eight weeks or more, lasting longest on hands and feet. 988 MEDICAL DIAGNOSIS, EUBELLA. Infectiveness lasts from ten to fourteen days if disinfection effi- cient. Sequelae few and not frequent ; glandular enlargements may follow. Usually complete re- covery in two weeks. Measlbs. Infectiveness does not last for more tlian from fourteen to twenty days, if disr infection efficient. Pneumonia, bronchitis, pleurisy, ophthalmia, otitis, etc. Usually complete re- covery in two weeks ; sometimes followed by prolonged period of ill health. Scarlet Fever. At onset only slightly in- fective; is very infective after first forty - eight hours ; infectiveness may continue for six or eight weeks or longer. Nephritis ; suppuration of submaxillary and' other lymphatic glands ; oti- tis ; arthritis ; endocar- ditis. Usually complete recovery ; sometimes prolonged convalescence from , se- quelae ; mortality high in the very young. Typhus fever, at least as regards the eruption, has some simi- larity to German measles. But the severe fever, the far greater gravity of the constitutional symptoms, the rash not appearing on the face, and the absence of catarrhal symptoms, render it strikingly unlike the latter affection. Rubella is contagious, and affects especially children ; it is extremely uncommon after forty years of age. Second attacks are also very rare. It does not protect from either scarlet fever or measles, nor do they from it. Smallpox, — Smallpox, or variola, attacks both children and adults. It is a highly contagious malady, spreading rapidly among those who are unprotected by vaccination, and among masses of men. The chief symptoms of the stage of invasion are chills, fever, and pain in the back. The fever runs very high, and exacerbates markedly toward evening. The pain in the back is severe, par- ticularly in grave cases ; it may be attended by pain in the limbs like those of rheumatism ; there are also nausea, vomiting, head- ache, and great restlessness. All these symptoms subside at the end of the third or on the fourth day, when an eruption shows itself on the lips and forehead, and soon extends to the trunk, and from the trunk to the extremities; and with the appear- ance and the spread of the eruption there is a very decided fall in temperature. FEVEES. 989 At first the eruption has the appearance of papulae ; but on the second and third days the coarse spots undergo a decided change. At the top of each papule appears a vesicle, \¥hich gradually becomes larger, and fills up with a milky, thick fluid ; in short, becomes a pustule. By the fifth or sixth day this change has been fully accomplished, and the pustules are spheroidal and lose the umbilicated look which they had while forming. On the eighth day matter begins to ooze from their edges, and a second- ary fever sets in, lasting for three or four days, — until, indeed, all the pustules are broken ; this secondary fever is sometimes ushered in by a chill ; it is of remittent type, and the evening temperature marks between 103° and 105°. By the time it subsides, crusts form where previously there had been pustules ; and as these crusts dry and fall off, the skin beneath is seen to be of a red color, which only very gradually fades, and here and there are noticed those scars and pits which the patient carries during the remainder of his life. Preceding the characteristic eruption in smallpox a red rash is at times noticed in the pubic and the inguinal regions, which is very significant.* When the pustules are in great abundance, they run together, constituting confluent smallpox. The eruption may be discovered a day earlier than in the discrete form, and the rough, i-ed blotches are often so thickly clustered as to give a uniformly red aspect to the whole surface. When the pustules completely fill up, whole portions of the face or of the trunk seem to be covered by one extensive pustule, which gradually dries into a continuous brown- ish and most disfiguring crust. While the process of maturation is going on, the features are observed to be greatly swollen ; the eyes may be hidden from view ; the nose and lips are tumid. The patient complains of the tension of the skin, and not infrequently of sore throat and of a steady flow of saliva from the mouth, — a symptom that may be also met with in measles. The secondary fever is violent, far more so than in discrete variola. It may not ■ appear until a day or two later, but lasts longer, shows a higher temperature, and is the period of danger, since it is at this time that death is most apt to happen. Death is sometimes pre- ceded by extraordinarily high temperature, 108° or upwards. * Pagge, Practice of Medicine, vol. i p. 223. 62 990 MEDICAL DIAGNOSIS. A fatal issue is often preceded by a dry tongue, by delirium, and by great restlessness ; by what, in fact, are called typhoid symp- toms. Sometimes death is occasioned by attacks of dysentery or of diarrhoea, by affections of the larynx or the trachea, by Fio. 85. iBIHIBWSBIHWIHRIHBIHIBilJiBiillMlKlHBIB imniiimiHr ■RlliiHIIIIIHL laiiiiniHDiii I ii I III IHIIIIH n a liHiini lillHil lliilliiil R ■ I Temperature in the seTere form of variola; death during the secondary fever. (After Wunderlioh.) acute endocarditis, or by plugging of a vessel in the brain ; * by some complication, therefore, which the worn and irritated frame is unable to withstand. A case of variola has been reported com- plicated, during convalescence, by convulsions, followed by left hemiplegia, in which after death an area of softening was found in * Quinquad, Arch. Gen. de Med., Sept. 1870. FEVEES. 991 the motor area of the right cerebral hemisphere, due to vascular oc- clusion.* Cases of variola have also been observed complicated by purulent peritonitis.f Now and then death takes place from super- vening pleurisy or pneumonia or bronchitis ; but an unfortunate termination from maladies of the respiratory' organs does not occur in the secondary fever only, as these affections are also en- countered during the period of eruption. Sometimes the patient sinks at the very onset of the disease. In these malignant cases, mostly met with at the beginning of an epidemic, he dies from the virulence of the poison. He is stupid, delirious ; the eruption seems, as it were, to struggle to reach the surface, is ill defined and of a livid hue, and may fail to appear until after death. Many of the malignant cases, too, are of the hemorrhagic type, marked by petechial blotches and ecchymoses, and profuse hemorrhages from mucous membranes. Bay J has found in the lymph obtained from a case of confluent smallpox, as well as from a large number of vaccine-points, non-motile bacilli with a long diameter of from 0.6 to 1 /i and a short diameter of from 0.2 to 0.3 fi, which he believes to be the specific cause of both variola and vaccinia. Smallpox is occasionally met with during the progress of other disorders, blending its symptoms with those of the com- plaint to which it becomes superadded. It is thus found as an intercurrent affection in typhoid fever, in typhus, in scarlet fever, and in measles ; yet even then there is no difficulty in recognizing its peculiar traits, — its lumbar pain and characteristic eruption. Ordinarily the detection of variola is extremely easy, except at its onset. But the points of similarity it may present, in its early stages, to typhus fever, to erysipelas, and to several other diseases, have been already discussed, and need not be repeated ; we have often to wait the course of the eruption before framing a positive diagnosis from the symptoms alone, and without taking into account the epidemic influences prevailing. When the disorder is fully developed, all difficulty in its diagnosis ceases. Let us here look at the marks of distinction between it and the other principal eruptive fevers, premising the statement that in the period of inva- sion the pain in the loins is the most significant differential sign. * Davezac and Delmas, Journal de Medeoine de Bordeaux, 1893, No. 38, p. 421. ■)- Auche, Bulletin Medical, Jan. 25, 1893. J Medical News, Jan. 26, 1895, p. 92. 992 MEDICAL DIAGNOSIS. Table exhibiting the Differences between Scarlbt Fever, Measles, and Smallpox. Scarlet Peter. Period of incubation generally a week or less. Fever, with very fre- quent pulse ; persists unabated during erup- tion. Eruption on second day, first on neck and chest ; spreads rapidly. Eruption uniform or in large patches of scarlet hue, with interspersed raised spots and some vesicles ; rash, followed, after the seventh day from its appearance, by complete desquama- tion. Sore throat; rarely co- ryza or bronchitis. Ked "strawberry" tongue. Cerebral symptoms fre- quent and grave. Temperature very high ; may range from 105° to 110° ; no fall soon after eruption, nor de- cided increase of heat preceding it ; high temperature during height of eruption ; subsequently gradual decline. In protracted cases, a fall of tempera- ture takes place on the Measles. Period of incubation generally from seven to fourteen days. Fever, with moderate frequency of pulse ; not relieved, but rather increased, by eruption. Eruption on fourth day, first on face; spreads gradually, in course of about forty-eight hours, to rest of body. Eruption in crescentic patches, with inter- vening portions of healthy skin ; lasts about five days ; fol- lowed by partial and very incomplete des- quamation ; scales, as a rule, very fine. Coryza and bronchitis very constant ; rarely sore throat. Tongue coated; may be red at edges. Cerebral symptoms neither frequent nor grave. Temperature during the fever preceding erup- tion rarely over from 102° to 103° ; falls on second day, rises rap- idly toward breaking out of the eruption, and remains high dur- ing its appearance and spread ; then sinks speedily. The defer- vescence that takes Smallpox. Period of incubation generally about twelve days. Fever, with hounding pulse, and pain in the loins ; great relief from occurrence of eruption. Eruption at end of third or on fourth day ; first on lips and forehead; a preceding red erup- tion on arms, in pubic and inguinal regions. Eruption first papular; remains so about a day ; then becomes vesicular, then pustu- lar ; on the eighth day of eruption, pustules maturate. Often sore throat and dry cough ; bronchitis only as a complication. Tongue coated and swol- len ; may become red at edges. Cerebral symptoms, es- pecially convulsions in children, frequent. Temperature during the fever preceding erup- tion very high, often 106° ; then decided defervescence, taking place within thirty-six hours ; subsequently thermometer indica- ting a temperature of about 100°, notwith- standing the progress- ing development of FEVERS. 993 Table exhibiting the Dipperencbs between Scarlet Peter, Measles, and Smallpox. — Contiimed. Scarlet Peter. fifth, tenth, and fif- teenth days of the dis- ease.* Irregular cases have irregular, though mostly very high, tem- peratures. No secondary fever. Pneumonia rare; pleu- risy more frequent. Sequelae : Bright's dis- ease ; dropsy ; con- junctivitis ; deafness ; phthisis ; chronic diar- rhoea ; glandular en- largements; epilepsy. Measles. place, generally with- in from twenty-four to forty-eight houre, is hoth rapid and com- plete. A protracted defervescence indicates a severe case ; a high temperature after the rash has faded is due to a complication. No secondary fever j although sometimes a slight increase of fever just before erup- tion leaves. Pneumonia a very fre- quent complication. Sequelae: chronic bron- chitis I phthisis ; con- junctivitis. Smallpox. the pimples into pus- tules. Decided rise of temperature during secondary fever, and then gradual and pro- tracted defervescence ; a slight rise during desiccation. Always secondary fever. Pneumonia not a very frequent complication. Sequels : chronic diar- rhea ; glandular en- largements ; various diseases of the eyeball and eyelids. The contagion of smallpox does not always manifest itself by an attack of variola. Sometimes it is modified by happening in a person who is partially protected by vaccination. This varioloid disease is mild and very rarely fatal ; it protects against smallpox. It is distinguished from variola by the pustules passing more quickly through all their stages, and, above all, by an absence of secondary fever. Soon after the eruption — within thirty-six hours — the thermometer shows freedom from fever, and, unless serious complications happen, the temperature remains nearly normal. The suppuration is far less deep ; and the resulting cicatrices are often scarcely discernible. Varicella. — A specific disorder similar to but not identical with variola or varioloid is chicken-pox, or varicella. It diifers, as regards its symptoms, from smallpox in the leniency of the intro- * Kinger. 994 MEDICAL DIAGNOSIS. Fig. 86. iDDDDiaaDaaaaii HMHIIIi WFmnn mil diictory fever ; in the eruption beginning generally first on the trunk, occurring often on the second day, though it may not show itself until the end of the third, and continuing to appear and disappear in crops, the mass of the eruption, however, having become evident Avithin twenty-four hours ; in the vesicles being sur- rounded by little or no inflamma- tory redness; in their remaining vesicles and not becoming pus- tules; in their attaining their height on the third or fourth day of the eruption, and then burst- ing and shrivelling without pre- senting depressions at their apices, and in the crust which falls off about five days subsequently being followed by a smooth, shining, round, and irregular pit. Then the eruption is rarely prominent on the face ; and the disease does not protect, as mild forms of smallpox do, from a subsequent attack of variola. Sometimes the vesicles may be found, as are the pustules of smallpox, on the roof of the mouth and at the back of the throat. But, although they may be everywhere very plentiful, the disorder is not a grave one. Still, I have known it in one instance to terminate fatally. Spivak* has de- scribed a case of gangrene of the scrotum that followed varicella. Dengue. — This is an arthritic fever with a cutaneous erup- tion. It has been prevalent in the form of epidemics chiefly in India, and in the West Indies, as well as in Virginia, South Caro- Temperature-record in varioloid ending in recovery ; the absence of secondary fever is clearly seen. (After Wunderlicb.) * Medical News, Marcli, 1895. FEVERS. 995 lina, Texas, and other of the Southern States. We owe some of its best descriptions to Dickson. It usually begins with pain, stiffness, and swelling of some of the smaller joints, or with severe muscular pains, aching in the back, and stiffness of the muscles of the neck. Fever follows, with suffusion of the eyes, violent headache, hurried breathing, and coated tongue ; but, as a rule, without nausea and vomiting. The temperature usually attains its height within the first twenty- four hours, and then shows during defervescence marked remis- sions and exacerbations. On the third day the fever ceases altogether, or subsides markedly, though the muscular and ar- thritic pains do not pass off entirely. The febrile paroxysm may last somewhat longer, indeed, five to seven days, or only six to twelve hours. In any case it is apt to be succeeded by an interval of two to four days free from absolute suffering, though not from great debility. Then the pain returns, and with it a moderate fever ; nausea and vomiting and a thickly-coated tongue, too, are noticed. This new phase of the complaint is generally relieved by the appearance of an eruption, which may be accompanied by a slight rise in temperature. The eruption shows itself on the fifth, sixth, or seventh day of the malady, and, therefore, very much later than the rash of scarlatina, which it resembles in hue and aspect. But not invariably ; for it may occur in patches and be papular, or even vesicular or like urticaria. The erup- tion is attended with a sense of burning and of itching, and disappears after two or three days' duration, with more or less decided desquamation. It is much more pronounced than the slight and inconstant erythematous rash of the period of invasion, which disappears ^vithout desquamation with the febrile stage. With the occurrence of desquamation following the marked rash of the third period of the disease convalescence sets in, marked by considerable muscular weakness and general depres- sion, and frequently Avith the i-heumatic stiffness or soreness per- sisting for some time. Swellings of the lymphatic glands of the neck, axilla, and groin occur in many instances, and may continue during convalescence, which in any case is apt to be prolonged, and may be interrupted by a relapse. The cause of this singular malady — the breakbone fever of 996 MEDICAL DIAGNOSIS. parts of our country — is unknown. McLaughlin * has invaria- bly found in the blood micrococci in great numbers, about one- twentieth to one-thirtieth the diameter of the red corpuscles, of spherical shape, and red or purplish in color. Dengue is generally a harmless disorder, epidemic, and con- tagious. Isolated cases are difficult of diagnosis, but when the disease largely prevails its recognition is easy. It differs from rheumatism or gout by the significant features of the fever and the eruption ; from scarlet fever, by the different character and want of continuousness of the fever, and the arthritic symptoms ; from influenza by these and the eruption. The remission may cause the disease to be mistaken for a malarial fever ; but the irregularity of the fever in dengue, the joint and muscle pains, and the absence of hepatic and splenic enlargement are very unlike. Dengue has a closer resemblance to yellow fever, and the difficulty of distinction becomes the greater because epidemics of both may be present side by side. But the single paroxysm, the tongue with red edges, the yellow skin, the frequent vomiting, the hemorrhage, the grave nervous symptoms, and the albuminous urine are not met with in dengue. Erysipelas. — This disease, as the physician sees it, is mostly confined to the head and face. It may or may not be found to have been preceded by a scratch or an abrasion. It is an eruptive fever beginning with a chill. Soon a portion of the face is no- ticed to be red and hot. The redness spreads, a clearly-defined edge marking its onward march ; and generally it does not stop until it has occupied the whole of the face and a considerable portion of the scalp. The features are then so tumefied as to be hardly recognizable. The patient is very restless, has high fever, and not unfrequently enlargement of the glands at the angle of the jaw, and sore throat. By the seventh or eighth day the dis- ease is over, and large patches of cuticle fall from the countenance no longer swollen and disfigured. The temperature remains high for a few days, with marked evening exacerbations and morning remissions, and then falls, not to rise again to any con- siderable height. This is simple erysipelas ; but the affection may extend — as is, * Joum. Amer. Med. Assoc, June 19, 1886. FEVERS. 997 in truth, its tendency — from the true skin to the subcutaneous areolar tissue, and give rise there to collections of pus, which reveal their presence by chills and an obscure sense of fluctuation. Fig. 87. F 105° S. 1 < T - l-=r -r -J < TF 5^ Z 1 s- 5r i: < nr ^ i ± J 2. T 'S: k^ - 1 5?^ s S J is- p4l' ^ iJ - ^ ■s 1 <■ uT 3 0. IS- 5r — - - - — ~ - — _ _ _ _ - _ _ _ _ _ _ _ _ _ _ _ _ 104° 103° 102° 101° 100° 99° 9S° 97° DAY OF DISEASE PULSE RESP. DATE, SEPT. — — — — — ~ — — — — — — ~ — — — — P — — — — — ' — - — — 1 _ -3^ -38" -37" -36" ",% 100 1U 114 126 102 96 106 106 10B 130 '%0 %. 102 'U %%, 100 90 100 ^^. ^%, BEgj "» •°s, 30- 28 =",0 '»,. SB "2B ^^2* "2* ".7 "26 24 24 '^25 '\o 23 26 ''*24 "27 ".5 "« ".! "„ l-SS 11 12 13 14 -11 16 [Ai TemperHture-cliart in a case of facial eryBipelas, seen soon after outbreak of the disease. and keep up an irritative fever until they are discharged. Irre- spective of this, the tumefaction, while the complaint is at its height, is much greater in this phlegmonous Variety of the malady, and there is more constitutional disturbance ; but, on the other hand, there is not so much local irritation, for the morbid action travels less rapidly, and often remains more circumscribed. In some cases the inflammation extends to the brain, and instead of wandering at night, always a very common symptom, we have violent delirium, soon succeeded by coma and rapid sinking. In other cases, again, and they are by far the most frequent, we may find these active cerebral symptoms and yet not be able to detect, after death, signs of inflammation of the brain or its membranes. Now and then the disorder passes to the throat, reaches the larynx and bronchial tubes, and places life in imminent peril from oedema of the glottis, or from a hazardous form of capillary bronchitis. In some instances a highly-asthenic state becomes developed, and 998 MEDICAL DIAGNOSIS. the patient dies exhausted. The disease often manifests a distinct tendency to recur. The contagious principle of erysipelas is the streptocoecvs erysipelatis, also called after Fehleisen, who has specially described it. Internal lesions happen not unfrequently in erysipelas. I have found the urine albuminous in the great majority of instances.* Heart-murmurs are not unusual, and are said to depend upon endocarditis, which is doubtful. Friedreichf speaks of swelling of the spleen being of common occurrence both in erysipelas and in diphtheria. The diagnosis of erysipelas is not beset with dilEculties. Ery- thema resembles it very closely ; but there is this manifest differ- ence : in erythema there is scarcely any swelling, not much ten- dency to spread, and almost no constitutional disturbance. The ordinary exanthematous fevers may, at an eai'ly stage, be mistaken for erysipelas. But all of them, even scaiiatina, have a longer period of febrile invasion ; in all, too, although the eruption takes its origin at one spot, and generally on the face, it is not lim- ited there. The thickly-clustered blotches of beginning confluent smallpox and the swelling attending them give at times to the face the look of erysipelas. But here, also, evidences can be found of a rash about to appear all over the body ; and should doubt still exist, it is soon dispelled by the progress of the eruption. Some- times vesicles and even irregular pustules form in erysipelas, and occasion some misgivings as to whether the malady be not a chronic disease of the skin, such as eczema, pemphigus, or impe- tigo ; but these affections lack the constitutional symptoms and the history of a recent acute disease, and in reality the likeness is not a very striking one, if the inflamed surface be carefully examined. The closest similarity is to herpes zoster of the forehead and face. But the eruption in this does not pass the middle line.J The red color of the skin and the attending symptoms distinguish erysipelas from the swelling of angeio^newotic oedema. Erysipelas may break out in one part of the body after an- other, and the disease be thus kept up for a long period. This * On the Internal Complications of Acute Erysipelas, Amer. Journ. Med. Soi., Oct. 1877. t Klinische Vortrage, No. 75, 1874. % I'agge, Practice of Medicine, vol i. p. 271. FEVEES. 999 erysipelas migrans runs its course more rapidly and more com- pletely in one part than in another, and in accordance with a general law which it obeys.* Erysipelas may be confounded with mumps. This does not seem at first sight likely; but I have known the error to be com- mitted. It was mainly caused by too much stress being laid on the redness which is frequently found beneath one or both ears in parotitis, but which, unlike erysipelas, is attended with much pain on moving the jaw, and with decided glandular tumefaction. The redness, moreover, shows no tendency to spread, and rarely con- tinues for the four or five days during which mumps lasts. In very young children, however, there may be some difficulty in diagnosis. I have seen the glands at the angle of the jaw much swollen for one or two days prior to the slight discoloration over them taking on a deeper blush, and then spreading rapidly as marked erysipelas over the whole face and part of the scalp, reach- ing the other jaw, where subsequently the glands began to swell. In such cases great weight must be attached to the history of the ease, to determine which disorder was primary, and whether the glandular complaint was or was not the complication. A fever with a distinct pharyngitis as a local manifestation, the so-called pharyngeal fever, is probably an epidemic erysipelatous fever of light type. It has been particularly described by Austin Flint, Eochester,t and Harvey E. Brown. J The fever lasts from three to six days, and, besides the marked pharyngitis, is ordi- narily attended with swelling of the lymphatic glands of the neck, accompanied by pain. The disease shows a certain proportion of cases with erysipelas of the face, and is thought to be a mild form of the fever, known popularly as the " black tongue," which pre- vailed in this country from 1841 to 1846, and in about one-sixth of the cases of which erysipelas happened. § * Traced by Pfliiger in 70 cases ; quoted in Schmidt's Jahrb., No. 7, 1873. f Buffalo Medical Journal, 1857. J Flint's Principles and Practice of Medicine. I Ibid. CHAPTER XIII. DISEASES OF THE SKIN. To facilitate the discrimination of diseases of the skin, they have been grouped into classed. These have been arranged by some in accordance with the obvious characters of the eruption, by others in accordance with its presupposed cause and attending structural alteration. An extensively-used system of classification takes for its basis the anatomical seat and arrangement of the cuta- neous malady : it is that of Hebra. As developed by him, it is, however, not a purely anatomical, but a mixed system, resting largely on a pathological basis. Similar is the classification of the American Dermatological Association, now much followed. All diseases of the skin are arranged in eight classes : Disorders of the Glands, sweat and sebaceous ; Inflammations ; Hemorrhages ; Hypertrophies, of pigment, epidermal, and papillary layers, and of connective tissue ; Atrophies, of pigment, hair, nail, and cutis ; New Growths, of connective tissue, vessels, and granulation-tis- sue; Neuroses; and Parasitic Aifections, vegetable and animal. Whatever classification we adopt, when a disease of the skin is presented for examination we generally first endeavor to ascertain the group it belongs to ; for instance, is it macular, papular, vesic- ular, or pustular, or does it present lesions representing more than one group ? Having determined this, we next fix which member of the group it is, and then regard its precise seat and its pathological causation. When this has been accomplished, we inquire into the history of the affection and its duration, whether acute or chronic ; take into account the presence or absence of fever, and the general condition of the patient ; search for the evidences of a cachexia or of some visceral disturbance, — a study the importance of which is as great as that of the recognition of the cutaneous malady ; and trace, so far as possible, the cause of the disorder. In many instances microscopical and bacteriologi- 1000 DISEASES OF THE SKIN. 1001 cal examination will be necessary to supplement the clinical evidence and complete the diagnosis. Having done all this, we have a groundwork upon which to institute suitable treatment. Here is a table in which cutaneous affections, omitting some of the less important ones, are grouped according to their most obvious features, as well as according to their pathological bearings : Diseases of the Skin. Erythematous Diseases.. Inplammatoby. Papitlae Diseases., Vesicular Diseases. Bullous Diseases < Pustular Diseases. Squamous Diseases., Macule ; Pigmentary Changes., Hypertrophies of Special Textures.. Initial rashes of eruptive fevers. Erythema. Eoseola. Urticaria. Papular eczema. Lichen. Prurigo. Eczema. Herpes. Dermatitis herpetiformis. Pemphigus. Hydroa. f Acne. Boils, or Furuncle. Sycosis non-parasitica. Impetigo. Ecthyma. Bupia. Glanders. Psoriasis. Pityriasis. Ichthyosis. Squamous eczema. Melasma. Ephelides. Vitiligo. Chloasmata. Nsevi. Purpura simplex. Xanthoma, or Xanthe- lasma. Elephantiasis Arabum. Scleroderma. Keloid. Dermatolysis. Warts, Corns, etc. 1002 MEDICAL DIAGNOSIS. Atrophies.. Parasitic Diseases., New Growths., Diseases of the Skin. — Continued. f As of the Hair ; the Nails, \ Senile Atrophy. Scabies. Phtheiriasis. Pavus. Anthrax. Tuberculosis. Molluscum epitheliale. Lepra. Mycetoma. Actinomycosis. Tinea sycosis, or Men- tagra. Tinea circinata. Tinea tonsurans. Tinea decalvans. Tinea -versicolor, etc. Cancer. Sarcoma. Molluscum fibrosum. Lupus. Leprosy, etc. r Seborrhoea. \ Comedo. I Sebaceous cyst. Hyperidrosis. Anidrosis. Chromidrosis. Bromidrosis. Miliaria, etc. ■ Hypersesthesia. Ansesthesia. Pruritus. Neuroma. Dermatitis herpetiformis. Herpes Zoster. Peliosis rheumatica. Plica Polonica. Alopecia areata. CoNSTiTiTTioifAL Skin Aefbctions , / Syphilodermata. t. Scrofulodermata, etc. Altered Gland-Secretion-.. ■ of Sebaceous Glands of Sweat- Glands. . Nektous Affections.. Most diseases of the skin are again subdivided into several varieties, based, for the most part, on their duration, situation, form, feel, and color. Thus, we have constantly recurring the DISEASES OF THE SKIN. 1003 terms fugax, inveterata, capitis, facialis, palmaris ; guttata, when like a drop on the skin ; nummularis, when lilie a coin ; larvalis, like a mask; the qualifying words Iseve, induratum; cir- cinatum, annulatum, marginatum, indicating configuration, and the adjectives of color, nigrum, rubrum, versicolor. But these divisions are all of secondary importance ; and in this outline not much regard will be paid to them. Premising this statement, let us briefly examine the characteristics of the various cutaneous affections of more common form, beginning with those of inflam- matory origin. Erythematous Diseases. — There are only three affections which, strictly speaking, come under this division of cutaneous complaints : erythema, roseola, and urticaria. In all of these the skin is more or less red, and its surface unbroken ; the hypersemia affects chiefly the papillary layer. Erythema. — This is characterized by a uniform and continuous redness of the skin, occurring in irregular patches of some size, attended with some burning, and with but slight swelling, if with any, and disappearing without desquamation or mark or scar. The eruption is chiefly found on the back of the hands, the forearms, the legs, and the face and neck ; rarely on the trunk. There is little or no itching. The affection may be due to the action of heat or cold, or of irritants ; or it may be connected with some visceral abdominal disorder. It is usually acute. There is only one variety apt to be combined with decided con- stitutional or febrile symptoms, — the hard, painful, reddish pro- tuberances most commonly seen on the legs, and constituting the so-called " erythema nodosum." This form of the complaint, in which there is a serous effusion into or under the skin, is chiefly observed in those of rheumatic diathesis, and, unlike the simple erythema and the erythema intertrigo, which are looked upon as mere hypersemias, is classed with the exudations or inflammations. All the exudative forms of erythema may be grouped under the title of erythema multiforme, the varieties of which are the papu- lar, bullous, and nodose, the lesions appearing principally on the backs of the hands and feet. There is a desquamative form of erythema resembling scarlet fever, attended with fever of a few days' duration, with epistaxis, and showing an extraordinary tendency to relapse. The erup- 1004 MEDICAL DIAGNOSIS. tion is uniform and intensely red, and there is no sore throat, or there is mere redness of the fauces. Erythema solare, or super- ficial dermatitis following exposure to the sun's rays, is usually followed by free desquamation. A chronic form of erythema results from pressure, or the rub- bing together of folds of skin, the erythema intertrigo ; a slight discharge may coat the rubbed surface. It is liable to acute ex- acerbations. Roseola. — This term is applied to circumscribed spots of a rose-red color and of a more or less circular form. The spots are smaller than those of erythema simplex.. In erythema eonges- tivum, or roseola, there is slight fever, and at times redness of the fauces. The aifection often exists in connection with a derange- ment of the stomach, or with rheumatism, is frequent in summer and in autumn, is generally acute, and bears a certain resem- blance to scarlatina and to measles ; but it is not contagious, its constitutional symptoms are much milder, the rash is rosy, not crescentic, nor present over the whole body, and we find neither the marked sore throat of scarlet fever nor the catarrh of measles. A roserash occurs in the course of typhoid fever, and there is also a syphilitic form. Urticaria. — Nettle-rash gives rise to prominent and perfectly smooth patches, the color of which is either redder or whiter than the surrounding skin ; the white wheals may be sur- rounded by a red border. The wheals are generally small, but they may be of the size of the palm. The eruption is fugitive and capricious, is attended with more itching, burning, and tingling than the other exanthemata, and is much more evan- escent, generally disappearing in two days at furthest. It may, however, exist in a chronic form, the wheals coming out in con- stant succession, especially after scratching or other irritation of the surface. Pigmentation occurs in the variety known as urti- caria pigmentosa. The cause of urticaria is irritation of the gastro-intestinal, pul- monary, or urinary mucous membrane. Certain kinds of fish, especially shell-fish, are particularly prone to produce it ; so do mushrooms and strawberries. At times it is due to menstrual disorders, or to sudden mental emotion, or to the excessive use of mineral waters, or to antipyrin. It may be secondary to the DISEASES OF THE SKIN. 1005 itch, or to phtheiriasis. It occurs in cerebro- spinal fever, and is common in dengue, especially in children.* Urticaria is thought generally to be an exudative disease of the skin ; yet it seems most probable that it is a reflex phenomenon, caused chiefly by reflected irritation to the cutaneous vaso-motor nerves. Urticaria resembles erythema nodosum ; but there is no itching in the latter affection, which is chiefly found in the lower limbs, and the swellings change like bruises. Papular Diseases. — A papule, or pimple, is a small elevation of the cuticle with an inflamed base ; it does not contain fluid, and usually terminates in desquamation. It results from a small amount of lymph or a newly-formed growth in the derm itself. Lichen. — This furnishes the best-marked example of a papular eruption. It consists of minute conical papulae, generally of red- dish color, and occurring in clusters. It is most frequently en- countered in the summer months and in adults, and often in persons who are in good health but who have been exposed to much fatigue or anxiety. Sometimes it is evidently connected with disordered digestion. It is commonly chronic. There is often a mixture of papulse with an eczematous eruption. Prickly heat, or lichen tropicus, frequently exhibits also sudamina, and is called by some " miliaria papulosa." In the lichen ruber of Hebra the red papules are of the size of the head of a pin ; they spread by peripheral growth, are flat, irregular, and have a glazed look and very slight scales ; there is considerable itching. The disease, which is an inflammatory one, is chronic ; its common site is on the forearm. It resembles psoriasis, but at the edge of the patch are the characteristic papules. Poor nutrition and nervous exhaustion are its main causes. In the lichen serofulosorum the eruption consists of little pale papules, which are chiefly found on the trunk. There is no itching ; but we find marked signs of scrofula. The lesions of lichen planus are small, hard, red papules, that may be umbilicated and coalesce into patches. In the latter case scaling occurs, and more or less itching is a frequent accompaniment. The smallness of the recent lesions, which are * J. C. "Wilson, Treatise on the Continued Fevers, 1881. 63 1006 MEDICAL DIAGNOSIS. at first of the same color as the surroundiug slcin, the flat glazed tops of the older papules, the pure white color of the silvery scales, which are not heaped up, and the unsymmetrical character and distribution of the patches, none of which are circular, will serve to distinguish this from psoriasis. Papular eczema has its lesions in groups upon an inflamed base, and vesiculation and desquamation are apt to occur. Prurigo. — This is characterized by a papular affection of the skin attended with excessive itching. It is a very rare disease in this country.* The pimples are generally torn by the finger- nails, and are surmounted by black scabs. They are not red, as those of lichen usually are, and are, as a rule, larger, and accom- panied by much more pruritus and by thickening of the skin. The affection, which is uncommon, may or may not be attended with , constitutional symptoms. It is very obstinate, especially when happening in old persons. It generally affects the legs, the arms, and the trunk, rarely the face and the neck, never the palms and the soles. The skin of the anterior and outer part of the leg is most changed ; that over the flexors in the forearm is always healthy. The distressing disorder may be purely local, occurring around the anus, or on the scrotum and the root of the penis, or on the pudenda. Some of these cases, however, though called prurigo, present no papulae, and the disorder is due to perverted sensibility of the cutaneous nerves alone, and is really a pruritus. Prurigo is often attended with eczema, and may follow urticaria, especially of the chronic variety. A good many supposed instances of the malady are not really prurigo, but phtheiriasis, due to the irritation of body-lice, that produce papules, whose apices are scratched off and show little points of dried blood. True prurigo is frequently found to be connected with deterioration of the health, and is chiefly met with among the poor and the neglected. It may last a lifetime, begin- ning in childhood. Its local forms are associated with irritation of the bladder, the rectum, or the uterus. Papules and tubercles, or large papules, occur in I he later stages of syphilis ; they are often preceded by the pigmented e'rythematous syphiloderm. Gumma is a tertiary manifestation. * Only 31 cases in 123,746 of skin-disease : VanHarlingen on Skin-Diseases, DISEASES OF THE SKIN. 1007 mostly appearing in the subcutaneous or submucous connective tissue without inflammation, irritation, or itching, gradually in- volving the tissues above and below, the lesions ultimately attain- ing a considerable size. At iirst the color of the skin is not changed, but ultimately it becomes deeply congested and glazed, and as the contents of the lesion soften, the overlying skin is thinned, and finally it breaks down, discharging the purulent material. Vesicular Diseases. — These are characterized by an effusion of a clear or a sero-purulent fluid beneath the epidermis, which is generally raised in small elevations. To the class of vesicular diseases belong especially eczema and herpes. Eczema. — The malady consists of minute vesicles collected together in irregular patches. The vesicles are often confluent, and it then appears as if the whole surface were secreting fluid. This may harden, from exposure to the air, in scabs of various thickness and color. The skin itself is often of a vividly red hue ; indeed, it is inflamed, and a new cell-growth takes place both in the rete mucosum and in the papillary layer of the derm. It is there that the effusion of serum begins. In chronic cases the inflammatory infiltration extends deeper into the skin. Eczema is the most common of all the cutaneous maladies ; but it is not contagious. It may affect the whole body, yet is ordi- narily limited to some portion of it. It is acute or chronic. The former is generally seen as the effect of local irritants, and may be met with in young and healthy persons. Chronic eczema is more usual, is often the consequence of constitutional disturbance, and is frequently found to be associated with some disorder of the digestive system. It has as a frequent seat the flexor surfaces of the limbs. Dentition and unhealthy milk are common sources of the affection in very young children. In them the disease is extremely apt to attack the scalp and face, forming the complaint often described as " crusta lactea ;" or, if the secretion be partly purulent, or early become so, and dry into large, dark scabs, the malady is designated as eczema impetiginodes. This is most often met with in scrofulous subjects. There is less heat and itching than in other forms of eczema. In some of the forms of eczema, especially in its chronic varie- ties, the vesicles supposed to characterize the disorder can often 1008 MEDICAL DIAGNOSIS. not be found. This and other reasons have caused several derma- tologists, especially Hebra and Anderson, to deny that eczema need be vesicular at all. Infiltration of the skin, exudation on its surface, the formation of crusts, and itching, are held to be its distinctive signs while the eruption is at its height ; but the erup- tion may consist of clusters of papules, vesicles, or pustules, or there may not be a vestige of any of these, the skin being thick- ened, red, and smooth and secreting a sticky discharge, or covered with green or gummy crusts, or fissured with deep cracks ; yet there are no ulcerations. Not unfrequently the disorder begins as an erythema. A scaly form of eczema, eczema squamosum, is apt to be confined to the hands and feet. In all the forms of eczema, as Hebra insists upon, there is severe itching. This itching is especially violent in the form with the deep-red and weeping surface, named eczema ruhrum. It is in this variety that we find the signs of local inflammation very marked, and we often see it in gouty or in dyspeptic subjects. It has a predi- lection for the flexures of the joints. Eczema, especially when it affects the scalp and face, must not be confounded with the morbid secretion from the sebaceous follicles that gives rise to soft crusts. Seborrhoea by preference attacks the parts mentioned ; but its crusts, as Hardy has shown, are unlike those of eczema in the readiness with which they are detached, and are susceptible of being moulded between the fingers. The surface beneath the crusts, too, is dissimilar. It has an oily, glistening look ; there is no discharge. Uuna* has distinguished a seborrhceic form of eczema, which, beginning usually cm the scalp, spreads to other portions of the cutaneous surface ; but he attributes the source of the fatty scales and crusts to disorder of the sudoriparous, rather than to the sebaceous glands. Patches of seborrhceic eczema are also found on the sternal region, which, after the scalp, is the most frequent locality to be affected. The scales are yellowish in color, the patches spreading by small pap- ules at the border, leaving the centre less scaly and even smooth, while the margin is a red, scale-covered, bow-formed wall. Eczema may be confounded with pityriasis rubra. But this very rare disease speedily involves the whole surface of the body, * Journal of Cutaneous and Grenito-Urinary Diseases, 1887. DISEASES OP THE SKIN. 1009 is very chronic, and is not accompanied by discharge ; and there are large, thin epidermic scales. Herpes. — Like eczema, herpes is classed as a vesicular affection, although it diffei's from the obviously vesicular form of eczema by the larger size of the vesicles. These are generally of a glob- ular form, and are symmetrically arranged in clusters upon an inflamed patch of skin. Each vesicle is distinct, and remains so throughout its course. It lasts about eight to twelve days, and often terminates by the formation of a thin incrustation. The eruption is attended with burning, and in the acute variety with some fever. Herpes has seldom a longer duration than three weeks ; though it may be a chronic disease. It happens usually in persons of delicate skin ; is generally very local, having its seat on the lips, eyelids, prepuce, or pudenda ; and is very often associated with an internal disease, especially with irritation of some portion of the gastro-pulmonary mucous membrane. Herpes labialis mostly appears at the decline or termination of fevers ; sometimes at the height of acute maladies, as in pneumonia. Herpes gestationis, or the herpes of pregnancy, is identical with dermatitis herpeti- formis of Duhring. The most distressing form of herpes is that usually extending around one-half of the trunk, — herpes zoster, an acute disorder, which may show itself over the course of any of the superficial nerves, and is attended by nerve-pain. Indeed, herpetic or bullous eruptions often happen over the course of the nerves, and any nerve-lesion the result of disease or of an injury will produce them ; the vesicles are seated upon a highly -inflamed base. In herpes zoster around the chest, the severe pain pre- ceding the eruption is often mistaken for pleurisy, but inspection of the surface and palpation will reveal local spots of tenderness along the course of the affected intercostal nerve. Herpes and eczema may both be confounded with scabies, which, like them, occasions a vesicular eruption that is apt to be found on the inner surface of the limbs and flexures of the joints. The distinction consists in the more severe itching, especially at night ; in the small conical vesicles, torn, as they usually are, by scratching ; and in the presence of the acarus, which may be removed from its burrow with the point of a needle or of any sharp instrument. 1010 MEDICAL DIAGNOSIS. Bullous Diseases. — Bullse differ from vesicles only in their size. The typical bullous disease is pemphigus. This affection is not often met with ; it is more common in children than in adults. It appears in very large vesicles or bullae surrounded by a slight zone of erythematous redness. The blebs occur in crops, and look like small blisters filled with serum. They are not met with on the scalp. Where there are few bullse, we generally find them on the ankle or on the hand. The disorder may be acute or chronic. It is ordinarily chronic, and happens in persons of enfeebled con- stitution. Eelapses are frequent, and a fatal result is common. Pemphigus may be produced by the administration of iodide of potassium,* or by syphilis. Syphilitic pemphigus is mainly met with on the soles of the feet and the palms of the hands of newly- born syphilitic children. There is a form of extensive pemphigus with flaky incrustations like eczema, — pemphigus foliaceus; but we can still find bullse, and there is great attending prostration. Neurotic vesicular erythema occurs after injury to a nerve, and sometimes causes blebs which may be mistaken for herpes or pem- phigus, as in a case reported by Shields,! in which recurrent attacks of vesicular (or bullous) erythema were observed in the forearm, following the crush of a finger. The symptoms were en- tirely obviated by amputation of the stump of the finger, after the affection had existed for a period of three years. jHi/c^roa.— This is a disease like herpes, only occurring in a more diffused manner and presenting larger vesicles, arranged for the most part in the form of crescentic rings. It is a chronic condi- tion, lasting usually from five to eight months, and there are in this period many acute or subacute outbreaks, in which the large vesicles form and then dry away. These attacks are non-febrile, and are attended with marked itching. The base of the vesicle is red, and it forms out of a red papule. The disorder happens chiefly in persons of depressed nervous system or gouty taint. It has been confounded with the eruption of bullse from iodide of potassium ; but these are much larger, are more persistent, and leave a marked scar. Van Harlingen considers cases of hydroa to be examples either of erythema iris or of dermatitis herpetiformis. * Bumstead, Amer. Journ. Med. Sci., July, 1872. f The Cincinnati Lancet-Clinic, May 25, 1895. DISEASES OF THE SKIN. 1011 Pustular Diseases. — These are marked by circumscribed elevations of the cuticle which contain pus. Acne, impetigo, and ecthyma belong to this group. Rupia, too, although often classed among the bullous disorders, appertains more strictly to the pus- tular or to the syphilides. Acne. — This is an eruption of hard, isolated, red elevations, due to chronic inflammation of the sebaceous follicles and the areolar tissue around them ; plugs of sebum are retained in the ducts. At the apices of many of these elevations pUs forms, which is discharged, leaving a hardened base, that only gradually disappears. Acne is generally seen on the face and shoulders. Men of sedentary occupations and drunkards are very liable to it. In women it is frequently associated with uterine disturbances ; in men, with some digestive or genito- urinary disorder. An acne eruption also follows the use of the bromides and the iodides internally, and the local use of tar. In acne rosacea, lymph is generally effused into the papillary layer of the skin, and some acne pustules are seen, surrounded by the reddened, altered skin. It is a disease of years' duration, but no ulcerations happen, al- though scarring is a not infrequent result from the small abscesses. Impetigo. — This is a malady often happening in persons of good general health, and mostly soon ending in recovery. It presents small pustules occurring in successive crops and arranged in clus- ters. The pustules are isolated, are little raised above the surface, break, and a thick yellowish or greenish crust is developed ; no scar follows. When the disorder attacks the scalp and face, especially in infants and children, it gives rise to very extensive incrusta- tions, and constitutes, particularly if conjoined with eczema, the affection formerly designated as " porrigo larvalis." There is a contagious form of it, described by Tilbury Fox, which occurs acutely, is epidemic, preceded by fever, and unattended with pain or itching. Another form of impetigo, first mentioned by Hebra, consists in a multiform eruption of vesicles, vesico-pustules, and pustules. Impetigo contagiosa is characterized by vesico-pustules or blebs drying into flat, straw-colored crusts. It is contagious, and is especialty encountered in children. The lesions occur especially on the face and hands, and vary in size from a pin-head to a quarter of a dollar; their contents, at first serous, become sero- 1012 MEL.ICAL DIAGNOSIS. purulent in the process of drying. Dermatitis herpetiformis, or Duhring's disease, differs in being not contagious, and in its hap- pening in older persons who are frequently of an hysterical type. Leredde and Parin^ at the H6pita] St.-Louis, found in the skin, at the site of the lesions, numbers of eosinophile granules and cells. These cells, unusually rare in the skin, play a considerable part in this affection, and by their extraordinary frequency serve to distinguish this from other cutaneous diseases. Suppuration did not occur, and no micro-organism was found in the vesicles. There is a close connection between this disease and herpes gesta- tionis, in which the same cellular elements have been found.* There is deficiency of urea in the urine of Duhring's impetigo, and M. Bar found that the toxicity of the urine was increased at the time that the eruption occurred. Stephen Mackenzie f considers Duhring's disease a cutaneous neurosis, and Leredde suggests that the exciting cause may be deficient elimination by the kidneys, as nephritis has been found by Gaston J in two autop- sies. The eruption upon the skin is due to nervous influence owing to an alteration of the blood and a functional disorder of the kidneys. § Ecthyma. — This differs from impetigo by the larger size and greater prominence of the pustules and their inflamed base. When the crust that forms on each pustule falls, a highly-congested sur- face or a superficial ulceration is seen, which leaves a cicatrix. This disorder is painful, generally chronic, and connected with a cachectic state of the system ; irritation of the skin may excite it. It bears a certain resemblance to sycosis ; but the limitation to the hairy portions of the face, the yellow color of the pustules, their conical form aud smaller size, and the brown crusts they occasion, distinguish this malady. Rupia. — This affection produces at first bullae, but soon very large pustules, which desiccate into thick, brownish crusts, often of conical shape or resembling the shell of an oyster, which, when thrown off, expose ulcerations of various depth that are * Anatomie pathologique de la Dermatose de Duhring : Annales de Derma- tologie et de Syphiligraphie, No. 4, April, 1895. t British Journal of Dermatology, Jan. 1893. X Annales de Derm et de Syph., Paris, April, 1895. 2 Loc. oit. DISEASES OF THE SKIN. 1013 slow to heal, and on which fresh crusts arise. The disease runs a chronic course. It occurs especially on the lower extremities, is due to syphilis, and coexists with a deteriorated constitution. It is very like ecthyma, and can be distinguished only by the history of the case, the evidences of syphilitic taint, the persistent ulcerations, and the prominent, peculiarly-shaped crusts. Squamous Diseases, — The predominant characteristic of these is the formation of small, whitish patches of unhealthy cuticle covering red papular elevations or a deep-red, dry, some- what thickened surface ; the scales are generally very freely cast off. Psoriasis is the main disorder belonging to the group. Pity- riasis is included by many, while others regard it as merely a variety of chronic erythema, or of eczema. It differs from lepra and psoriasis by the production of minute scales, which are con- stantly thrown off and reformed, and which are seated on a red- dened integument : hence its chief variety is designated pityriasis rubra. It begins at a special point, and, unlike psoriasis, spreads over the whole body. The skin is very red, and not thickened except in instances of long standing ; there is no discharge, as in eczema, nor itching or burning ; the scales are loosely adherent to the surface, and at times come off in large flakes. The disease is most apparent on the body and the limbs ; in chronic cases the general health deteriorates, and a fatal result is the rule. Pity- riasis rubra is to be distinguished from exfoliative dermatitis, which is an acute affection and more amenable to treatment. In this disease the scales are thicker, larger, and more abundant than in pityriasis rubra ; there may be some spots of moist eczema, the lesions being papular at first and then vesicular, ending in profuse exfoliation, large casts coming away from the fingers, and toes. Alopecia and shedding of the nails are com- mon. Savill * reports an epidemic of this disorder in an infirmary affecting twenty per cent, of all the patients. Pityriasis rosea, or pityriasis maculata et cirdnata of Duhring, is recognized by the presence of macules, or very slightly elevated patches, varying from a pin-point to a half-dollar in size, the color being rosy, or pink, with a yellowish tint. The surface of the lesions is dry and slightly scaly ; the appearance is circinate. * Britisli Medical Journal, Jan. 2, 1893. 1014 MEDICAL DIAGNOSIS. The eruption usually appears on the trunk, is moderately acute, and may last two or three months or longer. It is not con- tagious, and apparently is not parasitic in origin, though this is a matter of doubt. The general health is not impaired, and the patches give no annoyance except by the itching, which is not excessive, and by their appearance, which may lead to their being taken for lesions of syphilis, or for ringworm, lichen ruber, psoriasis, or one of the eruptive fevers, as in cases reported by Duhring and Stel wagon. Psoriasis. — Here we find patches of a red hue raised above the surrounding integument and covered by scales of dried epidermis. The patches are infiltrated and thickened, and they often have a circular or circumscribed shape, with large pearly white scales. But generally the scales which completely cover the morbid por- tion of skin are small, though thick ; the patches are large or consist of small ones which have coalesced into a single large one, are not of an annular form, or completely separated by healthy skin ; they are very symmetrical. Psoriasis generally first appears on the extensor surfaces of the elbow- and knee- joints, and finally on the face, where the scales are usually very small. As Beverley Robinson has proved, the morbid change begins in the cells of the epidermis. There is no watery dis- charge, and scarcely any itching, attending the affection. Psoi'iasis is often hereditary ; in old persons it is frequently of gouty origin. It is a chronic affection, and extremely obstinate. It is liable to be mistaken for lichen, especially the isolated circu- lar form of it, the so-called lepra. It is, however, distinguished by the distinct, dry, and silvery scales, and by the smooth, red, pei'haps bleeding skin which is at once perceived when the scales are detached. Psoriasis has a predilection for the vicinity, of the joints, especially the elbow- and knee-joints. Sometimes it appears exclusively on the palm of the hand ; and in this form especially we are apt to find deep cracks. Palmar psoriasis is rare ; but a condition resembling it in the production of scales and fissures occurs in constitutional syphilis, the so-called syphilitio psoriasis, which is common and is usually attended by other symptoms of syphilis. Psoriasis differs from eczema squamosum by the pre- ceding vesicles, severe itching, and the want of uniformity of lesion of the latter. In scaly syphilitic eruption the scales are DISEASES OF THE SKIN. 1015 comparatively few and fine ; when they are removed, the dense skin underneath does not bleed ; and the eruption is not likely to be met with on the elbows and the knees. Ichthyosis. — Fish-skin is also a squamous disease ; but it diifers from the others of this class in being much more general, in- volving as it does often the whole integument, and in the ab- sence of reddening or any signs of inflammation of the harsh, dry surface ; it is, indeed, an hypertrophy of the cuticle. The skin is dry, dirty, and rough, and covered with thickened and ex- foliating cuticle and with sebum ; there may also be fissures and cracks. Ichthyosis is almost always of congenital origin and begins in childhood ; it affects the whole body, though the face but very slightly. Among the inflammatory diseases of the skin, those resulting from medicines may be here mentioned. This dermatitis medica- mentosa is brought about by a variety of drugs, and differs axxiording to the special drug. Among the principal ones pro- ducing morbid appearances of the skin are arsenic, quinine, belladonna, opium, chloral, salicylic acid, antipyrin, arnica, copaiba, the bromides, and the iodides. The acneiform eruption due to the bromides, with the dusky-red color of parts of the skin, or the ulcers they may occasion ; the papular or bullous eruption caused by the iodides, especially by iodide of potassium, and the scarlet rash of belladonna, — are well known. Maculse. — These include stains on the skin which are due to chemical substances, such as nitrate of silver, or blood-spots, as in purpura, or spots in consequence of parasitic formations, as in tinea versicolor. But their chief cause is increased pigmentation ; and it is this cause that we shall look at more particularly. First, lentigo may be mentioned. This consists of the little vellow or yellowish-brown spots which are so often met with on the face and on the arms in children under eight years of age, and- which, if they have persisted, disappear in middle life. Simi- lar spots are ephelides, or freckles ; these, though aggravated by exposm'e to the sun, may exist all the year round. Melasma is a very dark pigmentation, which, although it has been met with in an epidemic form, is commonly seen in connection with Addison's disease. Chloasma consists of a brownish or yellowish -brown pigmen- 1016 MEDICAL DIAGNOSIS. tatiou, giving rise to the so called liver spots. They are smooth and well-defined maculse without scales, and may result from any local irritation or from exposure to the sun or heat. They may also happen in cases of faulty digestion with torpor of the liver, in uterine disorders, and in the pregnant state. Tinea versicolor is constantly confounded with these so-called liver spots. But it is almost entirely a disease of the trunk, is much more itchy, is slightly raised, and in the scales we scrape oif is found the characteristic fungus. New Growths. — These are hard, indolent, and often per- manent tumors of the skin, which in their main forms consist of granulation tissue. Lupus, fibroma molluscum, and elephan- tiasis of the Greeks mainly illustrate this group. lyapus. — In lupus the new growth mostly takes place in the form of isolated tubercles. These may or may not ulcerate. They are of a dull-red color, elevated above the surface, with a well- defined outline, spread outward into normal textures, and, if they ulcerate, destroy the tissues in which they are situated. The ulcers also spread, and occasion much devastation. When they heal, they leave a strongly- marked whitish cicatrix and unhealthy- looking skin. The disorder occurs in syphilitic or in scrofulous persons, — generally in the latter, — appears often in childhood, is attended with some pain and itching, and pursues a very slow course. The nose and cheek are the favorite sites. There is a form of lupus occurring only in strumous subjects, and charac- terized by warty formations. This lupus verrucosus is without pain or itching, but cicatrices form, though there has been no previous ulceration.* In lupus erythematodes the disease is super- ficial, and the sebaceous glands particularly are distended. The surface is somewhat raised, the centre of the diseased patch is pale and sinks in. The tubercles form late, if at all, and there is no ulceration. The most common site of the disease is under the eye. It does not generally appear until after puberty, and is preceded by erythema of the affected parts. The diagnosis of lupus vul- garis depends principally upon the small nodules deeply em- bedded in the corium of the skin, that have a tendency to un- dergo ulceration, leaving upon healing a peculiar cicatricial tissue * McCall Anderson, Journal of Cutaneous Medicine, vol. i. DISEASES OP THE SKIN. 1017 of uneven thickness. Tubercle-bacilli and giant cells have been found in these lesions, but Virchow has shown that the giant cells may be found in normal granulations and elsewhere. Baum * has determined the bacilli to be comparatively rare ; they are only demonstrable in those nodules which have undergone retrograde metamorphosis. Lepra. — Leprosy is a chronic constitutional disorder, and the symptoms of general depression may precede the characteristic local features. The true leprosy, the elephantiasis of the Greeks, is distinguished by tubercles, from the size of a pea to that of a walnut, of reddish or whitish or bronze-like hue, which slowly ulcerate, and which are preceded by erythematous patches ; ulcera- tion is apt to take place about the fingers and toes. Like lupus, the tubercles have the structure of granulation tissue. Often, too, there are symptoms of defective innervation, especially de- ficient sensation of the surface, anaesthesia of the fingers being an early symptom. The nerve-trunks are invaded, cutaneous erup- tions in their course result, and the blood is seriously affected. Muscular weakness and wasting may be also i)resent. The face is most frequently the seat of the malady, and becomes very much thickened and disfigured ; similar changes may also be seen in the limbs. Pemphigus-like blebs are among the earliest signs. When marked nodules form, the skin is decidedly dis- colored, often copper-colored, and the face is distorted and has a fierce expression. Sometimes antesthesia is the main symptom ; the uneven thickening may occur in circular patches like psori- asis, but without tubercles, and be markedly anaesthetic. The disease is often hereditary. Two forms of the disease are generally recognized, — the tu- bercular and the anaesthetic ; but there is no absolute distinction between them. The disease is common in tropical regions, es- pecially the East, and in Africa and Brazil ; it is also found in Norway and in the Hawaiian Islands, and has become natural- ized in the United States. f Hypertrophies, — There are many forms of these, according * International Clinic, Fourth Series, vol. ii. p. 349. f See Transact. Amer. Dermatol. Assoc, 1879, and Henry Dickson Bruns, Archives of Medicine, New York, Dec. 1881. 1018 MEDICAL DIAGNOSIS. to whether the connective tissue, the epidermis, the arteries and veins, or the lymphatic vessels are affected. I shall notice par- ticularly two ; and first, elephantiasis Arabum. Elephantiasis of the Arabs. — This, the Barbadoes leg, is an enormous increase in size of the limb, usually dependent upon an indurated swelling of the subcutaneous tissues, with some altera- tion of the skin proper, and lymphangitis. The tumefaction may be in swellings separated by deep furrows, giving somewhat of a tuberculated look to the part, or it may be uniform ; it chiefly attacks males, and gives rise to great deformities. It is a dis- ease of the tropics. The cases, especially of elephantiasis of the scrotum, have been frequently traced to filarise. There is a form of enlargement of the leg to which we may here briefly refer, — one in which the overgrowth of the affected limb is associated with disease in the lymphatic system. Vesicles form, which are connected by ridge-like elevations, and which from time to time discharge a chylous fluid.* The sub- cutaneous lymphatics near the groin are usually found to be distended. Scleroderma. — Scleroderma, or sclerema, is an induration of the skin and areolar texture, which may be partial or general, affecting nearly the whole body.t The skin is dense and hard, and in the true skin and the subcutaneous tissue the fibrous ele- ments are much increased. The true skin shrinks and binds down and is bound to the parts beneath. If the malady seize upon the fingers, it renders them rigid and immovable. The disease is generally symmetrical, and is much more common in. women than in men. In cases reported by Goldzieher,J the disease appeared in the extremities after unusual exposure to cold, and resulting frost-bite. It frequently coexists with feeble health ; and in time the internal organs become affected, or these may be from the first deeply implicated. § The general health may, however, remain good. * W. H. Day, Transact. Clin. Soc. Lond., vol. ii., 1869. f See tlie cases collected by Van Harlingen, Amer. J.ourn. of Syphilography and Dermatology, 1873. t Beitrage der Berlin. Dermatolog. Gessellsch., March, 1893. I Harley, Med.-Chir. Transact., 1877. DISEASES OF THE SKIN. 1019 I had some years since a marked case of this strange affection under my chai'ge at the Pennsylvania Hospital, in a woman, forty- two years of age, who, admitted with oedema of the feet, was at the same time noticed to have a swelling of both wrists and fore- arms as well as of the cheeks. The swelling was firm and resist- ant, and did not pit on pressure. The skin covering it was very smooth, and of redder hue than at other portions of the body ; there was well-preserved sensibility. The oedema disappeared from the feet, but the signs of the indurated cellular tissue did not leave the affected parts. On the contrary, the condition of these parts became worse, though the general health was excellent, all the internal viscera being in a normal state. Gradually the hands, particularly the fingers, were found to be more and more resisting and immovable, and she could scarcely bend them ; occa- sionally they were the seat of pain. The skin lost all suppleness, and could not be raised up. At no time while under observation was albumen present in the urine. She left the hospital unim- proved by the sulphur baths, the bichloride of mercury, and the various other alteratives she took ; and I afterward learned that she died of an acute pleurisy succeeding an attack of acute men- ingitis. Prior to her death, so great was the pressure exerted by the dense and contra -ting cellular tissue that dry gangrene of a finger ensued, as well as of a toe, the disease having been also noticed in the lower extremities. She died about one year from the beginning of the complaint. Examined after death, the skin over the diseased parts was found to be firmly united to the muscles beneath by the dense and augmented areolar textures. Scleroderma is very similar in many of its features to myx- cedema. But the marked anaemia of this, the decided nervous symptoms, and the fact that we do not find the stiff, hard skin compressing the parts beneath and bound to them causing in time marked atrophies, distinguish the two maladies. The recent siiccessfiil treatment of myxcedema by thyroid extract suggests a means of diagnosis between the two affections. Goldzieher* considers scleroderma a progressive chronic dermatitis accom- panied by permanent oedema. Repeated attacks of erysipelas * Beitriige der Berlin. Derraatolog. Gesellsch., March 12, 1893. 1020 MEDICAL DIAGNOSIS. thicken the skin, but we do not find atrophies from compres- sion. Scleroderma is closely related to morphoea. This occurs over the course of nerve tracts, the thickening being in circumscribed patches and lacking the peculiar hardness of sclerema; then changes in the structure of the skin, hypersemic appearances at first, pigmentation and cicatrization afterward, occur in morphoea, with pain and tingling in the affected parts. The color of the patch of morphoea is characteristic. The central part is usually of a yellowish-white or ivory color, which is surrounded by a zone of lilac, due to enlarged capillaries. By some, morphoea is regarded as a local expression and an early stage of scleroderma, each being a form of tropho-neurosis. Parasitic Diseases. — These may be caused by the presence either of parasitic animals or of parasitic plants. To affec- tions of the former origin, or the epizoa, belongs especially scabies ; though the various forms of lice producing the ailment presenting a pruriginous eruption with little hemorrhagic marks — phtheiriasis — must be mentioned. Another animal parasite, the entozoon or demodex foUiculorum, inhabits the sebaceous and hair follicles, but does not, so far as is known, cause disease. The complaints associated with the vegetable parasites, the epi- phytes, or, as those on the skin are called, the dermatophytes, also known by the generic name of tinea, are chiefly favus, mentagra, pityriasis versicolor, and some of the forms of ringworm, tinea circinata, and tinea tonsurans. Pellagra, also supposed to be due to a vegetable parasitic growth, is not an affection met with in this country. Nor does the presumed parasitic fungus lodge in the skin. It is said to be found in diseased Indian corn or maize, which, when eaten, causes the general cachexia or cutaneous eruption that characterizes the malady, of which the eruption, moreover, is determined by exposure to the sun. Belmondo found lesions of the spinal cord in a number of cases of this grave nutritive disorder. As stated by Eichhoff, many cases of eczema are of parasitic origin, and indeed it is asserted by others that all eczemas are of this character, and that the non-parasitic forms ai-e simply cases of dermatitis. DISEASES OF THE SKIN. 1021 Scabies. — Scabies, or the itch, is owing to the acarus scabiei. This burrows into the skin, particularly between the fingers and between the toes, about the wrists, and on the buttocks and ab- domen and the upper part of the penis. The channels produced are generally somewhat curved, and may be traced as whitish or more generally black streaks several lines in length, in the situa- tions just indicated. The disease is attended with excessive itch- ing, which is increased at night, and with the eruption of conical vesicles, or even of a marked eczema and of papules and pustules ; most of the rash is due to the irritation of scratching. At the close of our civil war we had a form of itch very prevalent in this country, which was spread far and wide, as is presumed, by contact with the troops, — the so-called army itch. It was a chronic and distressing affection, and no age or social state was exempt from it. Indeed, so prevalent was it that it almost appeared as an epidemic. The itching was intense ; the eruption, as by far most frequently met with, was like prurigo, but vesicles, or even an eczematous condition of the skin, or pus- FiQ. 88. A female acarus, taken from a photograph from nature ; magnified 220 diameters. The ventral surface is shown. tules, attended the intolerable itching ; and in cases of very long duration the appearance of the skin was altered, and all trace of a distinctive eruption was gone. The eruption was seen on the arms, forearms, chest, abdomen, and lower extremities, particularly on the ulnar side of the forearm and the inner aspect of the thigh, 64 1022 MEDICAL DIAGNOSIS. It was sometimes found on the- scalp, but very seldom in the groins, in the axillae, on the hands, or between the fingers. It was benefited by sulphur ; for almost all the preparations recom- mended for it contained sulphur. Whether it was due to the same acarus as ordinary scabies, or to a different species, I am unable to say. Tinea Favosa. — Tinea favosa, or favus, is a chronic disease which gives rise to bright-yellow umbilicated crusts, of circular shape and smooth surface, which often form yellow rings around the hair follicles and are not much elevated above the skin. There is no discharge. The disease rarely affects any other part of the body than the scalp, and produces baldness ; when the nails are attacked, they become brittle and yellow. In cases of doubt, the microscope furnishes us with a certain means of diagnosis, by exhibiting the cryptogamic plants. Tinea Sycosis. — Tinea sycosis, or barber's itch, is to be dis- tinguished from a non-parasitic form. The distinctive marks of the disease consist in the development of yellowish pustules, having a bright-red base, around the roots of the hair of the beard ; the hairy portion of the neck may also be affected. The crusts may run together, and more or less inflammatory thickening of the skin exists. This is especially seen in the parasitic form of the disease, in which, however, less suppuration happens, and less pain or itching, but in which the hairs become brittle and lose their healthy look. The upper lip is rarely implicated in tinea sycosis. Non-parasitic sycosis consists chiefly in an inflammation around the follicles, which always starts in these parts.* linea Oirdnata and Tinea Tonsurans. — The trichophyton ton- surans is the parasite met with in tinea eirdnata, the ringworm of the body, and in tinea tonsurans, the ringworm of the scalp. This is common in children, and spreads by contagion. It exists in circular scaly patches, on which are dry broken hairs. In ringworm of the body the patches are also circular and scaly; but they are red and very itchy, and much paler in the centre than at the edge. Examining the scurf, we find the fungous growth. Tinea kerion is a suppurative form of tinea tonsurans. Tinea Versicolor. — This parasitic affection, also known as pityi'i- * Kobinson, New York Medical Journal, Aug. and Sept. 1877. DISEASES OF THE SKIN. 1023 asis versicolor, occasions those yellow or yellowish-brown discol- orations which may be not infrequently seen on various parts of the body. The affection is to be distinguished from chloasma, which is common in women, especially in pregnant women. The microsporon furfur of Eichstadt is the parasite present in this disorder ; and it is found abundantly in the scales which can be scraped from the raised, itching patches. In pityriasis affecting the scalp we may also find parasitic growths of vegetable nature ; they are often the cause of baldness, as in tiriea deoalvans. Pity- riasis capitis, or dandruff, is readily distinguished from ordinary seborrhcea, in which the oily element predominates in the scales, that are aggregated in masses. This is in marked contrast to the fine pearly scales of pityriasis, which are due to epithelial exfoliation. This condition often leads also to baldness. Some forms of alopecia are of parasitic nature. The diagnosis of actinomycosis of the skin depends upon the history, the mode of invasion, and the distribution of the tumors in necklace-like series, either in lines or in circles, or in groups. The disease pursues a rapid course, with fever, sometimes septicse- mic in character. Majocci * recognizes two forms, the anthracoid and the ulcero-fungous. In the former the lesions are flat-topped, with a multitude of small openings from which thick yellow pus exudes ; in the latter ulceration occurs early, with large granula- tions. In both forms the lymphatic glands in the neighborhood of the lesions are not involved. The lesions are situated chiefly around the buccal cavity. Microscopical examination of the yellow granules reveals the characteristic actinomyces. Altered Gland-secretions. — One of these, sehorrhcea, or in- creased secretion from the sebaceous glands mixed with epidermic scales, has been already mentioned. It is especially found on the scalp, nose, and genitals, and is often seen among those who have menstrual disorders. It is unattended by itching ; the crusts are readily removed by strong alkaline soaps, and the skin beneath is healthy, or pale and glistening or slightly reddened. Where the sebum is retained in the follicle, giving rise to little prominences, apt to be discolored by dirt, and without, as happens in acne, decided inflammation around the gland and its duct, the * Annales de Derm, et de Syph., Paris, 1892, p. 310. 1024 MEDICAL DIAGNOSIS. disorder is called comedo. The plug of sebum can be easily squeezed out. The disorder is most common on the face and shoulders of young persons of lymphatic. temperament. The sweat-glands are often altered in their activity, and excess- ive perspiration results. This may be general, or confined to particular localities, as to the hands and feet. This local sweat- ing is often offensive, and makes the parts very tender. The disease formerly known as lichen tropicus is now regarded as due to congestion or inflammation of the sweat-glands, and is therefore termed more correctly miliaria papulosa. The strophulus or " red gum" of infants is miliaria vesiculosa. At times there is sweating of blood from the skin, as in the case recorded by Hart.* This condition, known as hsemidrosis, is due to some alteration in inner- vation, and may be preceded or accompanied by a localized ery- thema or eczema ; or the bleeding may come from the follicles of the skin; it is not a secretion of the sweat glands, but is a hemorrhage, or an exudation. Molluscum epitheliale presents numerous globular or flattish nodules, sometimes seated on a broad base or attached to a pedicle. They are due to the presence of a psorosperm in the deep layer's of the skin and the sebaceous glands. The lesions occur chiefly in groups on the face and neck, or on the trunk ; they have often a doughy feel, vary in size from that of a pea to that of a pigeon's egg, show no tendency to inflame or ulcerate, and are not attended with increased sensibility of surface. They are of the color of the skin or of brownish hue. They may last during life and increase slowly without affecting the general health. There is a variety met with especially in children, which has at the top or the side of each tubercle a small orifice, from which a creamy, fatty fluid can be pressed. This variety is regarded as contagious; though there are many who doubt the contagious nature of " molluscum contagiosum." The little tumors are distinguished from so-called molluscum fibroma by the central aperture, and by the substance resembling sebum that can be squeezed out of them. Although plica polonica is of rare occurrence in this country, yet among immigrants it is occasionally met with, and may be * Louisville Medical Journal, Jan. 1875. DISEASES OP THE SKIN. 1025 recognized by the mass of matted hair, which is felted and defies efforts to untangle the mass. Associated with it is some inflam- mation of the scalp, from which serous oozing occurs. The mass of hair affords refuge for vermin, and the secretions from the scalp produce a peculiar odor, which has led to the supposition that the disease is caused solely by dirt. Dumesnil considers it a neurosis and the dirt only incidental.* Under the microscope the hairs show decided change, affecting mainly the medulla, which in the most diseased parts is entirely lost. Jarochevski has pronounced the disease a disturbance of nutrition of neurotic origin. It is related on the one hand to gray hair and on the other to alopecia. Nervous Affections. — These are of many varieties. Several of these, such as herpes zoster, have already been considered. The large group of itching affections in which no obvious local affection exists, find here their place. Such are, for instance, the various forms of pruritus, either local or general, which are specially ap^ to affect elderly persons. Sometimes the itching is very violent and obstinate, and we cannot even trace it to reflected irritation, though this is often its cause. Again, diabetes, gout, lithEeniia, or jaundice may lie at the root of the pruritus. At times we can find no cause for it. Season influences it much, as seen in the winter itching, the pruritus hiemalis, described by Duhring. It happens particularly about the thighs and legs, and there may be prominence of the hair follicles. Among the other manifestations of nervous skin affections are dermatalgia, hypersesthesia, anaes- thesia ; then there are undoubtedly cutaneous diseases which are being more and more recognized as of nervous origin. The disorders of the skin which we have been considering do not always occur isolated ; they may be combined. Again, they are altered by the existence of a special taint, as by the syphilitic. Now, without making any attempt to describe syphilitic diseases of the skin, it may briefly be stated that they differ chiefly by their copper-colored tint, by the stained aspect they leave, and by the absence of pain and of itching. In syphilitic erythema the eruption runs a very chronic course, and is very distinct generally on the trunk. It belongs to early syphilis. Syphilitic lichen ha§ * International Climes, Pourth Series, vol. ii., 1894. 1026 MEDICAL DIAGNOSIS. better-defined, more obvious papules than simple lichen. The ulcerations in the pustular affections are deeper; while in the squamous disorders the scabs are smaller and the papules larger than in the non-syphilitic eruptions. A furunculoid eruption is occasionally met with in hereditary syphilis. Syphilitic affections of the skin are very apt to be mixed, and light is thrown on them by this fact, as well as by the history of the case, the sore throat, the falling of the hair, and the nerve- and bone-pains. CHAPTER XIV. POISONS AND PARASITES. Toxic symptoms from causes arising within the body, either from fermentative or putrefactive changes of the food within the intestinal tract, or from micro-organisms causing infectious dis- eases, septicaemia, saprsemia, and the like, have been referred to in other chapters, especially those on Diseases of the Blood, the Acute Infectious Diseases, and Gastro-Intestinal Affections and Fevers. In this section will be considered only those disorders due to poisons or parasites, the morbid phenomena of which are clearly occasioned by causes introduced into the system from without. Thus they agree in being affections of external origin ; and as re- gards both the diagnosis and the treatment, our chief aim is to as- certain precisely to what foreign substance the symptoms are due. POISONS. Cases of poisoning may arise from accident, attempt at sui- cide, or criminal intent. It is not necessary hei'e to enter at any length into the subject of toxicology, but merely to set forth the main signs by which the most common poisons may be recognized and distinguished. For this purpose it will be convenient to consider the cases as divided into acute and chronic, subdividing these classes according to the character and effects of the different substances. Acute Poisoning. The attack comes on suddenly, the patient, previously in perfect health, having taken some food, drink, or medicine which has been followed by the severe symptoms. It is always, in a case of suspected poisoning, of the utmost importance to be able to make out these points. 1027 1028 MEDICAL DIAGNOSIS. Irritant Poisons. — The chief articles which give rise to acute poisoning belong to the class of irritant poisons. The symptoms are generally those of acute gastritis, attended often with more or less inflammation of the mouth, the fauces, and the oesophagus. Sometimes the air-passages may be involved, either directly or by sympathy, and we find hoarseness and cough. Convulsions are occasionally observed, and collapse is apt to occur sooner or later. The acute pain, the tenderness, and the vomiting come on shortly after a meal, or at least after something has been swal- lowed. This distinguishes the acute gastritis caused by poisons from idiopathic acute gastritis or from acute gastric catarrh. Some- times several persons are similarly afi^ected, — a circumstance always strongly in favor of the idea of poisoning. From perfora- tion of the stomach or intestines, irritant poisoning is discriminated by noting that the acute signs in the former case follow upon the manifestations of some gastric or intestinal disorder ; and the at- tending phenomena of collapse are not, as in poisoning, associated with cramps or convulsions. Choler-a morbus is separated by the history of the case, by the absence of epigastric tenderness, and by the purging and vomiting often coming on simultaneously. Cholera resembles poisoning in the suddenness and the violence of the attack, but is distinguished by the rice-water discharges and by its epidemic character. Bacteriological examination of the stools also aflbrds a means of diagnosis. In strangulated her- nia, the comparatively gradual onset, the pain, the tumor, and the constipation will be significant. As regards the separation of those cases of poisoning in which blood is ejected, from or- dinary hemorrhage from the stomach, we find that pain and purging are both absent in the latter, while in irritant poisoning they are well-marked symptoms. Let us now examine some special poisons. Strong acids are sometimes used in self-destruction. Nitric acid stains the lips and mouth orange-yellow wherever it touches them. Sulphuric acid stains the skin or mucous membrane white or even dark gray ; the pain is excessive, and nervous symptoms are not infre- quent. If the vomited matter be mixed with a solution of barium nitrate, a dense white precipitate of barium sulphate is thrown down. Hydrochloric acid is less irritant and corrosive than sul- POISONS AND PARASITES. 1029 phuric acid ; in the ejected matter silver nitrate produces a copious white precipitate insoluble in nitric acid. Oxalic acid, when con- centrated, is rapidly fatal. The irritant eifects are those of the mineral acids ; but we also meet with dyspnoea and with nervous phenomena, such as anesthesia, parsesthesia, palsies, and convul- sions. The strong alkalies, when taken into the stomach, cause inflam- mation of the organ and of the fauces and the oesophagus. Should the case end in recovery from the poisonous influence, thickening of the oesophagus is apt to occur. Ammonia may also induce severe nervous symptoms, similar to those of tetanus ; its vapor sometimes acts powerfully on the air-passages, producing harass- ing cough. Potassium and sodium hydroxides — commonly known as caustic potash and caustic soda — give rise to violent local in- flammation in the mouth, oesophagus, and stomach. The vomited matter has an alkaline reaction. Potassium nitrate is a strong cardiac sedative. Potassium iodide, ioditie, bromine, and chlorine are all capable of destroying life by their intensely irritant effect. Phosphorus, which is not infrequently taken as a poison, imparts to the breath, to the faeces, and even to the urine an alliaceous smell, and may make them luminous in the dark. It acts as an irritant, causing obstinate vomiting and purging, pain at the epi- gastrium, rapid, weak pulse, jaundice, and unquenchable thirst. The local pain and inflammation are usually extreme, and col- lapse, with or without convulsions, comes on early. In some cases painful cramps in the limbs occur, and various disturb- ances of sensibility, and, later, violent delirium and convulsions, eventuating in coma and in death. In other cases hemorrhage is a striking feature, the blood is very fluid, and issues from all the passages, and petechise form beneath the skin. The tempera- ture remains normal until near death. The pulse becomes feeble and small ; the fijst sound of the heart almost disappears ; pep- tonuria is observed.* Jaundice is a constant symptom ; it seldom, however, comes on before the third day, and is rarely intense ; it may be associated with urticaria. The spleen increases in size * L'Abeille, Medioale, July, 1882, quoted in Medical News, Phila., vol. ii., 1882 ; also Jaksch, Wien. Med. Presse, Oct. 1882. 1030 MEDICAL DIAGNOSIS. simultaneously with the liver. The urine becomes very scanty. Albumin, blood, and casts are occasionally present in the seci-e- tion, and the biliary coloring-matter is usually; urea is very de- fective. In cases of phosphorus poisoning, acute and extreme fatty degeneration of the tissues happens. It occurs with astonishing rapidity. It has been seen, in the bodies of persons poisoned by phosphorus, within so short a period as forty-eight hours, and has been found to affect the heart, the smaller blood-vessels and capil- laries, the liver, the kidneys, the glands of the stomach, and the voluntary muscles.* The liver is always principally impli- cated. Various compounds of potassium, copper, sine, silver, lead, and iron occasionally cause death. They act, for the most part, as irritants merely ; but some of them are powerfully astringent, and even caustic, as, for instance, zinc chloride or silver nitrate. If the toxical phenomena are due to the nitrate of silver, the stain- ing of the lips may afford a cine to the natui-e of the case. There are no really distinctive symptoms produced by large doses of arsenic, of antimony, of mercury, or of their compounds, which are among the best known of irritant poisons : the peculiar effects of each of these substances, when insidiously introduced into the economy, will be presently mentioned. In acute arsenical poison- ing, besides the pain and the gastro-enteric symptoms, convul- sions, delirium, palsies, and bloody or albuminous urine have been specially noticed. Arsenical poisoning is a very common form of self-destruction. It is also observed among those who accidentally take Scheele's green, or among children who swallow arsenical paints. There is in the internal organs a fatty degeneration sim- ilar to that in phosphorus poisoning. In the recognition of the cause of the symptoms, Reinsch's test, applied to the vomited matter, is very convenient and satisfactory. In poisoning by corrosive sublimate, epigastric pain, vomiting, diarrhoea, bloody stools, and finally collapse, are met with. Among animal substances, cantharides has sometimes been pro- ductive of poisonous effects ; strangury, bloody urine, albumi- nuria, more permanent than that produced by turpentine, priapism, and spasm of the glottis, are the most marked symptoms ; while * Tardieu, Etude medioo-legale sur I'Empoisonnement, 1867, p. 445. POISONS AND PARASITES. 1031 the shining, green particles of the drug, if taken in substance, have been detected in the vomited matters. Sausage, milk, cheese, eggs, especially in articles of confectionery, such as cream puffs, frequently produce violent symptoms sug- gesting some of the more powerful irritants, although chemical examination fails to reveal any mineral poison. The researches of Vaughan have shown the main cause of these actions. Under the influence of certain micro-organisms, the albuminous matters undergo rapid decomposition, producing a nitrogenous body which has been identified as diazobenzene. Vaughan originally called this body tyrotoxicon, cheese poison. It is highly poisonous, but also very unstable. It is produced early in the decay of the albuminous articles, and is decomposed subsequently. We can therefore understand why articles of food may be less irritating when decidedly decomposed than when decomposition has just set in. Besides the signs of gastro-intestinal irritation, vertigo, head- ache, marked anxiety, and muscular weakness have been noticed among the effects of these ptomaines. The vegetable irritants are mainly articles commonly used as purgatives. Thus, elaterium, aloes, colocynth, and colchicum have all proved fatal when taken too freely. The symptoms do not differ materially from those caused by other poisons of this class. Tobacco and lobelia are powerful local excitants, occasioning emesis and purging, with a speedy collapse of the system. The former, when the nicotine produces acute symptoms of poisoning, gives rise also to salivation, cold sweats, slow pulse, colicky pains, and at times convulsions. Savin not only produces inflammation of the alimentary canal, but is apt also to give rise to strangury ; it is most frequently resorted to with the view of bringing on abortion. JSrgot is also used for the same purpose; the most striking symptoms of acute ergot poisoning are colic, vomiting, diarrhoea, increased salivation, retardation and weakening of pulse, muscular weakness, and, in severe instances, stupor. The poisoning rarely ends fatally. Poisonous fungi, such as the fly fungus, which are eaten by mis- take for mushrooms, produce violent symptoms of irritant poison- ing attended with other phenomena. The poisonous agent in the fly fungus is muscarine, and it gives rise to vomiting, violent colic, and diarrhoea, besides slowing of the pulse and the breathing, and 1032 MEDICAL DIAGNOSIS. violent excitement followed by stupor and somnolency. The case generally lasts two or three days, and may then end in recovery or in collapse ; but it may terminate fatally in six or seven hours, hsemoglobinuria being among the symptoms. Finding the fungi in the vomited matter or in the stools greatly facilitates the diag- nosis. Other poisonous fungi produce much the same symptoms ; and even the usually-eaten and innocuous kinds of mushrooms may, if at all spoiled, or in certain individuals, or when eaten raw, occasion similar symptoms. Narcotic Poisoning. — The symptoms of narcotic poisoning vary more, according to the special article taken, than those caused by irritants. Narcotic poisons affect chiefly the nervous system and the circulation. Many of them produce phenomena like apoplexy and intoxication, from which they need to be carefully distinguished. Narcotic poisoning is, for the most part, of the acute form. Opium is by far the most important of narcotic poisons. It induces giddiness, stupor, and lethargic sleep, from which, how- ever, the patient can at first be roused, if sharply spoken to. Subsequently this sleep deepens into coma and cannot be broken ; the skin is relaxed and perspiring ; the face is usually pale ; the pupils are contracted and insensible to light; erections of the penis are common. A more or less evident odor of opium may often be perceived about the person or on the breath. No distinction can be drawn between the effects of different forms of this poison : the stronger the preparation, however, the more marked and the more rapid will be the progress of the case. Morphine, codeine, nar- cotine, and the other alkaloids give rise to similar symptoms, but the smell of opium is absent ; convulsions are most likely to occur from narcotine, papaverine, and thebaine. The diagnosis of opium poisoning from apoplexy and from the coma of urcemia has been discussed in a former chapter. We may merely recall that the contracted pupil caused by opium is of very great significance, and does not, with the exceptions there referred to, exist in the other states. Moreover, the coma of apoplexy is at once developed ; while in narcotic poisoning it is not sudden, but is preceded by drowsiness or stupor, which gradually passes into coma. These phenomena occur also in the same sequence in uraemia ; but they are even slower in their progress, and are POISONS AHD PARASITES. 1033 frequently associated with convulsions and with markedly albu- minous urine and dropsy. From acwfe alcoholism we discriminate opium poisoning chiefly by the absence of the alcoholic odor, the slow respiration, and the presence of morphine in the urine. The characteristic smell of chloroform, the great pallor of the countenance, the complete and speedy collapse, and the absence of contracted pupils distinguish chloroform poisoning from opium poisoning. It is the same with ether. Poisoning by chloroform and by ether is mostly encoun- tered during surgical operations. Chloral, in excessive doses, produces heavy sleep, with con- tracted pupils ; but they dilate on awaking.* There is some re- duction of temperature, with rapid pulse, giddiness, inability to walk straight, double vision, and headache, in cases in which consciousness, sensibility, and muscular power have not been entirely suspended by the drug. Weak action of the heart is another of the dangers of chloral poisoning, and I have known a dilated heart almost paralyzed even by small doses. In some instances a stage of excitement like alcoholic intoxication pre- cedes the narcotism. The urine may or may not contain sugar.f Chloral itself simulates sugar in the copper and bismuth tests. It is occasionally used for drugging liquor for purposes of robbery or rape. Benzene, when taken internally, occasions noises in the head, muscular tremor and twitchings, and deep sleep ; but the narcotic depression ends in recovery. Alcohol, if taken in large quantities and not much diluted, gives rise to symptoms like those caused by opium. The eye is in- jected and the seat of ecchymosis; the pupils are, as a rule, dilated and very sluggish ; the breathing is irregular and stertorous ; the temperature lowered ; the insensibility may alternate with convul- sions ; the breath has a strong smell of alcohol or may be quite free from spirituous odor. This absence of odor of the breath, although not usual, may give rise to a confusion between alcoholic poisoning and apoplexy, and the discrimination of these condi- * Taylor, On Poisons, 3d edit, 1875. f See a case of mine recorded in a Clinical Lecture on Chloral Poisoning, PWla. Med. Times, March, 1883. 1034 MEDICAL DIAGNOSIS. tions must then depend in some measure upon evidence furnished by the history of the occurrence of the insensibility, and by the presence or absence of palsy. Alcohol may readily be detected in the urine. Woodbury's * modification of Ainstie's test is very convenient. Into a tube containing a gramme of sulphuric acid, which should be colorless or nearly so, twice as much of the urine to be tested is poured. A small crystal of bichromate of potassium is then dropped in, and the liquid slowly mixed by rotating the test-tube. If alcohol be present in proportion as large as two or three parts per thou- sand, a permanent green discoloration will result ; if there be less than this, the liquid will remain of ruby color. Chloral in the urine does not produce the peculiar reaction. Belladonna, or its active principle, atropine, and hyoscyamus produce more marked excitement of the brain than opium does, causing delirium of active kind, perhaps with convulsions. The pupils are greatly dilated, and vision is singularly deranged ; there is intense thirst, with great dryness, redness, spasm, and burning in the throat; the breathing is rapid, thus differing from apo- plectic conditions. The temperature is always lowered ; the pulse becomes quick and compressible; a scarlet efflorescence may happen. The surest test of poisoning by atropine is to take some of the urine passed, and with it to dilate the pupil in the eye of a cat. Conium occasions stupor, paralyzes the muscular system, and dilates the pupils; there is dyspnoea, while the heart, though rendered slower, is not much affected. Convulsions may come on. These help to distinguish conium poisoning from curare poisoning, which it much resembles. In the latter, however, the palsy is greater. Carbolic add, if taken in poisonous doses, produces rapidly dangerous symptoms, which in bad cases terminate in death in a few hours. Vomiting, slow pulse, noisy breathing, loss of consciousness, deepening into profound coma, abolition of reflex movements, cool skin, suppression of urine, are the main symp- toms. When the urine is obtained, it is of dark-green or black color ; this and the odor of carbolic acid about the patient are * PMla. Med. Times, March, 1883. POISONS AND PARASITES. 1035 very significant features. The discolored urine is apt to contain blood-corpuscles, casts, epithelium, and tube-casts. Aniline poisoning is met with among the workers in factories in which the aniline colors are made. It is the breathins: of the aniline vapor, especially, which occasions the toxic effect. Ver- tigo, headache, a sense of suffocation, vomiting, ansesthesia, pain in the extremities, somnolency, and a dark cyanotic discoloration of the ears, the nails, and the mucous membrane of the nose, have been especially noticed. Hydrocyanic or prussio add usually leads to convulsive con- tractions of the muscles of the limbs and trunk, and destroys life by stopping the circulation and the respiration. Sometimes the odor of the acid, resembling that of bitter almonds, is percepti- ble in the breath ; but too much reliance must not be placed upon this point. Unfortunately, the diagnosis of this poison has generally to be made after death, for medico-legal purposes. The gases arising from burning coal and charcoal may cause death by asphyxia ; and a knowledge of this fact has, particularly in France, led to many suicides. In those cases in which the asphyxia has not a fatal termination, yet has been decided, dis- orders in the peripheral nerves may manifest themselves, either by the signs of neuritis, or by pain and swelling simulating a phlegmon, or by vesicular eruptions in the course of an affected nerve. The peripheral disturbances may appear at once or not until after some days. The signs of disorder of the vaso-motor nerves do not last long ; those of the motor or sensitive nerves have a longer duration ; the complaint induced may be incurable, extending from the centre to the periphery, or in the reverse direction ; or, lastly, the affection may cause an acute ascending paralysis.* The poisonous action in these cases is due largely to carbon mon- oxide, carbonic oxide, a gas which has a strong affinity for haemo- globin, and suspends the oxygen-absorbing function of the blood, thus establishing a chemical asphyxia. The gas, being non-irri- tating, may be inhaled without exciting immediate suspicion. , The so-called water-gas contains large amounts of carbon mon- oxide. Experiment has shown that such gas is much more dan- * Leudet, Arch. Gen. de Med , May, 1865. 1036 MEDICAL DIAGNOSIS. gerous when inhaled than the ordinary illuminating gas, which consists almost entirely of compounds of carbon and hydrogen. Antipyrine given in large doses may produce extreme lowering of the temperature and collapse. Cyanosis, frequency of respira- tion and of pulse, dyspncBa, a feeling of extreme heat over the body, and an erythematous, urticarial, or measly eruption, have also been noticed. In one instance reported, the use of the drug led to the formation of membranes in the mouth and to symp- toms of laryngeal spasm, which was not the case when phenacetin, antifebrin, or exalgin was substituted.* Petroleum taken in excessive quantities produces giddiness, faintness, and palpitation, with tonic and clonic convulsions, con- tracted pupils, hot skin, and slow pulse ; it does not occasion either stupor or vomiting ; the urine has an aromatic odor. Recovery is the, rule. Nitroglycerine occasions a throbbing headache increased by motion, mental confusion, flushing of the face, pulsations all over the body, arterial relaxation, and collapse. Following these poisons, which are in the main narcotic poisons or belong to the group of poisonous carbon compounds, we shall examine some forms of acute poisoning produced by certain powerful vegetable poisons. Aconite has a strongly sedative influence upon the action of the heart, brain, and spinal cord, as well as an irritant action upon the alimentary canal ; slow pulse, giddiness, delirium, numbness, and tingling of the skin, loss of power in the legs, with formica- tion, tingling of the tongue, vomiting, and purging, are followed by syncope and death. Digitalis causes dilatation of the pupil, generally with vomiting, often with purging and with headache, giddiness, and suppression of urine; its chief effect, however, is upon the pulse, which is strikingly lessened both in frequency and in force, and becomes irregular ; the action of the heart, too, becomes weak, and blood- pressure is diminished. The skin is cold, pale, and covered with sweat ; the mind is generally clear, though there is great lassi- tude, with muscular debility, a tendency to sleep, and at times convulsions. The action of the poison generally extends over * Salinger, Amer. Jouru. Med. Sci., May, 1890. POISONS AND PARASITES. 1037 days. Verati'um viride resembles digitalis in its action. It markedly reduces the pulse, and gives rise to vomiting, to great prostration, and to irregular breathing. The temperature is much lowered. Calabar bean acts as a direct sedative to the spinal marrow, particularly to the medulla, and produces great muscular debility or relaxation, or even paralysis, extending to the heart and respi- ratory muscles. The mental faculties remain unaffected, and in this its action differs from that of the cerebral sedatives. It is, however, irritant to the alimentary canal, causing vomiting or purging, a peculiar epigastric sensation is generally experienced, and increased salivation is met with. Calabar bean contracts the pupil and also the ciliary muscle, thus making the eye myopic. The condition of the eye is the main diagnostic sign that dis- tinguishes poisoning by calabar bean from poisoning by curare or by conium. Strychnine and hrudne, the active principles of nux vomica and of several allied plants, give rise to phenomena strongly resem- bling those of tetanus. A very short time, however, — from a few minutes to an hour or two, — will determine the issue of a case of poisoning ; while tetanus may run a course of several weeks. The first symptoms of strychnine poisoning are apt to be a sense of suffocation and dyspnoea, followed by spasms of the respiratory muscles, by starting and twitching and rigidity of the arms and legs, especially of the extensor muscles, but not by lock-jaw ; teta- nus, on the other hand, comes on with setting or locking of the jaws, and the limbs are not at first affected with spasms ; indeed, the arms remain throughout nearly free from them, and the paroxysms of spasm do not follow one another so rapidly as in strychnine poisoning, and are of shorter duration. Again, idio- pathic tetanus is extremely rare ; almost always there has been some wound or injury as a proximate cause of the malady. But we need not pursue these points of diagnosis further : they have been already mentioned in connection with tetanus. From epilepsy strychnine poisoning differs by the unimpaired consciousness; from hydrophobia, by the absence of spasm of the oesophagus and of the terrible dysphagia. Piarotoxin also produces convulsions which may be mistaken for those caused by strychnine. But they are not of a reflex nature, 65 1038 MEDICAL DIAGNOSIS. and reflex spasms are not induced. The breathing is rapid ; the contraction of the heart is retarded ; there are often somnolence and muscular debility. A scarlatinal eruption has been noticed. Chronic Poisoning. When the patient has been subjected to the continuous action of a noxious substance, the case is said to be one of chronic or slow poisoning. Any of the irritant poisons, given in small and re- peated doses, will keep up a morbid condition of the stomach and bowels much like ordinary chronic inflammation. The narcotics, taken in the same manner, act upon the vaso- motor nerves and the cerebro-spinal system, and through this upon the alimentary canal, so deranging digestion and nutrition as even indirectly to cause death. Opium is the most important of the articles thus used ; it is often administered to infants for the purpose of quieting their cries, and the frequent repetition of the dose induces a series of phenomena closely allied to those observed in the adult. With the effects, on the mind, of opium taken persistently for the sake of intoxication, the i-eading world is familiar through the published experiences of De Quincey and of Coleridge. The habit is here and in Europe generally acquired only by persons who have begun the practice for the relief of some painful affection ; in the East, opium is used much more commonly, and, in many Oriental countries, to smoke it is a favorite amusement. Those who employ it constantly are pale, or have a sallow, hag- gard countenance and a dull eye. They lose their power of will and their energy, and are troubled by loss of appetite, giddiness, anomalous neuralgic pains, sleeplessness, and low spirits, which they remove by resorting to the opiate. Though, in spite of the pernicious custom, the general health may remain for many years good, yet sooner or later it gives way, and the opium-eater dies worn out ; or death may be the consequence of disease of the liver, of palsy, or of inveterate diarrhoea, produced by long addiction to the vice. Persons who consume large quantities of opium are apt to have, from time to time, attacks of extreme nervous pros- tration, attended, pei-haps, with violent headache, and requiring free stimulation for their relief. The employment of morphine hypodermically has become an alarmingly frequent form of the POISONS AND PARASITES. 1039 opium habit, especially among members of the medical profes- sion. Besides the general symptoms of chronic opium poisoning, we may have extensive ulcers and other local signs of skin irrita- tion to deal with. Ether and chloroform, habitually made use of, also cause serious disturbance of the nervous system; and so does alcohol. The abuse of spirituous liquors gives rise to a disorder of the mental, motor, and sensory functions, producing sleeplessness, headache, giddiness, hallucinations, imbecility, anaesthesia, disordered vision, and palsies. There results a fine irregular tremor, affecting par- ticularly the hands, Hps, and tongue, and occurring only on at- tempted movement. Multiple neuritis is also a common sequel. Chronic alcoholism also occasions a sensation of choking, a dimin- ished vitality, a persistent catarrh of the gastro-intestinal mem- brane, a tendency to fatty degeneration, especially of the liver and kidneys ; in short, the symptoms met with in drunkards and constituting the state described as chronic alcoholism. Chronic alcoholism in the parent may produce epilepsy in the child. Chloral has proved, like opium and like chloroform, a very fascinating drug to many. The chief symptoms of chronic chloral poisoning are digestive disorders, irregular breathing, impairment of intelligence and of memory, persistent drowsiness, almost stupor, striking enfeeblement of will, want of power in the legs amounting at times to paralysis, and occasional tremor. Defective co-ordination with marked ataxic symptoms, similar to those of locomotor ataxia, and loss of knee-jerk, occur from the habit of taking chloral.* I have known delirium tremens to follow its use, when large quantities of it had been taken and the medicine stopped. Feeble, irregular action of the heart, and sweating, I have also found among the symptoms of chloral poisoning. An erythematous inflammation of the skin of the fingers, with des- quamation and ulceration around the borders of the nails, has been pointed out as a result ;t and various forms of eruption, such as urticaria, lichen, and purpurous spots, as well as bed-sores, have been observed after its prolonged use. Paraldehyde is abused like chloral and morphine. It gives * J. C. Wilson, article " Opium Habit and Kindred Affections," System of Practical Medicine by American Authors, vol. v. f Smith, Lancet, vol. 11., 1871. 1040 MEDICAL DIAGNOSIS. rise, when taken habitually, to gastric disorder, diari'hcea, sleep- lessness, feeble circulation, sweating, and delirium tremens. Tobacco used in excess gives rise to tremors, to giddiness, to emaciation, to impaired digestion, and to intermittence in the pulse, with irregular cardiac action and palpitations,, which may become very annoying and originate the belief of an organic dis- ease of the heart. Like the pereistent abuse of alcoholic drinks, tobacco may occasion amaurosis ; and it is also affirmed that an insidious, obstinate form of otitis is developed in inveterate smokers, and is attended with very minute granulations of the pharynx, nasal fossse, tubes, and middle ear.* When taken in large quantities by those previously unaccustomed to it, tobacco produces colic, diarrhoea, weakness, sleeplessness, dull hearing, vomiting, difficulty in breathing, cold sweats, feeble action of the heart, and will even cause collapse and death. The peculiar odor of tobacco may assist us in the diagnosis of tobacco poisoning ; but it must be remembered that this may attend other morbid states in those who use tobacco largely. Ergot long continued, particularly when taken contained in impure flour, gives rise to the well-characterized disease, chronic ergotism. This appears mainly in two forms : the first is marked by convulsions vrith disturbance of sensation ; the second by gan- grene; both are apt to show themselves in epidemics. In the convulsive form there is at first formication, which lasts, Avhether attended with anaesthesia or not, throughout the whole illness. Soon muscular twitchings and cramps followed by painful con- tractions happen, and the convulsions may become very general. These spasms especially aifect the flexors of the arm, and, unlike those of strychnine, they are not reflex spasms. There is no fever ; the circulation is slow and feeble ; the appetite is insatiable ; we find nausea, vomiting, and diarrhoea. The disease generally lasts one or two months. In severe cases delirium occurs as a precursor to death. In gangrenous ergotism the same symptoms happen ; but in addition we meet with gangrene without fever or signs of inflammation. The gangrene may be in the extremities or in the face. Where ergot is being taken in diabetes, the gangrene results from the malady, not from the drug. * Triquet, Le Briert. POISONS AND PAEASITES. 1041 Let us now examine some of the features of slow poisoning by the metals. Mercury, in any of its preparations, may lead to chronic poison- ing. The mouth is inflamed, the gums are sore and swollen, the salivary glands act inordinately, and the breath is very offensive. Colicky pains, and sometimes diarrhoea, occur. Tremors of the limbs when any motion is attempted are particularly frequent in cases where the poison has been inhaled in the form of vapor ; they come on by degrees, and are associated with loss of power of locomotion and with digestive disturbances. The tremors may be incessant and the movements involuntary, like those of chorea, and so rapid as to prevent the patient from obtaining rest at night.* In some cases an eczematous affection is observed. Poisoning by mercury is generally the result of the exposure to its action incidental to certain occupations, such as glass-plating, gilding, and working in quicksilver-mines. Lead poisoning is by no means uncommon among painters, plumbers, type-setters, and other workers in lead. Sometimes it may be caused by accidental circumstances, as when the patient has drunk water passed through leaden pipes, or taken snuff which has been impregnated with lead for the purpose of coloring it. Poisonous properties are also acquired by snuff wi'apped in lead- foil ; and lead poisoning has been observed after the use of cos- metics ; and among those engaged in the manufacture of lucifer matches, of brushes, of lace, or working in glass enamel or glass powder;t and in consequence of food adulteration, especially of the use of lead chromate to color cakes.J In such cases, the physician may have to depend entirely upon a correct appreciation of the symptoms for the diagnosis. Pain and uneasiness in the course of the colon, constipation, loss of appetite, anaemia, weakness, mental depression, and emaciation are the earlier signs. A metallic taste is perceived; the breath is * As in a ease reported by Taylor, in which the patient died from the effects of the poison, without, however, having presented salivation or mer- curial fetor of the breath, or a blue line on the gums. Guy's Hospital Keports, 3d Series, vol. x. t Lacharriere, Arch. Gen. de Med., Dec. 1859. X Stewart, Clinical Analysis of Sixty-Pour Cases of Poisoning by Lead Chromate, Medical News, Dec. 31, 1887, andii., .Jan. 26, 1889. 1042 MEDICAI, DIAGNOSIS. fetid, the tongue pale and furred ; the gums are edged with a narrow blue line of sulphide of lead, deposited mainly outside loops of blood-vessels. Colicky pains are felt from time to time, and a severe and long-continued attack of colic may form the culmination of the disease. The muscles atrophy ; electro-mus- cular contractility to the faradaic current is greatly diminished, to the galvanic current it is frequently unaltered or increased ; the sensibility of the skin is but little affected. Occasionally wrist- drop or paralysis of the extensor muscles of the forearms, the well-known phenomenon of lead jioisoning, occurs among the first symptoms; but it is more generally preceded by one or more attacks of colic. The right arm mostly suffers first. "We also find at times lesions of the tendons in saturnine palsy.* Yet aS regards this palsy we must bear in mind that a paralysis of the extensors occurs which is not due to lead.f Another manifestation of lead poisoning is found in the severe pains in the joints and the neighboring muscles. These pains have violent exacerbations, and may be associated with cramps of the painful muscles. They are most common in the lower extremity, especially over and near the knee-joints. There are no signs of inflammation of the affected joints and muscles; pressure tends to relieve the pains. Sometimes, in cases of saturnine poisoning, there is evidence of grave cerebral disorder : epileptiform convulsions, attacks resem- bling apoplexy, or general tremors and extended paralysis of the muscles, with acute delirium, inequality of the pupil, optic neu- ritis, retinal hemorrhages, loss of sight, and other signs of nervous disturbance, are noticed. Of course the diagnosis, under these circumstances, will be materially assisted by an accurate knowl- edge of the previous history of the patient as regards exposure to the action of the poison. The tremors are, like those caused by mercury, peculiar in ceasing when the limbs are supported or at rest ; they are increased by movement. There may be tremor in the muscles of the face, which, however, are not affected by paralysis. Another result of lead poisoning is that it leads to granular degeneration of the kidneys. This is apt, again, to * Medical Times and Gazette, May, 1868. t St. George's Hospital Keports, 18(j8, p. 86. POISONS AND PARASITES. 1043 coexist with a gouty condition, which, as Garrod has shown, is one of the results of the absorption of lead. But the kidney affection may be found whether or not the joints are markedly affected. Lancereaux * has attributed most of the cerebral symp- toms and the dyspnoea that may be met with to the diseased condition of the kidneys, which may, however, exist without albuminous urine. In instances in which the symptoms of lead poisoning are ob- scure or conflicting, we may search for lead in the urine. The detection of small amounts of lead is simple in principle, but practically cannot be undertaken except by a professional chemist. A considerable proportion of the lead is eliminated by the bowels. Copper poisoning gives rise to dyspeptic symptoms, to diuresis, to loss of flesh, to lassitude and giddiness, to a peculiar greenish- blue perspiration, and to a green line on the gums and teeth. It is said that workmen in copper are singularly insusceptible to cholera or choleraic diarrhcea,t and that wounds in them heal with extraordinary rapidity. Copper appears to be somewhat less liable than mercury, lead, arsenic, or antimony to cause serious chronic poisoning, possibly because it is less cumulative. Small amounts of copper are frequently present in the liver and brain of man and some of the lower animals, also in some articles of food. Dr. Leffmann informs me that, in the examination of viscera from the cases of lead poisoning which occurred in Phila- delphia, copper in minute amounts was fi'equently encountered, and in one case, that of a child four years of age, ah appreciable quantity was obtained from a portion of the liver. Arsenic, administered in small doses for a lengthened period, produces a state of chronic inflammation of the alimentary canal. Conjunctivitis, oedema of the face and the limbs, in some instances associated with albuminous urine, irritability of the stomach, diar- rhoea, sleeplessness, increasing weakness, numbness, formication, alterations of sensation, and even paralysis, mark the progress of these cases ; the hair and the nails occasionally fall out, and there is much frontal headache. Similar effects are noticed to follow the pernicious habit of arsenic-eating, and will be also encountered * Arch. Gen. de Med., Dec. 1881. ■f Clapton, Clinical Society's Transactions, vol. iii. 1044 MEDICAL DIAGNOSIS. among persons employed in making artificial flowers and toys, in dyeing cloths, in manufacturing and hanging green wall- papers, or in the sublimation of arsenical ores ; those, too, who live in rooms hung with papers containing much arsenic have exhibited the influences of the poison.* Besides the phenomena of internal poisoning, cutaneous eruptions occur from arsenic. The extensors of the hands and feet are especially affected. In some instances, said to be not uncommon in Russia,t paralysis of the extremities, with muscular atrophy, happens. "Arsenical paralysis may have mainly the symptoms of poliomyelitis, as I have had occasion to observe.J In other cases there are severe darting pains in the arms and legs, defective cutaneous sensibility, loss of knee-jerk, and the appearances of locomotor ataxia.§ The palsies of arsenical poisoning are now generally thought to be due to peripheral neuritis. The inhalation of the fumes of zino gives rise to a peculiar form of poisoning, characterized by a sense of weariness, by a feel- ing of tightness in the chest, and by attacks of shivering, followed by heat of skin and a profuse sweating-stage. This irregular form of ague is common among brass-founders. || Carbon disulphide produces toxical effects of a singular char- acter, conspicuous among which are gastric disturbances, inordinate appetite, loss of muscular strength, a cachectic condition, a feeling of icy coldness in the lower limbs, severe cramps in the calves of the legs, impotence, and, in severe cases, amaurosis, impaired hearing, hallucinations, loss of memory, and complete perversion of the intellect. Tf These phenomena are met with among workers in india-rubber. Phosphorus is often seen, pai-ticularly among those who work in lucifer-match factories, to give rise to serious lesions. When the poisoning is caused by inhaling the vapor, it may occasion, as acute phosphorus poisoning does, alteration of the composition * James Putnam, Analysis of Twenty-Six Cases, Bost. Med. and Surg. Journ., March, 1889. t Scolosuboff, Arch, de Phys., Sept. 1875. j Phila. Med. Times, March and July, 1881. § Dana, Brain, vol. ix. II Greenhow, Med.-Chir. Transact., 1862. f Delpech, Memoires de I'Academie de Medecine, 1856 ; and Heurtaux, Eecueil de la Sooiete Medicale d' Observation, 1860. POISOXS AND PARASITES. 1045 of the blood, a hemorrhagic diathesis, a fatty degeneration of several organs, as well as of the voluntary muscles,* and pepto- nuria. It also produces chronic bronchial catarrh, but especially necrosis of the jaw, for which the whole lower jaw has been re- moved.f The disease begins in carious teeth, and may extend to the cranial bones. Osteophytes form freely in the affected bones. Phosphorus taken internally in doses that gradually exert a poisonous effect leads to chronic inflammation and thickening of the stomach, colicky pains, diarrhoea, ^ectic fever, general emacia- tion, falling out of the hair, and to palsies, which are generally the precursors of a fatal termination. Animal poisons. — These may give rise to chronic as well as to acute poisoning. We find, for instance, syphilis, gonorrhoea, hy- drophobia, dissecting wounds, snake-bites, acute glanders, and farcy, — all disorders exhibiting -the effect of an animal virus. But we have already discussed some of these as far as is admis- sible in a work of this kind ; and of the others it need only be said that the antecedent circumstances generally place the diag- nosis beyond a doubt. Yet there are a few illustrations of animal poisons and their effects which must here, however briefly, be mentioned. One of these is the malignant pustule, or ardhrax, a terrible malady, which is the cause of many deaths on the Continent of Europe, and which is identical with the charbon of animals. The disorder is also prevalent in New Mexico.f It is communicated to man by direct inoculation ; or by means of the skin or hair of the diseased beast, or by eating its flesh ; or by insects which, sucking the poison from the sick animal, implant it on the skin of man. The poison produces a red speck, which develops into a vesicle, under and around which an extremely hard spot forms that becomes gangrenous. The surrounding skin inflames, new vesicles or pustules spring up, and the gangrene spreads rapidly, the patient speedily sinking ; or the death of the parts is arrested, and separation takes place between the living and the gangrenous textures. In some cases it is attended with extended oedematous * Lancereaux, li'Union Medicale, 1863. f Cases of Hunt and Boker, Amer. Journ. Med. Sci., April, 1865 ; Wells, New Tork Med. Journ., Jan. 1866; Wegener, Virchow's AreHv, Bd. xl. J A. H. Smith, Amer. Journ. Med. Soi., April, 1867. 1046 MEDICAL DIAGNOSIS. swelling and infiltration of the areolar tissue spreading from the anthrax pimple. It is remarkable how little local pain attends the grave constitutional disturbance, and the signs of low, irrita- tive fever. The disease is found on the exposed portions of the body, as on the neck and hands. It has been traced by Davaine to the presence of filiform bacteria, bacillus anthracis. The blood swarms with these bacilli ; and, as Koch has proved, they propagate themselves by spores, which finally grow into bac- teria. The researches of P^isteur and of Koch fully confirm the parasitic view of the origin of the disease. Closely connected with malignant pustule is the so-called " wool- sorter's disease." The wool from sheep is not nearly so dan- gerous as the hair from the goat, the alpaca, and the camel. The mohair from the Lake Van district, Asia Minor, is the most dangerous. The symptoms may be those of malignant pustule with secondary splenic fever, or there often is an utter absence of either external or internal pustule.* The manifestations of the disease are frequently a low fever with secondary abscesses, pysemic symptoms, and pleuro-pneumonia. The complaint is a dangerous one, and often fatal ; when ending in recovery, con- valescence is slow. Another disease transmitted from infected animals, and due, it is thought, to fungi, is the so-called actinomycosis hominis, de- scribed chiefly by Israel f and by Ponfick.J The disease first ap- pears in the lower part of the face, in the shape of little abscesses containing yellowish granules, which consist of ray fungi. These vegetations are readily detected by the microscope. The disease spreads to the ribs and vertebrae, and produces great destruction of tissue ; it is also found in the liver and the lungs, in the brain, in the intestines, and in the skin ; there are the symptoms of chronic pyaemia. Various forms of it, as of the liver and of the lungs, have been already described in connection with those organs. The foot and mouth disease is an affection from which especially children suffer who have drunk the milk from mfected cows. The * Bell, Lancet, June 12, 1860. f Virchow's AreWv, Bde. Ixxxv., Ixxviii. J Die Actinomykose des Menschen, Berlin, 1832. POISONS A2SD PAEASITES. 1047 poison produces an aphthous stomatitis with digestive disorder, and frequently also a vesicular eruption on the face and on the fingers and hands, which gradually dries into brownish scales, and at times a similar eruption between the toes. The disorder is not a serious one. It is due to a micro-organism, the strepto- cytus of Schottelius. There is another form of animal poisoning which may be in this connection briefly considered, — namely, milk-sickness. Now, its phenomena are so variously described by writers that its characteristic signs are difficult to define. It prevails in the southern and southwestern portions of North America, and is brought on by drinking the milk or eating the flesh of cattle which have been exposed to certain influences the nature of which is as yet unknown. Gastritis and enteritis seem to be more or less blended in the early stage of the disordei", which at a later period is said strongly to resemble typhus fever. The symptoms dwelt upon more especially are lassitude, nausea and vomiting, with a sense of burning at the epigastrium, great oppression, intense thirst, hot, dry skin, obstinate constipation, and obvious abdominal pulsation. If at all, recovery takes place very tardily, the tone of the stomach being often left impaired for life. Other forms of animal poisons originate in alkaloids generated during decay. The poisoning by these ptomaines from milk and eggs and other substances has already been mentisned. Fre- quently the ptomaine poisoning resembles that of the vegetable alkaloids, such as of morphine, codeine, and veratrine. Besides these forms of animal poisoning, which are produced by the direct contact with the virus, or at all events by its intro- duction into the system through the stomach, we find morbid states occasioned by animal poisons which arise from decomposing bodies or excretions, or from the crowding of many together, par- ticularly of those of uncleanly habits, or of the wounded. These poisons reach the blood for the most part by the lungs, in the shape of poisonous exhalations. They are very depressing in their action, may lead to low fevers, or to septicaemia, and in the case of the wounded to pysemia and to hospital gangrene. Persistent nausea, too, and a lowering of all vital energy are not uncom- monly observed in those who breathe continuously the foul air under the circumstances alluded to, — as in hospitals and in prisons 1048 MEDICAL DIAGNOSIS, in which thorough cleanliness is not enforced and due regard is not paid to ventilation. In some persons deleterious emanations from the human body give rise to a form of toxsemia, one of the chief features of which is the marked anorexia which attends the great debility.* The exposure to animal effluvia may also excite violent diar- rhoea, or even symptoms like those of cholera, certainly like those of severe attacks of cholera morbus. Of the occurrence of the former we have an illustration in the dissecting-room diarrhoea, which is usually attended with very fetid discharges, and may be accompanied by colicky pains, by nausea and vomiting, and by headache. The same kind of diarrhoea also happens in those who clean privies, or who are exposed to the emanations arising from sewers ; or dysentery or choleraic attacks may follow the exposure. Nay, as in instances recorded by Becquerel, the instant disengage- ment of large quantities of putrid gases, arising from bodies far advanced in decomposition, where coffins have been opened, has caused sudden deaths, or has resulted in so serious a state of poison- ing as to give rise to very grave illnesses, having mostly a fatal termination.! In individuals who, in consequence of their voca- tion, are habitually brought in contact with animal effluvia and are liable to inhale noxious gases, besides the attacks of diarrhoea referred to, chronic disturbances of the stomach and liver, with marked impairment of the general health, may happen. Cases occur of self-infection from ptomaines resulting from decomposi- tion of faecal matter lodged in the csecum, or by perforations taking place from the intestine into abscesses near by, into which the contents of the bowel find their way. PAKASITES. Parasites are organisms which become secondarily implanted within or upon the body. Some parasites give rise to no symp- toms at all ; many occasion phenomena closely resembling those of other irritations. In any case, the only absolutely convincing evidence of the presence of a parasite is obtained by seeing it. * See Dr. Hunt's case, described by himself, in Pennsylvania Hospital Ke- ports, vol. i. f Traite d'Hygiene, 3d edit., p. 218. POISONS AND PARASITES. 1049 Vegetable Parasites. — ^The chief vegetable parasites have been mentioned in connection with diseases of the skin ; the oidium albicans, present in. thrush, and the sarcinse ventriculi, have also been described. All these vegetable growths can be detected only by the microscope ; and, particularly in those in- volving the skin or the hair, it is of the utmost use to employ the liquor potassse, under the action of which the structures become transparent. The fungus that penetrates the internal tissues, the chionyphe Cai-teri, gives rise to that terrible disease known as podelcoma, or the fungus foot of India, — a complaint found among the natives of India who go about with naked feet. Tlie fungus, introduced either through a scratch or passing through the pores of the skin, soon spreads, eating its way into the bones of the tarsus and meta- tarsus, and into the lower end of the tibia and fibula, producing a species of caries, or rather a breaking up and absorption of the osseous tissues. The fungous particles or masses are generally of deep-black color, firm and globular, varying in size from that of a pea to that of a pistol-bullet ; or the fungus presents the ap- pearance of sloughing tissue, and exhibits chiefly white granules ; or it consists of particles of pinkish color. The foot is enlarged about the ankle and over the instep ; and on each side of the ankle-joint, and on the dorsum as well as on the sole of the foot, are small, soft swellings, having pouting openings that lead to fistulous canals communicating with the bones, which they perfo- rate in every direction. The fungous mass is for the most part situated in the cavities in the bones, and from the canals passing to them transudes a discolored, glairy, or purulent and fetid fluid. The toes are distorted, and the muscles of the leg atrophied ; but the fungus does not spread up the leg. The tendency of the dis- ease is to cause death by exhaustion ; the only remedy is amputa- tion.* The aifection has also been observed in this country, f A similar disease, leading to local destruction, is the perforating ulcer of the foot. It is very uncommon in this country, although I have known of cases ; in France it is not uncommon. It is sup- * See Carter, in Transact. Bombay Med. and Phys. Soc. ; and on Myce- toma, or the Fungus Disease of India, London, 1874 ; Aitlien, Practice of Medicine; Lewis and Cunningham, Arch, of Dermatol., Oct. 1880. f Kemper, American Practitioner, Sept. 1876. 1050 MEDICAL DIAGNOSIS. posed to be due to defective vitality of the parts from altered nerve-supply. Local ansesthesia, lowered temperature, and a tendency to profuse perspiration exist. The ulcer leads down to diseased bone. It is generally situated on the first or the last toe, over the articulation of the metatarsarbone with the phalanx.* The toes sometimes drop off from a disease which constricts them and enlarges them beyond the point of constriction. The affection is not unusual in Brazil, and seems to be peculiar to the negro. It is known as ainhum.'\ Animal Parasites. — When speaking of the affections of particular structures, some of these intruders have been men- tioned, — those found in the skin or in the liver, for instance. It remains to consider chiefly such of the more important ones as inhabit the hollow viscera, certain solid organs, and the rauscles.J Intestinal worms are the most common of all parasites. The general symptoms induced by them are those of intestinal irrita- tion with disordered digestion. The appetite is capricious ; the bowels are irregular, sometimes constipated, sometimes relaxed ; the abdomen is frequently swollen and hard, and the seat of dis- tressing uneasiness or of colicky pains ; the tongue is furred ; the breath is fetid ; and there is constant itching about the nostrils and anus. The patient, furthermore, grits his teeth during sleep, and is often annoyed by nightmare. Phenomena indicative of a greater or less degree of nervous disturbance are also met with ; they may range from mere fretfulness up to delirium, convul- sions, chorea, epilepsy, or insanity. Strabismus and amaurosis may be also due to worms. § There are many kinds of worms known to infest the alimentary canal of man, and they belong to the order of nematoda, or round worms, or to that of cestoidea, or tape-worms. The round worms are parasites of an attenuated or cylindrical form, and present these varieties : * Savory and Butlin, Med.-Chir. Transact., 1879. f Da Silva Lima, Arch, of Dermatol., Oct. 1880; Duhring, Amer. Journ. Med. Sci., Jan. 1884. X 'Pot full description, see the admirable works of Joseph Leidy, A Flora and Fauna within Living Animals, Smithson. Pub., vol. v. ; Davaine, Traite des Entozoaires et des Maladies vermineuses ; Cobbold, Entozoa ; Leuckart, Die Menschlichen Parasiten, Leipsic ; Kiichenmeister, Manual of Parasites. i Hogg, Brit. Med. Journ., July, 1888. POISONS AND PARASITES. 1051 1. The ascaris lumbricoides, or round worm, bears a consider- able resemHance to the common earth-worm, from which it is, however, anatomically different. It inhabits the small intestine, sometimes finding its way into the stomach, or even into the oesophagus, or being discharged through the abdominal parietes.* When it ascends to the stomach and oesophagus, it causes, before it is expelled by the mouth, sudden attacks of fever and gastric derangement, with nausea and vomiting; and even, at times, marked delirium.! The worms have been known to be so numer- ous as to obstruct the intestine. 2. The oxyuris vermicularis, thread-worm or seat-worm, is very small, the male being about two lines, the female about five lines in length. The parasite is white, slender, and extremely active ; it is found in the anus, and causes intense itching of this part. The annoyance is sometimes such as to excite a suspicion of the existence of piles. It may creep into the vagina, giving rise there to profuse discharges ; or into the urethra. It affects chil- dren frequently, but is not uncommon in adults. 3. The ascaris mystax, a parasite which inhabits the cat, may also infest the human body. It is a moderate-sized nematode, from two to three inches long, though the female may reach about four inches. Its head end is spear-shaped. 4. The trichocephalus dispar, or lorig thread-worm, is detected in very large numbers in the ileum near its termination, or in the colon, particularly at its head. It has been found in persons laboring under typhus or typhoid fever, or dying from cholera or diarrhcea. It is from an inch and a half to two inches in length, and is characterized by the hair-like appearance of the head, which is genei'ally buried in the mucous membrane of the intestine. It is not a common parasite, and it is doubtful whether its presence gives rise to any marked derangement. The tape-worms, or cestoidea, are jointed entozoa, of a ribbon- like form. They embrace the true tape-worms, or tseniadse, and the bothriocephali. Of the former there are eight varieties, all of which have been found in man, though only two — ^the solium and the mediocanellata — are at all common ; the taenia saginata. * Gamier, L'Union Medicale, Oct. 1861. ■f Schmidt's Jahrbiicher, No. 10, 1868. 1052 MEDICAL DIAGNOSIS. however, has spread over parts of Western Europe.* The bothriocephalus latus is the usual species of bothriocephalus met with in the human intestine ; it, too, is increasing greatly in Europe, and, it is said, in Texas, particularly in the western portions.f The txnia solium, or pork tape-worm, consists of an immense number of joints in connection with a single head. It may attain an enormous length, and inhabits chieily the small intestines. The researches of Kuchenmeister,J Von Siebold,§ and others have shown that its eggs become developed into the cysticercus cellulosse discerned in the muscles of the pig, rabbit, and other animals whose flesh is used as food. Cysticerci have also been detected in the muscles, the cellular tissue, the brain, the spinal cord, the heart, and the liver of man, and are most commonly met with in middle age and in the destitute ; they are the most frequent parasite in the eye.|| They cannot, as a rule, be diag- nosticated, except they be in positions in which they can be seen or felt, or the little tumors they occasion in the subcutaneous tissues are extirpated and examined. In the brain their chief symptom is violent and rapidly-increasing epilepsy. Being once introduced into the alimentary canal, they find there a nidus in which to undergo development into the tape-worm. The tape-worm is nourished from its head, the newly-created segments pushing those already formed before them, so that the caudal extremity is the oldest portion of the animal. Each £eg;ment is flat and rectansrular, and contains both a male and a female organ, the orifices of which, are joined at the apex of a lateral papilla. In the taenia solium, the papillae are arranged alternately at one side and the other. The size of the segments increases gradually toward the caudal extremity, the largest being three or four lines in breadth. There may be upwards of eight hundred segments, and the worm may measure above * Von Zehender, Parasitical Diseases of the Eye, Bowman Lectures, Deutsch. Med. Wochenschr., No. 50, 1887. ■j- Colman, quoted in Sajous' Annual, vol. i., 1890. J See Manual of Animal and Vegetable Parasites, Syd. Soc. transl., 1857. § Origin of Intestinal Worms, ib., 1857. II Berenger-Peraud, Le9ons de Clinique sur les Taenias de THomme, Paris, 1888. POISONS AND PARASITES. 1053 ten feet ; it has been stated even to be above thirty. Upon the head, which is about as large as that of a pin, is a double circle of hooks contained in sacs, Fig. 89. and around this circle are ar- ranged four sucking-cups or mouths. The slender neck exhibits no segmentation. The sucking - disks in the taenia mediocanellata are larger than those in the tsenia Fra. 90. Segments of tseuia solium. Drawn from a specimen. Heads of tseniee, magnified, except the small central figure, which represents the head and neck of taenia solium, natural size. The figure to the left is the tsenia solium, that to the right the mediocanellata. solium, but the liead, which is of blackish appearance, and obtuse, has no hooks. The form of tape-worm most frequently seen in this country is the tsenia mediocanellata, which is usually found in beef. Leidy states, as the result of a large experience, that he has rarely encountered the pork tape-worm, tsenia solium, as a parasite in the human intestines. The habit of eating partially-cooked beef is the cause of much of the infection with tape-worm. Tsenia occasions disordered digestion, colic, cramps, a feeling of 66 1054 MEDICAL DIAGNOSIS. uneasiness in the abdomen, irritation of the mouth, nose, and anus, anaemia, headache, dizziness, disturbed sleep, mental depression, emaciation, cough, fainting-fits, cutaneous eruptions, and various cerebro-spinal affections, such as convulsions and epilepsy; yet there are no absolute data for the diagnosis of this parasite, except its appearance in the discharges. In order that relief be perma- nent, the head must be expelled. The bothriocephalus lotas, tsenia lata, or broad tape-worm, differs from the common tape-worm in having no lateral papillae alter- nately arranged, but a single one at the centre of each segment ; the segments themselves are much broader, and with the breadth greatly preponderating over the length ; the head is of elongated form, has no hooks upon it, and only a pair of fissures instead of the four mouths of the tsenia solium, and we find no traces of joints mitil about three inches from the head. The parasite is of yellow or grayish-white color. Ediinoeocd belong also to the family of the tseniadse. They may take up their abode in the substance of almost any organ in the body, and are the immature brood of a species of tsenia. They consist of a vesicle having at one portion of its wall a head, upon which are six booklets circularly arranged. The whole animal is surrounded by an investing membrane, which may burst and allow it to escape ; the term hydatid designates the enveloping cyst. It forms when the tsenia embryo has bored its way to its resting- place in the liver, or has been carried with the circulation to other organs. The echinococcus, unlike other larval tsenise, retains a more or less globular figure, in place of exhibiting a head, neck, and body. When the echinococci are arrested in their normal development and are barren, not attaining to the production of scolices, they give rise to cysts with walls consisting of distinctly- developed, concentric layers, and having a peculiar gelatinous trembling, — the so-called acephalocysts ; and the same may be said of abortive cysticerci, embryonic forms of tsenia, which, some sup- pose, may also occasion the hydatid cysts ; though others maintain that the hydatids proceed from only one form of tsenia, — the tsenia echinococcus. The family of the distomata, belonging to the order of fluke- like parasites, is not at all uncommon in man. A species of distoma, measuring from eight to fourteen lines in POISONS AND PARASITES. 1055 length, called- the distoma hepaiicum, usual in the liver and gallr bladder of the sheep, has been seen in the human liver and gall- duct, and also, it is said, in abscesses of the scalp. Other species of distoma have been found in the portal vein, ureters, kidneys, and bladder, and upon the intestinal mucous membrane ; yet in the portal vein and its larger branches — a common seat of the distoma — ^the parasite produces little or no appreciable derange- ment ; but when in the intestine it may give rise to congestion of the membrane, extravasation of blood, and the symptoms of dysentery. This has been specially noticed of the distoma haematobium, or Bilharzia hsematobia, a worm which is common in Egypt, and which has been found to be the cause of the hsema- turia prevalent at the Cape of Good Hope and at the Mauritius. The entrance into the body is mainly through the urethra in persons bathing. FUarise have been met with in the urine. Lewis * regards the hsematozoon he has described as a filaria. The filaria sanguinis hominis is supposed to get into the system chiefly through the bites of mosquitoes, or by entering the skin of bathers. It gives rise to considerable pain in the loins, and leads to both bloody and chylous urine, and, according to Manson, to the elephantiasis of the tropics. Mastinf proves that the filaria in the United States may be the cause of chylocele of the tunica vaginalis testis. A worm called the strongylus gigas has been observed in the kidneys. It produces hsematuria, continuous pain, and an abdom- inal tumor,! and may lead to dropsy and death.§ The dochmius duodenalis is a worm producing a peculiar anaemia by sucking blood from the walls of the duodenum. It has been found especially among brickmakers, miners, and men working in tunnels, and the disorder has been identified by Leichenstern || with the so-called Egyptian chlorosis, tropical chlorosis, and brickmaker's anaemia. It has spread largely through Italian * Lancet, vol. ii., 1873 ; see also Manson, Medical Times and G-azette, 1881 j Mackenzie, On the Periodicity of Filarial Migration, Lancet, 1881. t Medical Record, Sept. 1888. X Magner, Journ. de Med. de Bordeaux, Feb. 1888. I George, Med. and Surg. Reporter, Aug. 1888. II Schmidt's Jahrbiicher, Sept. 1888 ; also, Internationale Klinische Rund- schau, Oct. 1888. 1056 MEDICAL DIAGNOSIS. and Polish laborers employed in building tunnels, in mining, and in brickmaking. Anchylostomiasis, as the disease caused by the parasite is called, is characterized by marked anaemia, by diges- tive disorder, abdominal pains, and bleeding from the bowels. There is a greater tendency to retinal hemorrhage than in simple ansemia.* Sandwith speaks of the marked sleepiness and dense stupidity.f Fly parasites may be found in the dejections from the bowel and in the urine, producing local irritation of the intestine or the bladder. The parasites which chiefly occupy the areolar tissues or the muscles remain to be described. Of these there are two of special importance. One is the filai'ia medinensis, dracun&dus, or Ouinea-worm. This is a very slender, flat, finely-ringed worm, which intro- duces itself into the subcutaneous cellular tissue : here it grows rapidly, and gives rise to swelling, with more or less inflamma- tion ; and sometimes to severe constitutional disturbance. After a time the swelling points, and breaks, and the worm may be laid hold of and carefully twisted around a little piece of stick or a quill until it is extracted entire; if broken off, the eggs with which it is filled, getting into the wound, will become the agents of fresh mischief. Many of these worms may be found in the same patient, occasioning great annoyance and distress, even fatal exhaustion ; but it is stated that there is often only one present. The number may vary between this and fifty. Some worms are twelve, others forty inches long, or even more. According to Busk, the parasite grows in the human areolar tissue at the rate of about an inch a week. Though it is most frequently found in the lower extremities, it has been observed to appear in the socket of the eye, in the mouth, the cheeks, the ears, and under the tongue and the scalp. It migrates rapidly from one part of the body to another. Where it exists, a pricking or an itching heat is felt ; a vesicle forms when the worm is about coming to the surface, and this vesicle opens, leaving an angry-looking ulcer, in the centre of which the parasite shows itself. Phlegmonous * Discussion at the Brit. Gynaecol. Soc, Brit. Med. Journ., June, 1888. •j- Trans. Eleventh Internal. Medical Congress, 1894. POISOXS AND PAEASITES. 1057 spots may appear all over the body in which specimens of dra- cunculus are found.* The period of incubation is from eight to twelve months: a year often elapses before the Guinea- worm makes itself manifest in the human body.f The disorder, com- mon in Asia and in Africa, is, fortunately, one with which we are unacquainted. Tnchina spiralis. — This parasite was discovered by Owen in 1835 in human muscles taken from the dissecting-room ; it was Fig. 91. Trichina in recent human muscle, talcen the thirteenth day of illness. (After Dalton.) subsequently found by Leidy in the animal which it most infests, the pig ; but it was not looked upon as other than harmless until * Woskresensky, quoted in Sajous' Annual, vol. i., 1889. f Aitken's Practice of Medicine, vol. i. 1058 MEDICAL DIAGNOSIS. in 1860 Zenker proved that trichinae may exist free in the muscles of man, that they are encapsuled only after some time, and that they are the cause of a very serious disease. The parasite is always introduced into the body by eating ham, pork, or sausages made from the flesh of pigs containing trichinae. It is very probable that the hogs themselves obtain them from rats, in which they are common. It has also been stated that trichinae may exist in beef; but this is not generally admitted. The trichina spiralis is the juvenile condition of a small nema- tode worm. It becomes fruitful only when introduced into the intestine. After being swallowed, the female trichina begins to throw off minute embryos, which migrate to the muscular struc- tures.* They pass to them through the intestinal walls, the mes- entery, and the blood-vessels. When they reach the muscles they grow there, but do not generate others. When the young trichina arrives in the muscles, it begins at once to destroy the muscular texture. It penetrates and irritates the sarcolemma, leading to its gradual thickening and to an exu- dation that fixes the worm to a particular spot. Thus is formed the cyst which encapsules the parasite, and which plays so important a part in its subsequent destruction. It takes a month or months for the cyst to form completely. Several trichinae may wander in the same track, and ultimately be enclosed in the same mass of exuded matter. Two are not infrequently seen in- timately coiled up, and the number may rise to five.f After the perfect formation of the cyst, further changes take place in it ; particles of calcium and magne- sium carbonate are deposited. The calcareous mass extends, and gradually covers the whole parasite, while around the prolonga- tions of the cyst fat-cells are deposited. The whole process is very destructive to the flesh-worm, and it is thus that the dis- FiG. 92. Tricbina capsule with shell-like calca- reous deposits. (After Leuckart.) * Leuckart, Untersuchungen liber Trichina Spiralis, Leipsic, 1866. t Thudiehum, Blue Book, Seventh Eeport of the Medical Officer of the Privy Council, p. 367. POISONS AND PAEASITES. 1059 order is cured. But it is apt to be months before this result is ac- complished. Nay, as we know from two cases recorded by Vir- chow, neither the encapsuling nor the calcareous transformation kills the worms of necessity at all speedily ; for in the one case they had remained alive for eight, in the other for thirteen and a half years after the infection,* and in one instance mentioned by Turner f they were alive and active after twenty-six years. The number of trichinse in the muscles may be from several hundreds to as many millions. Now, in accordance with their number in the muscles, with the character of the changes which there take place, and with the quantity in the intestines, will vary the extent of constitutional de- rangement and the signs of local irritation. Thus the symptoms and the dangers of trichiniasis are not always the same : we find, in- deed, all the degrees of the malady. When merely a few thousand trichinae occupy the muscles, there are chiefly muscular pains with stiffiiess and general debility ; signs which gradually cease as the worms Encap8,,led chalky concretions inmnscl., become fully encapsuled and ere- t^rl^^^^l^iM^ioJi^tt^ "'"'"' taceous alterations occur. When the muscles are occupied by many millions of the flesh-worms, the local phenomena are much more severe ; there may be almost complete immobility of the whole body, the muscles of respira- tion and of deglutition are implicated, irritative fever and the general cachexia are marked, and the patient is apt to perish by gradual exhaustion, or in consequence of the disordered respira- tory function, or of some pulmonary complication. The presence of large numbers of trichinae in the intestine produces diarrhoea, vomiting, abdominal pain and tenderness; or the worms may shortly after being swallowed give rise to a kind of cholera mor- * Virchow, op. cit , p. 40. j- Lancet, London, May, 1889. 1060 MEDICAL DIAGNOSIS. bus. Should the signs of the affection not appear until from twenty-one to twenty-five days after the use of the infected meat, and take the form similar to acute rheumatism of the joints, there are not as many trichinae present as in the choleroid or the typhoid variety of the malady, each of which Eupprecht* has told us shows from five to ten millions. Speaking generally, we may recognize in trichiniasis three stages : the first, lasting about a week, during which the trichinae are being generated in the intestines and in which we find only signs of gastro-intestinal irritation ; the second, the passage of the brood into the muscular textures, and the disturbances it there occasions ; the third, the retrogressive formation, which fairly sets in about three or four weeks after the beginning of the second. Now, it is this stage which yields the most striking manifestations of the malady:— loss of appetite; pasty taste in the mouth ; nausea or vomiting ; dry, somewhat coated tongue ; diarrhoea; abdominal pain and meteorism ; prostration; fever, with a quick pulse and copious sweating ; oedematous swelling of the face, followed in grave cases by almost general anasarca ; sensitiveness of the skin and the muscles to the touch, or pain- fulness when the latter are moved, and their contraction and difficult motion; dyspnoea; apathy; sleepless nights; nocturnal attacks of abdominal neuralgia ; and emaciation. Let us examine some of these phenomena more in detail : The fever is a marked symptom. It sets in early, owing to the intestinal irritation, though it is not until the end of, or after, the first week, after therefore the migration of the young trichinae has fairly begun, that it is strikingly developed. It is then, except in those cases in which fresh importations of trichinae from the intestine in considerable numbers produce ex- acerbations, a continuous fever, with a pulse ranging from 100 to 130, with scanty urine and profuse perspirations having a very unpleasant odor and which may continue in certain parts of the body after the general sweating has entirely ceased. The temperature is about 101°, though it may pass to 104° and 105° ; yet it does not, as a rule, reach the high heat which is observable in other continuous fevers. But it is especially in the * Vierteljahrssolirift fiir Ges. Med., Oct. 1880. POISONS AND PARASITES. 1061 profuse perspirations, the absence of enlargement of the spleen and of an eruption, the swelling of the face, the muscular symp- toms, and in a very red color of the visible mucous membranes, that the points of difference lie between the febrile excitement of Pig. 94. Trichina spiralis. Magnified 3U0 times. (After Virchow.) trichiniasis and typhoid fever, — a malady which, on account of the continuous fever, the prostration, the diarrhoea, and the su- damina, it resembles. In light cases of trichiniasis there may be no fever, or there may be a fever more of intermittent or remit- tent character. The appearance of the face may be like that of typhus fever ; here, however, the muscular pains are wanting.* The oedema marks the beginning of the second stage of the affection. It manifests itself first in the eyelids, about the seventh day of the disease, and is attended with a catarrhal state of the conjunctiva, with dilated pupils, great susceptibility to light, diminished power of accommodation, and pain in moving the * See Clinical Lecture on Acute Trichiniasis. reported in Medical News and Abstract, March, 1881. 1062 MEDICAL DIAGNOSIS. eye. The swelling may extend over the whole face, and is some- times associated with flushing. It is uninfluenced either by the sweats or by the diarrhoea, but lessens generally very much, or even disappears, after lasting eight or nine days, though it may vanish in a few days ; at the same time, too, the diarrhoea is apt to diminish, or even gradually to cease. But instead of the oedema subsiding, it may extend to the chin, to the arms and legs, and to the back ; or it may show itself in the extremities subse- quently to the disappearance from the face, and shortly afterward become perceptible over the trunk. In some cases an anasarcous condition, beginning at the ankles and extending upward, occurs during convalescence, and is of long duration. It is then prob- ably connected with the state of the blood ; whereas the oedema happening earlier in the malady is thought to be due to the press- ure upon the arteries, exerted by the parasites and the exudation of plastic material they produce, or, in accordance with the ob- servations of Thudichum, to their presence within the lymphatic spaces, vessels and glands, and blood-currents.* The dropsical swelling of trichiniasis is not associated with albumin in the urine, for, except an increased quantity of uric acid, the urinary secretion contains no abnormal ingredient. Still, we find occasion- ally some albumin in the urine, as well as polyuria, though generally the quantity of urine is diminished. The trichinae may at times be detected in the passages from the bowels. Boils, acne, and ecthyma are often noticed after the oedema has passed away.f The muscular symptoms begin in the second stage, at about the tenth day, with pain and stiffness in the limbs. Soon at all parts of the body the muscles give the impression of being swollen ; they are extremely painful when touched or moved ; and the patient lies in consequence as quietly as possible, or, in very severe in- stances of the affection, like a paralyzed person. The immobility is also due partially to the retracted state of the muscles which occurs in bad cases, and which produces a condition similar to a true spasm, manifest for instance in the semi-flexed position of the extremities, and in the rigid, trismus-like setting of the jaws. * Thudichum, loc. cit., pp. 362 and 386. f Meissner, Schmidt's Jahrbiicher, No. 4, 1868. POISONS AND PARASITES. 1063 The disturbance of function of certain muscles becomes particu- larly evident. The disorder of the muscles of the eye has already been spoken of; we encounter, besides, impaired hearing, diffi- culty of deglutition, and loss of voice, from the muscles of the ear, of the pharynx, and of the larynx being filled with trichinae. The respiratory muscles are commonly much aifected, and we find hurried and shallow breathing, and at times considerable distress in respiration. The muscles of the heart usually, and the un- striped muscles of organic life constantly, escape infection ; and, as the trichinae wander to the front of the body rather than to the back, the muscles anteriorly are more infested than those poste- riorly. A flabby condition of the muscles, with a certain want of power and painful sensation on motion, has been noticed as an early symptom and preceding their marked implication.* The marked muscular pain, the stiffness, the fever, the profuse sweats, the acid urine, simulate the signs of aaide rheumatism ; but we find in trichiniasis diarrhoea, no articular swelling, and no heart-complications. Error is more apt to happen with reference to acute muscular rheumatism. But the signs of prostration and of gastro-intestinal irritation are here wholly wanting. The condition of the respiratory muscles gives rise, as already stated, to the embarrassed respiration, but it is not the only cause of the pulmonary symptoms. Yet, whether it alone leads to con- gestion of the lung and to bronchitis or pleuritis, or other causes concur in producing them, it is certain that these states are usual. They are not uncommonly combined with pneumonia, which ap- pears suddenly, and selects the lower portion of the left lung by preference, occurs about the twenty-sixth day of the disease, and is apt to prove fatal. The sputa consist of dark unmixed blood ; and the pneumonia is thought to be due to a trichinous embo- lism, the clots being derived from thrombi, which, forming in the venous system, are sent through the heart into the lungs.f Limited catarrhal pneumonia may be also met with. If the patient escape a serious pulmonary complication, if he have strength enough to withstand the weeks of irritative fever and exhaustion, he enters at the end of a month or of five or six * Kratz, Die Trichinen-Krankheit im Hadersleben, Leipsio, 1867. f Kupprecht, Trichinen-Krankheit, 1864. 1064 MEDICAL DIAGNOSIS. weeks of suffering upon a gradual convalescence. The fever de- clines ; the respiration is less accelerated ; the perspirations are far less copious; the urine increases in quantity; the pains decrease ; and by about the sixth week of the malady the patient is suffi- ciently free from pain to lie on his side, and is thus able to sleep. The pallor of his countenance gives way to a healthier hue ; his appetite becomes insatiable ; and he moves his limbs with more and more freedom. But it is a long time before he regains his full muscular power. Indeed, this may be always somewhat impaired; though we have the authority of Rupprecht for the statement that it may entirely return, and perfect health be recov- ered. In some cases convalescence does not set in for four months; in others it is greatly retarded by boils, by inflammation of the lymphatic glands, and by dropsy. The change in the power of accommodation of the eye may also alter but slowly. Children convalesce more quickly than adults. They suffer, in truth, less from the disease, and are not very subject to it. The diagnosis of the malady has been made evident while discussing the symptoms. At first the signs of gastro-intestinal catarrh, the vomiting, the slight fever, the perspiration, the muscular feebleness, are the most significant, and these early manifestations might be mistaken for irritant poisoning ; we can tell their meaning prior to the marked development of the phe- nomena in the muscles only by the detection of trichinae in the stools. The same may be said of cholera morbus. Again, it must be borne in mind that in some cases of trichiniasis the first symptoms of the complaint do not happen for two or thi-ee weeks .after the infected meat has been eaten ; and that in others it runs a chronic course and the whole disease is very protracted. The so-called " sausage poisoning," not dependent on trichinse, differs from trichiniasis in its rapid course and in the quick appearance of the symptoms after the spoiled sausages have been partaken of. In periarteritis nodosa the severe muscular pains are associated with thickening of the vessels, and an examination of the muscles will explain the cause of the muscular affection. Indeed, in any instance, no matter what be the complaint trichiniasis may simu- late, there is but one means of determining the presence of the flesh-worms positively, — to examine a piece of muscle. This may be effected by cutting down upon a muscle and removing sufficient POISONS AND PARASITES. 1065 of its structure for a microscopical examination, or by using Middeldorpff's harpoon or Duchenne's or Hart's trocar. Owing to the oedema, and particularly the oedema of the eye- lids and face, the malady may be confounded with Bright' s disease. But the utter absence of albumin in the urine distinguishes it. The physical signs separate the dyspnoea it occasions from that of cardiac disease ; and the sweats and the muscular symptoms of trichiniasis tell us what we are dealing with. The chief epidemics of trichiniasis have occurred in Germany ; but we have not escaped in this country. Nor can we claim that our hogs are not infested. On the contrary, the report of the Chicago Academy shows that about one in fifty contains trichinae in the muscles.* Our comparative immunity from the affection is due to the pork being much more generally cooked thoroughly before it is eaten ; for the only prophylactic is thorough cook- ing, prolonged exposure to high temperature killing the trichinae. Pickling has little if any effect. Salting and smoking are pre- ventive means of some value, but do not insure safety. * Chicago Medical Examiner, May, 1866; quoted in Medical and Surgical Eeporter, June 2, 1866; see also Billings, New York Med. Journ., 1883, xxxviii. ; Mary T. Davis, Nashville Journ. Med. and Surg., 1884, N. S., ixxiii. ; J. A. Close, Transact. Internat. Med. Cong., ix., Wash., 1887; E. L. Mark, Eep. Board of Health Massachusetts, 1887-88, Boston, 1889. INDEX. Abdomen, abscess in walls of, 616, 628 auscultation of 560 diseases of 541 attended with pain .... 596 simulated by hysteria ... 619 dropsy of 702, 710 enlargement of, general . 542, 710 partial 718 inflammation of muscles of. . 616 inspection of 542 movements of 543 palpation of 543 percussion of 544 pulsation in 731 retraction of parietes of . . . 542 rheumatism of walls of . . . 618 tumors of 606, 718 Abscess, hepatic 682 lumbar 734 of abdominal walls 616 of brain distinguished from softening 238 distinguished from tumor . 241 of kidney 816 distinguished from cystitis . 818 from pyonephrosis . . . 822 of larynx 284 of liver 667, 675, 682 of mediastinum 608 of thoracic walls confounded with chronic pleurisy . . 422 perinephritic 818 peritoneal 730 peritonsillar 285 perityphlitic 626 post-csecal 624 psoas, confounded with aneu- rism . , 734 confounded with cEecal abscess 628 pulmonary 378, 879 pyaeraic 687 retrolaryngeal ....... 284 retropharyngeal 283, 537 tonsillar 285 tropical 667 Acanthosis nigricans 871 Aearus 1009 Acephalocysts 1054 Acetone 766, 824 Acetonuria 203 Achillodyjiia 897 Acidity of stomach as a symptom 566 Acne 1011 rosacea. 1011 Acromegaly . , 251 Acroparsesthesia 80 Actinomycosis hominis .... 1046 laryngeal 285 of the liver 684 of the skin 1023 pulmonary 381 Addison's disease 869 confounded with acanthosis nigricans 871 with disorders of liver . . 871 with discoloration of lac- tation and pregnancy . 871 with fever-hues 8T1 with hereditary hue . . . 871 with diseases of suprarenal capsules 872 with pernicious anaemia . 872 with phthisis 871 with pityriasis versicolor . 871 with sun-bronzing . . . 870 with syphilis 871 with vagrants' disease . . 871 Adenoid vegetations 857 Adhesions, pericardial . . . 475, 517 -lEgophony 325 .iEsthesiometer 77, 79 Agraphia 61, 207 Ague, dumb . 949 quintan 949 Ainhum 1050 Akataphasia 208 Albumin in the urine 767 tests for 768-771 Albuminometer 769 Albuminose 769 Albuminuria, cyclic 795 from excessive uric acid for- mation 795 in laryngeal diphtheria . . . 532 of uric acid and oxaluria . . . 796 1067 1068 INDEX. Albuminuria, simple .... 94, 794 Albuminuric ulceration of bowel 646 Alcoholism, acute, distinguished from apoplexy .... 201 from opium poisoning . . 1033 chronic 128, 1039 Alexia 207 Algesimeter 551 AUochiria 79 Alopecia 1013, 1023 Alvine discharges 593 Amaurosis 139, 1040 from gastric hemorrhage . . . 665 uriemic 801 Amblyopia 61, 96 Amenorrhoea 579, 856 Ametropia 88 Amoeba coli . . .341, 595, 650, 687 dysenterise 650 Amphoric voice 326 sound 306 Amygdalitis, follicular .... 276 Anemia ........ 94, 95, 855 as a cause of dropsy 831 cerebral 188 in Bright's disease 800 essential 857 from parasites 855 idiopathic 857 of amoebic dysentery .... 650 pernicious 95, 294, 857 retinal 95 'spinal ... 131 state of blood in 851 Anaesthesia .... 74, 103, 107, 125 crossed ■ . . . 76 dolorosa 77 extended 75 from poisoning 74 from reflex action 77 hysterical 75 in aft'ections of nervous centres 75 localized 75, 76 muscular 79 of spinal origin 75 one-sided 76 tests for 77 trigeminal 77 Anaesthetics in feigned aphonia . 289 Analgesia 78 Anasarca 830 Anchylostomiasis .... 856, 1056 Anchylostomum duodenale . . . 856 Aneurism, abdominal . 606, 699, 732 physical signs and symptoms of 732 intracranial 245 multiple, of renal artery . . . 823 of abdominal aorta confounded with aortic pulsation . . 733 Aneurism of abdominal aorta confounded with colic, 606, 733 with disease of the spine . . 733 with lumbar and psoas ab- scess 734 with neuralgia 733 with non-aneurismal pul- sating tumors 734 with rheumatism 733 of ascending aorta 506 of descending aorta 516 of heart 517 of hepatic artery 699 of innominate artery .... 517 of pulmonary artery 518 phantom . . i 518 thoracic 506 confounded with : abscess of the mediastinum . . . 508 with chronic laryngitis, 287, 507, 514 with intra-thoracic morbid growths 507 with malformation of chest 513 with pulsation of pulmo- nary artery 512 eructation as a symptom of . 558 tracheal tugging a sign of . 509 Angina pectoris 448 distinguished from cardiac epi- lepsy 451 from intercostal neuralgia . 451 from irritability of heart . . 451 Ludovici 534 rheumatic 276 simple acute . 522 ulcero-membranous, dis- tinguished from diphtheria 530 Animal parasites 1050 Ankle clonus 102, 132, 140 Ano, fistula in 3(;2 Anorexia 171, 555, 582 Anoxaemia 857 Anthracosis 702 Anthrax 1045 Aorta, aneurism of abdominal. See Aneurism, abdominal. aneurism of thoracic. See Aneurism., thoracic. coarctation of 511 constriction of 511 inflammation of 466, 508 malposition of 513 pulsation of 466, 731 valves of 497 insufliciency of 510 Aortitis 466 Apepsia, hysterical 556 Aphasia . . , . . 61, 121, 200, 206 amnesic 207 INDEX. 1069 Aphasia, auditory 208 motor 119, 207 sensory 207 visual 208 Aphemia 61, 207 Aphonia, feigned . 289 nervous 287 of hysteria 287 AphthsB 520, 530 distinguished from diphtheria 530 Apoplexy 71, 75, 194 attended with paralysis . . . 195 cerebellar 197 confounded with acute soften- ing of brain 204 with asphyxia 203 with catalepsy 212 with cerebral hysteria . . . 205 with diabetic coma .... 203 with epilepsy 199, 218 with insensibility from drink 201 with insensibility from nar- cotics 201, 1032 with meningitis 199 with obstruction of the cere- bral arteries 200 with protracted sleep . . . 204 with sudden extensive paral- ysis 204 with sun-stroke 210 with syncope 203 with tumors 199 with uraemic coma .... 203 hemorrhage the cause of . . . 197 cerebral . 198 seat of 197 of the cord 125 pulmonary 394 mistaken for acute pneu- monia 394 serous * 197 spinal 125 temperature in 195 Appendicitis 622 bacterium coli commune in . . 622 chronic 624 confounded with abscess of liver . 629 with colic .... ... 626 with distention of caecum . 62d with dropsy of the gall- bladder . . .■ 628 with extra-uterine preg- nancy 628 with Invagination of bowels 627 with obstruction of bowels , 627 with pelvic haematocele . . 628 with pneumonia ..... 630 with typhoid fever .... 626 with ulceration of ileum . . 627 Appendix caeci, diseases of . . . 622 perforation of . ^ ..... . 624 Appetite, loss of, as a symptom . 555 perverted ......... 592 Apyrexia 949 Arcus senilis 90, 485 Areolar tissue, irritation of . . . 833 Argyll- Robertson pupil . . 93, 160 Army itch 1021 Arteries, atheromatous changes in 838 cerebral, obstructions of, con- founded with apoplexy . 200 coagulation in 880 diseases of 836 aphasia in ........ 209 inflammation of coats of . 506, 836 pulmonary, aneurism of . . . 518 pulsation of 512 Arterio-sclerosis 837 Arteritis 836, 838, 893 Arthritis, rheumatic ..... 900 associated with haemophilia . . 888 distinguished from locomotor ataxia 902 from paralysis agitans . . . 902 spurious 902 Ascaris lumbricoides ..... 1051 mystax 1051 Ascites ...... 691, 703, 710 confounded with cancer of peri- toneum 715 with chronic peritonitis . . 714 with chronic tympanites . . 716 with distention of the blad- der . 716 with gravid uterus .... 716 with ovarian dropsy .... 711 with tubercular peritonitis . 714 Asiatic cholera .... 32, 656, 973 Asphyxia distinguished from apo- plexy 203 from coal and charcoal gases . 1035 local 840 Astasia-abasia 87 Asthenia, cardiac 459 Asthma 265, 331 cardiac 333 causes of 332 diagnosticated from croup . . 333 from dyspnoea of disease of the heart 333 from enlarged glands . . . 333 from goitre 333 from cedema and spasm of the glottis 333 from paralysis of vocal ap- paratus i 333 from pressure of aneurismal tumor 333 67 1070 INDEX. Asthma, dyspnoea in 331 hay 854 in Bright's disease . . . 334, 802 spasmodic 332 thymic 334 Astigmatism 81,88,89 Ataxia 159 Friedreich's 163, 174 hereditary 163 locomotor 129, 135, 159 See Locomotor Ataxia. progressive 163 distinguished from dis- eases of the spinal cord 163 Atheromatous changes in vessels 838 Athetosis 157, 223 Atrophy from overuse of muscles 1 52 idiopathic 154 in joint-inflammation .... 152 of hrain 239 of liver, acute yellow .... 676 chronic 709 of optic nerve 95 progressive muscular . . 149, 156 unilateral progressive, of the face 152 Auscultation 310 immediate 311 intra- thoracic 312 mediate 310 of abdominal viscera .... 550 of children 328 of the voice 325 Bacillus coli communis .... 595 of anthrax 1046 of cholera 657 of cholera morbus .... 655 of diphtheria .,.'.... 524 of smallpox 991 of tuberculosis 342 of typhoid fever 917 of typhus fever 930 Bacteria a cause of disease of the kidneys 793, 820 Barbadoes leg 1018 Bedsores 174 Bell's palsy 121, 144 Beriberi 153, 833 Bile, inspissated 601, 676 in the stools .... 594, 655, 677 in the urine 760 Bile-duct, obstruction of ... . 676 Bilharzia hamatobia . . 777, 1055 Biliary abscesses 685 acids 664, 761 Oliver's test for 762 Pettenkofer's test for ... 761 Biliary calculi . . . _ • 601, 663, 675 passages, inflammation of . . 673 confounded with acute hepatitis 673 Bilious attack 573 pneumonia 403 remittent fever 974 Black tongue 999 Bladder, distended, confounded with ascites 716 with peritonitis 615 fistula into 624 hemorrhage from 773 inflammation of 815 confounded with peritonitis 615 neuralgia of, distinguished from acute inflammation . 815 paralysis of 133 spasm of, confounded with colic 603 Blindness 246 Blisters 174 Blood, air in 884 coagulation of 201 in arteries 880 in heart 465 diseases of 842 Pilaria sanguinis hominis in . 781 impoverished 73 microscopic examination of, 842, 899 pigment in 883, 960, 969 Plasmodia in 965, 969 spirilla of relapsing fever in . 947 sweating of 1024 vomiting of . . . 563, 579, 1028 Blood-casts 774, 792 Blood-corpuscles 851 Blood-gloDule-counting .... 843 Blood-vessels, diseases of ... . 836 Bloody stools in typhoid .... 917 sweating 175, 1024 Body, position of, as a symptom . 30 Bothriooephalus latus, 858, 1052, 1054 Bowels, hemorrhage from . . . 651 inflammation of 606 intussusception of 635 invagination of 627, 635 lithsemic pain in 900 morbid discharges from . . . 643 obstruction of 627, 630 from internal strangulation . 636 paralysis of 634 strictures in 544 ulceration of 646 Brachycardia 453 Brain, abscess of 238 in cardiac malformation . . 491 metastatic 356 anaemia of 237 and spinal cord, table of dis- orders of 177 INDEX. 1071 Brain, atrophy of 239 concussion of, causing jaundice 665 congestion of "... 236 cortical centres in 60 cysts in 245 diseases of 57, 177 headache as a symptom of . 81 dropsy of 187 emboli in 881 geographical centre in ... . 61 hemorrhage into 236 hypertrophy of 250 distinguished from enlarge- ment of the head .... 250 inflammation of ...... 237 confounded with pericarditis 473 lesions of gray central ganglia 118 meningitis of base of ... . 180 sensory centres in 63 softening of ... . 75, 235, 241 acute 181, 204 chronic 235 syphilis of 142, 953 thrombosis of sinuses of . 242, 878 tumor of 240 distinguished from abscess . 241 from chronic meningitis . 242 from softening 241 gliomatous 245 intracranial 182 seat of 243 Brain-power, exhaustion of . . 239 Breathing. See Respiration. Breath-sound, metamorphosing . 320 Bright's disease, acute . 34, 241, 791 distinguished from acute ne- phritis 794 from coma 796 from dropsy 796 from epileptiform convul- sions 796 from hsematuria .... 794 from pericarditis .... 796 from pleurisy 796 from pulmonary cedema . 796 from purulent urine . . . 794 from simple albuminuria . 794 from suppurative nephritis 794 chronic 798 confounded with anaemia . 800 with asthma 802 with cancer of kidney . . 803 with cardiac dropsy . . . 802 with chronic bronchitis . 802 with chronic consecutive nephritis 805 with chronic rheumatism . 802 with cysts of kidney . . 805 with gastro-intestinal dis- orders 803 Bright's disease, chronic, con- founded with neuralgia 801 with renal inadequacy . . 806 with tubercle 804 contracting form of 808 nervous symptoms in .... 801 prealbuminuric stage of . . . 772 retinitis in 95, 801 table of clinical diflerences in . 812 Bronchial dilatation .... 379, 381 glands, tuberculization of . . 337 phthisis, distinguished from hooping-cough 337 Bronchiolitis exudativa .... 355 Bronchitis, acute . . . 348, 396, 983 associated with measles . . 983 diagnosticated from capillary bronchitis 351 from hooping-cough_ . . . 337 from pneumonia .... 850 from tuberculosis . . 350, 385 of large and middle-sized tubes 348 physical signs of 349 sputa in 349 capillary .... 285, 348, 350, 359 confounded with acute lobar pneumonia 351 with acute miliary tuber- culosis 385 with broncho-pneumonia 351 with catarrhal pneumonia 351 with phthisis 351 chronic 352 confounded with Bright's dis- ease 802 with nasal catarrh . . . 353 with phthisis 369 idiopathic, distinguished from typhoid fever 928 of the finer tubes .... 348, 885 plastic 341, 354 sputa in 341 putrid 339, 355, 381 Bronchophony 325 Broncho-pneumonia . . . 351, 386 distinguished from tuberculosis 386 mistaken for collapse ..... 360 tuberculous inspiration . . . 398 Bronchorrhcea 353 Bruit de moulin 476 Bulbar paralysis 147, 152 Bulimia 457, 556 Bulk of body 32 Bullous diseases 174, 1010 C. Cachexia strumipriva 863 Ceecum, appendix of, diseases of 626 1072 INDEX. Csecum, cancer of 629 distention of 629 inflammation of 625 solitary ulcer of 646 Calcium oxalate 757, 786 Calculi, biliary .... 601, 663, 675 renal 56, 590, 602, 786 irritation of 821 of the pancreas 722 Cancer of- brain 245 ' of caecum 629 melanotic 804 of cardiac orifice 586 of gall-bladder 695 of intestine 731 of kidney confounded with Bright 's disease 803 of larynx 294 of liver 690 confounded with acute con- gestion 693 with acute hepatitis . . . 693 with cancer of omentum . 696 with cancer of stomach . 696 with catarrhal jaundice . 693 with chronic congestion . 692 with disease of gall-blad- der 694 v/ith enlarged kidney . . 697 with fatty liver 692 with syphilitic liver . . . 694 with waxy liver 692 of lungs 375, 424 confounded with chronic pleurisy 424 with phthisis 375 of lymphatic glands 867 of lymphatic glands lying by side of vertebrae 727 of omentum .... 590, 696, 715 confounded with cancer of liver. ......... 696 of pancreas . . . 721 of peritoneum 715, 730 of retro-peritoneal glands . . 715 of pleura 420 of stomach 582, 696 confounded with cancer of liver 696 with chronic gastritis, 582, 585 with cirrhosis of liver . . 708 with gastric ulcer . . 582, 585 detection of tumor in . . . 586 situation of 586 of the pylorus 586 of the tongue 521 of the tonsils 523, 536 Cancrum oris 520 Capillaries, diseases of 840 Capillary pulsation 43 Carcinoma, gastric, test for . . 584 Cardiac asthenia 459 epilepsy' 451 nerve storms 453 Cardioscope 433 Cartilage, aortic 436 Catalepsy accompanying hys- teria 212 associated with hypnotism . . 213 confounded with apoplexy . . 212 with ecstasy 212 daymare form of 213 feigned 213 Cataract 90, 824 Catarrh, gastric . . . 573, 575, 1028 in measles 982 Intestinal 606 nasal 262, 353 suffocative 348 vesical 816 Catarrhal fever 909 distinguished from dengue . . 996 from hay-fever 912 lung complications in ... . 910 sequelae of 910 Cavernous voice 325 Cavity in lungs .... 367, 377, 379 Cell, granular, of ovarian fluid . 713 Cellulitis, pelvic 728 Cerebellum, diseases of . . 165, 243 gait in 165, 681 tumor of 681 Cerebral affections, table of . . . 177 pain in, distinguished from hemicrania 256 localization 57 symptoms in congestive fever . 964 thermometry 123 tumors 243 Cerebritis 2.S7 confounded with meningitis . 181 Cerebro-spinal disorders, 86, 88, 163, 189 fever 937 causes of 940 confounded with congestive fever 941 with inflammation of cord 941 with malignant measles . 942 with pneumonia .... 942 with rheumatism of cer- vical muscles 943 with scarlatina 942 with sporadic cerebro- spinal meningitis . . . 942 with tetanus 941 with tubercular meningitis 942 with typhoid fever . . . 940 with typhus fever .... 943 with uriemia 943 INDEX. 1073 Cerebrospinal fever, pulse in . . 938 state of blood in ..... 940 swelling of whole body fol- lowing 944 urticaria in 1005 meningitis 189, 987, 942 typhus 937 Cestoidea 1051 Charbon 1045 Charcot's disease 167 CharcotnLeyden crystals . . 332, 340 Chest, alterations of form, size, etc., of, in disease .... 356 contusions of, followed by pneumonia 401 dilatation of, diseases present- ing 410 inspection of, in diagnosis . . 299 malformation of 513 mapping out of, for physical diagnosis , 298 mensuration of . ....... 300 motions of, in diseases of . . . 299 retraction of, diseases attended with 423 tumor in ......... . 419 Cheyne-Stokes respiration . 335, 449 Chicken-pox 993 See Varicella. Chilblains 841 Childbed fever 612 Chloasma 1015, 1023 Chloral poisoning .... 1033, 1039 ataxic symptoms following . . 1039 Chlorides in the urine 755 Chlorosis 34, 43, 856 confounded with pernicious ansemia 863 Choked disk 95, 241, 244 Cholera 656, 1028 Asiatic, distinguished from yel- low fever 973 associated with uraemia . i . 660 comma-bacillus of 657 infantum 654 morbus 655, 660 distinguished from irritant poisoning . 656, 660, 1028 nostras 655 reaction 657 subnormal temperature in . . 659 with typhoid symptoms . . . 660 Cholerine 659 Chorditis tuberosa 291 Chorea 219 attended with salaam convul- sions 224 caused by eye-strain . . . 88, 221 distinguished from athetosis . 223 from cerebro-spinal sclerosis 222 Chorea distinguished from con- vulsive tremor 222 from epilepsy 222 from facial spasm ..... 223 from hysteria 224 from paralysis agitans . . 222 from spasms of acute cerebral disease . 222 from tetanus 222 from writer's cramp .... 223 electrical 221 following rheumatic fever . . 220 habit . 221 Huntington's 221 hysterical . 221 paralytic 221 post-hemiplegio ..... 157, 223 post-paralytic 120 relations of, to rheumatism . . 220 Choroid coat, inflammation of . 96 tubercles of 96 Chromocytometer 852 Chylous urine 781 Circulation, derangements of, in cardiac disease . . . 446, 460 paralysis from interference with 105 portal, disturbance of .... 661 Cirrhosis of liver 702 confounded with cancer of stomach 708 with chronic peritonitis . 708 with inflammation of por- tal vein 708 distinguished from cancer of liver 707 from hydatids 706 from malarial infection . 706 from red atrophy ... 707 from simple induration . 707 hypertrophic 702, 705 of children, syphilitic . . . 705 of lung confounded with chronic pleurisy .... 425 Clergyman's sore throat .... 535 Clots, fibrinous, in the heart . . 464 Coffee-ground vomit .... 564, 583 Colic as a symptom 596 bilious 597, 626 confounded with abdominal aneurism . 606 with abdominal neuralgia . 605 with abdominal tumors . , 606 with appendicitis 626 with enteritis 606 with gall-stones 601 with gastralgia .... 600, 605 with hepatic neuralgia . . . 601 with hernia 600 with nephralgia 602 1074 INDEX. Colic confounded with neuralgia of dorsal and lumbar nerves 605 with perforation of the intes- tine 600 with peritonitis .... 606, 620 with spasm of the bladder . 603 with spinal disease .... 606 with uterine colic 604 copper 598 flatulent 597 from disease of the bowel . . 599 lead 598 malarial 598 metallic 598 nervous 598 renal 626, 786, 822 simple 596 spasmodic 596 uterine 604 Colitis, croupous 390 ulcerative 646 Collapse, delirium in 69 in acute poisoning 1028 in appendicitis 625 in cholera 656, 659 in relapsing fever 946 in yellow fever 971 of the lung 359 confounded with chronic pleurisy 426 Colon, dilatation of . . 549, 638, 730 disease of, associated with heart disease 647 inflammation of 608 percussion of 549 solitary ulcer of 646 Color-blindness 76, 96 Coma 67, 70, 704 diabetic 71, 203 from narcotic poisoning . 71, 202 in typhoid 920 occurring in Bright's disease, 71, 796 ursemie 71, 203, 797 Coma-vigil 931 Comedo • 1024 Comma-bacillus of Koch .... 657 Concretion, intra-hepatic .... 952 Congestion, pulmonary .... 394 of brain discriminated from softening 236 of features, as a symptom . . 33 passive 564 Congestive fever 963 algid 964 cerebral 964 confounded with cerebro-spinal fever 941 gastro-enteric 963 thoracic 964 Conjunctiva, tuberculosis of . . 90 Conjunctivitis, from lithsemia . 900 Consciousness, diseases marked by sudden loss of ... . 194 Constipation as a symptom . . . 630 from mechanical changes . . 642 habitual 641 ulcers from 643 Consumption. See Phthisis. galloping 384, 388 Contractility, electro muscular, 109, 168 Contracture 174 Convulsions 171 See also Spasms. diseases marked by 214 distinguished from epilepsy . 218 epileptic 141, 151, 255 from irritant poisoning . . . 1028 from purulent otitis 217 hysterical 138, 151 in Bright's disease 796 in scarlet fever 978 in typhoid 920 salaam 224 ursemie 798 Convulsive tic 223 Cord. See Spinal Cord. Coryza 261 Cough 335 from nasal affections 353 hooping 285, 336 in laryngeal affections . . 267, 336 Countenance, expression of, as a symptom 32 Crackling in tubercle of lungs . 323 Cramp caused by various occupa^ tions 223 of stomach 566 writer's 223 Cranial reflexes 100 Craniotabes 905 Crepitation 322, 396 Croup 275, 278 catarrhal 278 diphtheritic 278 diseases confounded with . 283, 333 false 278, 282 membranous, or true 280 distinguished from abscess of larynx 284 from acute laryngitis . . . 283 from diphtheria .... 285, 531 from false croup 282 from cedema of the larynx . 283 from re'trolaryngeal ab- scesses 284 from retropharyngeal ab- scesses -. . . 283 from scarlet fever 980 INDEX. 1075 Croup, membranous, or true, dis- tinguished from secondary laryngitis of the exanthe- mata . 283 non-diphtheritic membranous . 285 spasm of glottis in 279 Crus cerebri, lesions of 117 Crusta lactea 1007 Crystals, Charcot-Leyden . 332, 340 Cyanosis 34, 392 Cyrtometer 300 Cysticercus cellulosas 1052 Cystine 786 Cystitis, acute 815 confounded with abscess of kidney . 818 ■with acute nephritis . . . 815 with metritis 816 with neuralgia of bladder 815 with peritonitis 615 chronic 816 Cysts of kidneys . . . 700, 805, 823 confounded with hydrone- phrosis 82.3 of nose 264 of vocal cords 294 ovarian 711 D. Day-blindness 96 Daymare 213 Dead fingers 840 Deafness 76, 98, 528 Debility confounded with typhoid fever 924 Deep reflexes 100 Delirium 67, 179 active 68 confounded with delirium tremens ........ 193 fierce 68 hysterical 70 in chorea 220 in typhoid 920 mistaken for insanity .... 69 of cerebral rheumatism . . . 893 of inanition 69 of pneumonia 68, 388 prominent as a symptom, acute affections with 179 simulated 70 tremens 72, 190, 388 confounded with acute mania 193 with acute meningitis . . 191 ursemic 68, 798 Dengue 994 distinguished from influenza . 996 from malarial fever .... 996 from rheumatism or gout . 996 Dengue distinguished from scar- let fever 996 from yellow fever 996 Dermatalgia 1025 Dermatitis exfoliative 1013 herpetiformis 1009, 1012 medicamentosa 1015 Dermatophytes. See Tinea. Diabetes 94, 823 distinguished from chronic polyuria 827 fatty diarrhoea in 653 Diabetes insipidus 826 intermitting 826 phosphatic 753 with coexisting albuminuria . 826 Diacetic acid 766 Diagnosis by exclusion .... 23 differential 22 methods of arriving at ... . 21 physical 297 sources of error in 23 Diaphragm 384 fatty degeneration of ... . 334 hernia of 414 inflammation of 334 paralysis of 334 rheumatism of 334 Diarrhoea 643 acute 644 bilious 644 choleraic 657 chronic 32, 644 fatty 653 in pulmonary consumption . . 362 intermittent 647 in typhoid fever 915 membranous 647 of dissecting-room 1048 of soldiers 645 strumous, of children .... 647 tubercular 646 Diazo-reaction 771 Digestion, disorders of 661 Dilatation, bronchial, confounded with phthisis 377 with pulmonary abscess . 378 with pulmonary gangrene 380 of heart 482 confounded with fatty de- generation 484 with pericardial effusion . 488 Diphtheria .......... 524 catarrhal 529 confounded with aphthse . . . 530 with croup 581 with erysipelas of the fauces 580 with gangrene of the mouth 529 with pharyngitis and tonsil- litis 529 1076 INDEX. Diphtheria confounded with scar- latina 532 with thrush 530 with ulcerative stomatitis . 529 with ulcero-membranous an- gina 530 croupous 526 faucial 262 intercurrent 533 laryngeal 285, 532 confounded with scarlet fever 980 nasal 262, 533 paralysis in 141,164,528 sequelse of 528 Diphtheria-bacilli 524 Diplococcus exanthematicus . . 930 in mumps 534 pneumoniiE 398, 940 Discharge?, alvine, as a symptom 593 Displacements of heart . . 410, 505 Distoma hjematobium 1055 hepaticum 1055 Dittrich's plugs 355 Diuresis, chronic 826 in hysterical women 827 Dochmius duodenalis 1055 Dracunculus 1056 Drink, insensibility from . . . 201 Dropsy 830 abdominal 702, 710 acute or active 835 cardiac ...... 446, 802, 832 causes of 832 chronic 835 dependent upon a tumor ... 831 diseases marked by 791 from ansemia 831 from malarial poisoning . . . 831 from scarlet fever 979 general 832 from irritation of areolar tis- sue 833 from peripheral multiple neuritis 833 hepatic 833 in beriberi 833 in Bright's disease 796 internal 831 of brain 187, 249 ovarian 711 pericardial, confounded with cardiac dilatation ... . . 488 renal 832 Duhring's disease 1012 Duodenum, catarrh of 608 ulcer of . 581 Dysentery 648 acute 648 amoebic 650 Dysentery, catarrhal 650 chronic 651 confounded with piles .... 649 with proctitis 649 diphtheritic 651 distinguished from diarrhosa . 650 epidemic 649 tropical 595 Dyspepsia as a symptom, 570, 575, 641 atonic 570 nervous 570 Dysphagia 284, 540 Dyspnoea . . 30, 284, 288, 330, 515 caused by aneurismal tumor, 333, 515 by goitre 333 diseases presenting 410 from disease of the dia- phragm 334 from enlarged glands of neck . 333 in asthma 331 in plastic bronchitis 354 Ear, disease of 217 causing abscess of brain . . 238 Ecchymoses 665 Echinococci . . 697, 700, 805, 1054 Ecstasy 212 distinguished from catalepsy . 212 Ecthyma 1012 Eczema ...... 175, 1007, 1020 distinguished from pityriasis rubra 1008 from scabies 1009 from seborrhoea 1008 impetiginodes 1007 papular 1006 rubrum 1008 squamosum 1008, 1014 Effusions, pericardial . 422, 469, 488 diagnostic sign of 470 peritoneal 610 pleural .... 374,405,411,700 Electricity in paralysis .... 108 faradaic 110 galvanic 110 static Ill Electro-muscular sensibility, 112, 115 Elephantiasis of the Arabs . . . 1018 of the Greeks 1017 Emaciation as a symptom ... 32 Embarras gastrique 573 Embolism 465, 877, 880 cerebral 201 fat 883 frorn accumulations of pigment in the blood 883 from acute endarteritis .... 884 INDEX. 1077 Embolism of arteries of the ex- tremities 882 of cerebral arteries ..... 881 of pulmonary artery .... 880 of renal artery '. 881 of vessels of liver '. 881 splenic. 881 trichinous 1063 Embryo-cardia 453 Emphysema . . . 332, 356, 411, 435 chest sounds in 413 coexisting with tubercle . , . 369 compensatory 358 confounded with aneurismal tumor 357 with chronic pleurisy . . . 419 diagnosticated from pleuritic effusions 358 from pneumothorax .... 358 interlobular 338 Emprosthotonos 229 Empyema, pulsating, confounded with aneurism 511 Encephalitis ......... 235 acute hemorrhagic 238 Endarteritis ....... 836, 884 gouty 899 Endocardial murmurs . . . 439, 461 Endocarditis, acute 461 confounded with pericarditis 471 complications of 464 diabBtic 824 puerperal 466 rheumatic 462 ulcerative 466 associated with pneumonia . 399 with pyemia 875 head-symptoms of, con- founded with acute men- ingitis 185 confounded with typhoid fever 467, 927 Engorgements, pulmonary, in fevers, mistaken for acute pneumonia 393 Enteralgia 600 Enteritis confounded with colic . 606 with peritonitis 614 with typhoid fever .... 926 croupous or diphtheritic . . . 609 membranous 647 muco- 606, 608, 644 Enteroptosis 592, 856 Bphelides • • • •, I0I5 Epidemic meningitis 937 Epigastrium, tumors of ... . 721 Epiglottis, disease of . . . 279, 290 Epilepsy 67, 214 abortive 215, 218 associated with vertigo . . . 215 Epilepsy, aura preceding . . . 214 cardiac 451 consecutive to scarlet fever . . 979 distinguished from apoplexy . 218 from chorea 222 from convulsions ..... 217 from hysteria 218 from strychnine poisoning . 1037 eccentric 216 feigned 218 idiopathic 217 Jacksoniau 217 masked 217 nocturnal 215 post-hemiplegic 215 se'quelse of 215 syphilitic. 217 tested by administration of ether 219 Epiphytes 1020 Episcleritis, from lithaemia . . . 900 Epistaxis . . . 345, 457, 533, 565, 921; Epithelioma 539 Ergotism 1040 Eructation as a symptom . . . 558 Eruption, herpetic 132 in measles 982 in typhoid 921 Erysipelas .... 90, 262, 530, 996 associated with pharyngeal fever 999 distinguished from angeio-neu- rotic cedema 998 from confluent smallpox . . 998 from erythema 998 from mumps 999 from scarlatina 998 from scleroderma 1019 in aortitis , 466 migrans 999 of the fauces confounded with diphtheria 530 Erythema 175, 1003 congestivum 1004 desquamative 1003 distinguished from erysipelas . 998 intertrigo 1004 marginatum 464 multiforme 1003 neurotic vesicular 1010 nodosum 1003 solare 1004 Erythromelalgia 841 Examination of patients, methods of 27 analytical 27 by anamnesis 27 synthetical 27 Exanthematous fevers . . . 976, 998 Excitation of muscles , , . . . 109 1078 INDEX. Excitation of muscles, direct and indirect 109 Exhalations, poisonous 1047 Exophthalmic goitre . . 90, 456, 513 Eye, abnormal changes in fundus of 94 abnormalities of pupils of, 89, 92, 219 appearance of, in disease ... 88 conjugate lateral deviation of . 91 spasm of 116 derangements of mechanism of, 88, 89 disorders of, from lithaemia . . 900 embolism of 95 hypersemia of 94 paralysis of accommodation of, 93, 96 paresis of ......... . 96 ptosis of 92 reflex neuroses of 96 refraction, errors of 900 sixth nerve of, affections of . . 92 strain of 88, 96, 900 subjective visual derangements of 96 third nerve of, affections of . . 92 Eyeball, protrusion of 466 Eyelids, drooping of 162 Eye-strain 88, 96, 900 as a cause of chorea . . 88, 89, 220 of epilepsy 89 of gastric derangements . . 89 of hysteria 89 of melancholia 89 F. Face, moon-shaped 251 spasm of 223, 255 Facial hemiatrophy 152 palsy 117, 200 Fsecal discharges 598 vomiting 562 Faeces, accumulation of, 638, 720, 730 impacted, simulating gall- > stones . ; 602 Paradaio excitability 110 Farcy, acute, confounded with pyaemia 874 Fat in intestinal discharges . . 653 in urine 653, 780 Fatty degeneration of heart . . 484 confounded with chills . . . 486 with dilatation 485 of pancreas 721 of tissues, in poisoning . . 1030 Fauces, diseases of 522 erysipelas of 530 inflammation of 522 ulcers of, syphilitic 536 Favus 1022 Feigned aphonia 289 delirium 70 epilepsy 218 hysteria 226 rheumatism ; 897 sciatica 259 Fever, bilious remittent .... 974 bilious typhoid 946 breakbone, or dengue .... 995 catarrhal 909 cerebro-spinal 937 Chickahominy 968 congestive 963 enteric 926 erysipelatous 999 gastro-enteric 963 hectic 951 hemorrhagic malarial .... 965 hepatic 675, 952 icterode pernicious 965 infantile remittent 961 intermittent 948 malario-typhoid 969 miasmatic 948 miliary 984 nervous 919 of erysipelas . 996 pharyngeal 999 puerperal malarial 953 relapsing 944 remittent 954 scarlet 976 simple continued 908 spotted 937 syphilitic 953 typhoid 913 typho-malarial 957, 968 typhus 929 urethral 952 yellow 969 Fevers 906 classification of 907 continued 907 head-symptoms of, con- founded with meningitis . 182 eruptive 976 exanthematous 976, 9i)8 periodical 908. 948 type of 907 Fibrin, clots of, in the heart . . 464 in the urine 781 Fifth nerve, painful anaesthesia of 255 Filaria medinensis 1056 sanguinis hominis . 214, 777, 781, 1055 Fissure of Rolando ... 58, 59, 63 of Sylvius .58, 63, 881 Fistula, gastro-pulmonary . . . 577 rectal 624 INDEX. 1079 Flagellate protozoa in influenza . 876 Flatulency as a symptom . . . 557 Fly parasites 1056 Follicular tonsillitis 524 Foot and mouth disease .... 1046 Foot clonus 168 fungus, of India 1049 perforating ulcer of 1049 Frsenum linguae, ulceration of . 337 Fremitus, bronchial 326 cavernous 326 friction 303 pleural 326 rhonchal 303 vocal 303, 326 Friction, pericardial 444 pleural 323 Friedreich's ataxia 163 Frontal sinus, diseases of . . . 260 neuralgia in 261 Fungi 339, 538, 561, 595 poisonous 1031 Fungus foot of India 1049 O. Gait as a symptom 31 in diseases of cerebellum . . . 165 in general paralysis 247 in hysterical hemiplegia ... 189 in locomotor ataxia ... 31, 160 waddling . 154 Gall-bladder, cancer of . . 694, 695 diseases of 673, 694 confounded with cancer of liver 694 distention of 674, 694 distinguished from hydatids of liver 699 dropsy of 628 inflammation of 673 rupture of 628 Gall-ducts, inflammation of, 602, 673 Gall-stones 590, 601, 695 impacted 676 passage of, confounded with cancer of the liver . . 696 with colic 601 with faecal accumulations 602 with intermittent fever . 952 Galvanic excitability 110 Gangrene of ergot poisoning . . 1040 of the mouth 520 confounded with diphtheria 529 pulmonary, confounded with phthisis 380 symmetrical 840 Ganglia, central gray, lesions of 118 Gastralgia 566, 580 confounded with colic . . 600, 605 Gastric cancer 582 crises 162, 580, 725 juice, examination of . . 653, 557 super-secretion of 592 motormeter 552 tubules, atrophy of . . . 576, 583 ulcer 676, 580 Gastritis, acute idiopathic . . . 571 distinguished from gastritis by poisoning . . . 571, 1028 chronic 675 confounded with gastric can- cer 582, 585 with gastric ulcer . . 576, 585 with hepatic congestion . 680 with peritonitis 613 of young children 574 Gastrodiaphane 551 Gastrodynia 666 Gastrograph 552 Gastro-intestinal disorders asso- ciated with congestive fever 963 confounded with Bright's disease 803 Gastromalacia 674 Gastroptosis 592, 856 Gastroxynsis 557 German measles 985 Girdle pain 133, 168 sense 129 Gland of axilla, enlarged . . . 508 of neck, enlarged .... 333, 508 retroperitoneal, cancer of . . 715 retropharyngeal 537 scrofulous 647, 868 thymus 334 thyroid 251, 456, 513 tuberculous 868 Glanders 263 acute, confounded with pyae- mia 264, 874 distinguished from rhinitis . 264 from typhoid fever . . . 264 Gland-secretions, altered .... 1023 Glaucoma 90 Glenard's disease 692 Glossoplegia 122 Glottis, cedeina of 333, 997 spasm of 279, 338 Glycosuria 266, 826 Goitre 90, 333, 513 exophthalmic .... 90, 456, 513 Gonorrhoeal rheumatism .... 891 Gout . . . . . . 73, 466, 889, 898 blood examination in ... . 899 distinguished from rheumatism 898 rheumatic . 900 Gram's tests for micro-organisms 345 Gravel 603, 750 1080 INDEX. Graves's disease 456, 457 Guinea-worm 1056 Gummata 163 Gums, bleeding from . . . 706, 855 red line of 362 Gyromele 551 H. Habit-chorea . 221 Habit-spasm 221 Hsemacytometer, forms of . 842, 845 Hsematemesis .... 346, 563, 917 alcoholic . 704 Hsmatinuria, intermittent . . . 776 Hsematocele, retro-uterine . . . 728 Hsematokrit 843,848,849 Hsematoma . 199 HiBmatoscope 852 Heematozoa of malaria .... 961 Hsematuria 772 confounded with acute Bright's disease 794 Intermittent 776 malarial 776, 966 parasitic 777 renal tubal 774, 777 diagnostic sign of 775 vesical 778 Hsemidrosis . 1024 Haemoglobin ..... 777, 849, 856 apparatuses for estimating . . 852 Haemoglobinometer 852 Hsemoglobinuria 776, 1032 interniittent 966 Hsemometer 849, 852, 853 Hsemophilia distinguished from leukaemia 888 from purpura 887 Haemoptysis 345, 355, 425 in typhoid 917 Handwriting, alteration of . . . 247 Hay asthma 262 Hay fever 90, 262, 354 distinguished from catarrhal fever 912 Head, enlargement of, diseases characterized by .... 249 gouty inflammation in . . . . 899 shapes of, in disease . . . 249, 250 Headache . , . 81 congestive 82 from astigmatism 81 from Bright's disease .... 802 from eye-strain 88 from lithsemia 900 from poisoning 83 in Bright's disease 83 in diseases of the brain ... 81 nervous and neuralgic .... 82 Headache, sick 82 sympathetic 83 Hearing, derangement of . . . 98 Heart, anatomy and physiology of 428 aneurism of 478 atrophy of 460, 487 auricle of, dilated 512 auscultation of 435 cavities of, accumulation of blood in • •. • '*88 chronic diseases of, with in- creased percussion dulness 478 clots of fibrin in 464 dilatation of 425, 482 diseases of 428 associated with asthma . . 333 with diseases of colon . . 647 confounded with intermittent fever 952 with pernicious ansemia . 862 symptoms of 445 displacements of, diseases pre- senting 410, 505 dropsy caused by disease of, 446, 802 enlargement of, symptoms of . 489 mistaken for aneurism . . . 512 examination of _ 431 fatty accumulation on . . 335, 487 fatty degeneration of ... . 484 functional disorders of . . 453, 491 gouty 481, 899 associated with contracting kidney 481 hemisystole of 455 hypertrophy of . 356, 425, 478, 802 impulse of 431, 453 inflammation of 476 inspection of 431 irregularity of action of . . . 455 irritable 451, 457 malformations of 490 causing abscess of brain . . 491 mitral disease of 489, 497 murmurs 439, 489 organic diseases of 460 overaction of 441, 459 pain in region of . . 448, 451, 460 palpation of 432 palpitation of 452, 454 paralysis of, in relapsing fever 946 percussion of 433 percussion dulness of, increased 478 rhythm of 454 rupture of 487 sounds of 438,460 starvation 487 strain 459 valvular affections of, 456, 489, 496 INDEX. 1081 Heart, valvular affections of, table of 499 Heart-burn 557 Heat exhaustion 211 Hectic fever distinguished from intermittent fever .... 951 Heller's test 768 Hemeralopia 96 Hemianopsia .... '61, 93, 97, 122 bilateral 61, 118 Hemianesthesia 76, 139 Hemicrania 82, 255, 801 distinguished from pain of or- ganic cerebral affections . 256 from periostitis 256 from rheumatism of the scalp 256 Hemiparaplegia 115 Hemiplegia . 113 alternating 114 anatomical diagnosis of . . . 115 appearance of muscles in . . 119 cerebral 115, 150, 200 corpus striatum in 116 cortical 118 electricity as a test of . . 115, 120 feigned 120 following epilepsy 215 lesions of capsule 118 of crus cerebri 117 of gray central ganglia . . 118 of optic tract 118 of pons Varolii . . . 114, 116 of prsefrontal lobes . . . 119 hysterical 139 ovarian tenderness in . . . 139 in diphtheria 528 in the course of typhoid fever . 921 nature of lesions in 119 optic thalamus in 116 pain in 120 pathological diagnosis of . . . 119 rigidity in 119 seat of lesion in 114 spinal 115 Hemorrhage a cause of apoplexy 194 between brain membranes . . 199 cerebellar 198 cerebral 199, 200 cortical 198 from aneurism 346 from the bladder 773 from the intestines . . . 681, 917 from the kidneys 773 from the larynx, trachea, etc. . 346 from the lungs 346, 372 from the CBSophagus 346 from the oral cavity 345 from the prostate gland . . . 778 from the stomach, 346, 563, 579, 609 Hemorrhage from the stomach distinguished from irritant poisoning 1028 from the urethra 778 from the uterus in myxoedema 834 from the ventricles of the brain 197 in apoplexy; seat of 197 in fevers . 345 in yellow fever 971 into cerebrum ovale 198 into lung texture 394 into the corpora quadrigemina 198 into the internal capsule . . . 197 into the pons ........ 198 into the pons Varolii .... 202 into the subarachnoid spaces . 198 into the thalamus 198 limited to the arachnoid . . . 198 to one crus cerebri .... 198 nasal 263 of the bowels 651 punctiform 238 relations of, to brain-softening 236 renal, clots in 774 spinal 125, 133 vicarious 345, 564, 652 Hemorrhagic diathesis 1045 malarial fever ....... 965 confounded with intermit- tent hsemoglobinuria . 966 with yellow fever .... 966 Hemorrhoids 641, 649, 652 Hepatic abscess 342 diseases, chronic and acute, confounded 670 dropsy 833 fever 675 confounded with intermit- tent fever 952 neuralgia 601 Hepatitis, acute 667, 675 confounded with acute in- fectious jaundice . . . 671 with acute non-hepatic diseases with jaundice . 670 with acute yellow atrophy, 673, 678 with cancer of liver . . . 693 with chronic hepatic dis- ease with acute symp- toms 670 with diaphragmatic pleu- risy 670 with inflammation of the biliary passages .... 673 with inflammation of the portal veins 669 with perihepatitis .... 668 ■ with pigment liver . . . 669 chronic 681 1082 INDEX. Hepatitis, interstitial , . . 702, 705 subacute infectious 705 suppurative 670 Hernia, diaphragmatic, con- founded with pneumo- thorax 414 irreducible 632 omental 590 strangulated, confounded with colic . 600 with intestinal obstructions . 632 with irritant poisoning . . 1028 through the recti muscles . . 687 Herpes 388, 1009 gestationis 1O09, 1012 labialis 1009 zoster 174, 1009 distinguished from erysipelas 998 ophthalmicus 90 pain in, mistaken forpleurisy 1009 Hiccough in diaphragmatic pleu- risy 671 in diphtheritic dysentery . . . 651 Hip-joint affections .... 258, 629 confounded with sciatica . . . 258 Hodgkin's disease 866 confounded with lymphatic cancer 867 with a malarial affection . . 868 Hooping-cough .... 285, 336, 359 diagnosticated from acute bron- chitis 337 from bronchial phthisis . . 337 Hydatid cysts 421 Hydatids of the liver . 683, 697, 706 distinctive character of fluid in 700 multilocular 701 Hydroa 1010 Hydrocephaloid disease .... 187 Hydrocephalus, acute . . . 185, 187 chronic 187, 249 Hydrochloric acid in gastric juice, 557, 567, 575 Hydronephrosis .... 700, 822, 828 confounded with hydatid tumor of kidney 822 with renal cysts 823 intermitting 725 Hydrophobia 232, 539 distinguished from strychnine poisoning 1037 from tetanus 232 Hydrorrhoea, nasal 262 Hydrothorax 331, 422 confounded with chronic pleu- risy 422 Hyperaemia of the disk .... 94 Hypersesthesia 72, 107 general 72 hysteria as a cause of ... . 73 Hyperaesthesia, one-sided ... 74 Hyperalgesia 73 Hyperopia 81, 88' Hypertrophy of brain 250 of heart 478 of mucous membrane .... 264 of skin : . . . 1017 Hypochondriasis 167, 569 Hypochondrium, tumors of . . . 718 Hypogastric region, tumors of . . 729 Hypo-leuksemia 866 false 866 Hysteria 34, 73, 151, 224 abdominal, confounded with peritonitis 619 with tubercular meningitis . 189 after railway accidents .... 227 associated with catalepsy . . . 212 with membranous diarrhoea . , 648 with muscular atrophy . . . 151 cerebral, distinguished from apoplexy 205 from chorea 224 from epilepsy 225 feigned 228 resembling locomotor ataxia . 165 spasms in 171 toxic 227 traumatic 140 Hysterical anorexia 556 complaints, local 226 contractures 231 delirium 70 headache 227 hydrophobia 233 locomotor ataxia 165 paralysis 138 pseudo-maladies 227 tetanus 229 urine in 228 Hystero-epilepsy 226 aura in 226 ovarian 226 I. Ichthyosis 175, 1015 Icterus 665 catarrhalis 673 distinguished from abscess of liver 675 from acute atrophy of liver 675 from biliary calculi . . . 675 from cancer of liver . . . 675 from cirrhosis 675 from congestion of liver . 674 from hepatic inflammation 675 neonatorum 665 Ileum, catarrh of 608 ulceration of 627 INDEX. 1083 Iliac fossa, disease in 622 region, tumor of 727 Illusions 87 Impetigo 1011 contagiosa 1011 India-rubber poisoning .... 1044 Indigestion, functional .... 570 Infantile paralysis 156 scurvy 885 Infarct, hemorrhagic . . . 395, 466 Influenza 262, 876, 909 See also Catarrhal fever. Innominate, aneurism of . ... 517 Inosite 766 Inosuria 766 Insanity 67 chronic 181 confounded with delirium . . 69 following acute rheumatism . 893 Insensibility from drink distin- guished from apoplexy . . 201 from narcotics distinguished from apoplexy 201 Insolatio. See Sun-stroke. Insomnia 67, 72 with delirium 72 Inspiration, jerking 316 Insufficiency of aortic valves confounded with aneurism 510 Intellection deranged 67 Intermittent fever 948 distinguished from chills of .pus formations .... 951 from diseases of the heart 952 from hectic fever .... 951 from hepatic fever . . . 952 from passage of gall- stones 952 from puerperal malarial fever 953 from remittent fever . . . 956 from syphilitic fever . . . 953 from urethral fever . . . 952 types of 949 Intestinal wonns 1050 Intestines, cancer of 731 contraction of 634, 638 dilatation of 592, 640 confounded with dilatation of ' stomach 592 diseases of . : 593 hemorrhage of . . . 651, 706, 917 inflammation of 606 internal strangulation of . . . 636 intussusception of 635 invagination of 627, 635 obstruction of 630, 637 causes of . . . 634 confounded with peritonitis . 631 with strangulated hernia . 632 Intestmes, obstruction of, fre- quency of 639 from passage of gall-stones . 637 from stricture 638 from volvulus 637 location of lesion in ... . 639 percussion of 547, 549 perforation of 612 distinguished from colic . . 600 from irritant poisoning . 1028 sloughing of 636 stricture of 638 tubercular disease of 646 worms in 1050 Intoxication 71 ursemic 796 Intra-hepatic concretion .... 952 Iris-contraction 100 Iritis 900 Irritant poisoning 1028 Itch 1005, 1021 army 1021 J. Jaundice 601, 662 acute infectious 671 catarrhal 673 diagnosis of 662 fatal forms of 665 from blood-poison 664 from mental emotion 665 in acute non-hepatic diseases . 670 in phosphorus poisoning . . . 1029 in pneumonia 890 obstructive 663 of the new-bom 665 Jaw-jerk 100 Joint affection, hip .... 258, 629 pyaemic 892 Joint-inflammations 162 K. Kakke. 153 Keratitis 90 Kidney, abscess around . . 627, 818 abscess of 627, 816 distinguished from cystitis . 818 affections of, with swelling . . 590 calculus in, symptoms of . . . 790 cancer of 700 distinguished from enlarged spleen 720 contracted . . .481, 646, 808, 810 associated with albuminuric ulceration of bowel . . 646 with gout 899 confounded with myxoedema 834 with pernicious anaemia . 862 1084 INDEX. Kidney, contracted, diuresis in . 827 displacement of 591 cysts of 805 enlarged, chronically inflamed 807 confounded with cancer of liver 697 with hydatids of liver . . 700 with ovarian tumor . . . 728 fattjr, enlarged 807 floating 627 hemorrhage from 773 hydatids of 822 confounded with hydrone- phrosis 822 inflammation of 784 of pelvis of 819 movable or displaced . . 724, 725 simulated by malignant dis- ease of colon 726 neuralgia of 786 pain in 785 confounded with colic . . . 602 paroxysmal 786 persistent 788 percussion of 547 sarcoma of ;....... . 804 suppurative inflammation of . 818 surgical 806 syphilomata of 804 tubercle of, confounded with Bright's disease 804 tumors of . 627, 805 waxy or amyloid, enlarged . . 808 Klebs-Loefller bacillus . . . 262, 524 Knee-jerk 101, 132 Kreatin and kreatinin 757 I.. Lactic acid 584, 689 Landry's paralysis 126 Laryngeal affections, acute . . . 274 cough 267 crises 162 diphtheria 285 paralysis 288 phthisis 292 rheumatism 276 spasm 280 from use of antipyrine . . . 1036 stenosis 293 stridor 266, 514 vertigo 86, 280 Laryngismus stridulus 279 Laryngitis, acute 267, 274 confounded with croup . . 275 distinguished from acute pul- monary affections . . . 275 from pharyngitis .... 275 from tonsillitis 275 Laryn^tis, chronic 286 aneurism of aorta confounded with .:...... 287, 514 combined with syphilis . . 286 with tuberculosis . . . 286 confounded with altered voice 287 with nervous aphonia . . 287 of epiglottis 290 diffuse cellular 275 diseases confounded with . . . 287 erysipelatous 275 feigned 289 hemorrhagic 276 hiemalis 275 membranous ...;.... 285 cedematous 277 secondary, of the exanthemata 283 sicca 275 spasmodic 280 syphilitic or tubercular .... 292 Laryngoscopy 267, 271 Larynx, abscess of 284 actinomycosis of 285 acute diseases of 274 affections of nerves of ... . 288 cancer of 294 cartilages and perichondrium of, diseases of 291 changes in breathing in dis- eases of 266 in voice in diseases of . . . 266 chronic diseases of 286,514 cough in diseases of 267 extirpation of 291 growths in 293 hypersesthesia of 289 inflammation of 274 myxomata of r . 274 oedema of 277 organic diseases of 273 pachydermia of 292 pain in diseases of 267 polypi in . . i 87 rupture of 358 stenosis of 293 table of diseases of 273 tubercle of 292 tumors of 293 ulcers in ..... . 292, 293, 539 venous congestion of .... 290 ventricular bands of, hyper- trophy of 290 Lead poisoning . 598, 609, 810, 1030, 1041 paralysis from, 105, 141, 151, 1042 Lentigo . 1015 Lepra, or leprosy .1017 Leptothrix 339^ 537 Lethargy, African 214 INDEX. 1085 Leucine 679, 745, 759 Leucocytosis 625 Leuksemia 95, 863 distinguished from hsemophilia and purpura 888 from pernicious anaemia . . 863 false hypo- 866 lymphatic 864, 865 medullary 866 myelogenous 864 of liver 690 pseudo-leuksemia distinguished from 867 splenic 864, 865 Lichen 1005, 1014 planus 1005 ruber 1005 scrofulosorum 1005 syphilitic 1026 tropicus 1005, 1024 Lipoma of intestine 636 Lithsemia 73, 85, 900 associated with disorders of vision 900 with pain in stomach and bowels 900 Liver, abscess of. . . ..667,675,682 distinguished from hydatids 699 actinomycosis of 684 acute affections of ... . 667, 676 confounded with pysemia . 874 congestion of 667, 674 confounded with cancer of liver 693 with remittent fever . . 956 inflammation of . . 667, 675, 693 distinguished from catar- rhal icterus .... 675, 693 yellow atrophy of . 672, 675, 676 confounded with hepatitis 678 with typhoid fever . . 678 with yellow fever . . . 678 from phosphorus-poisoning 679 - nervous symptoms in . . 677 cancer of ... . 675, 690, 699, 707 chronic aflections of 679 atrophy of 709 congestion of . . . 674, 679, 689 confounded with cancer of liver 692 with catarrhal icterus . 674 with chronic gastritis . 680 with hypertrophy of liver 680 with torpor of liver . . 680 nervous symptoms in . . 681 cirrhosis of 621, 675, 702 hypertrophic 70'), 709 decrease in size of ... . 676, 702 diseases of , 661, 666 Liver, diseases of, dropsy in . . 702 from inflammation of portal vein . . 708 jaundice in 661, 676 malarial infection in ... . 676 pain in 661, 702 with absence of jaundice, 679, 701 displacement of, diseases pre- senting ........ 410 from tight lacing 680 elastic tumors of 698 enlargement of . . . 589, 679, 689 confounded with chronic pleurisy 421 fatty 672, 688 confounded with cancer . , 692 fibro-fatty 706 hydatids of 683, 697, 706 hypertrophy of 680 infarcts in 467 inflammation of .' . . . . 668, 681 leukaemic 690 movable 726 percussion of 545 pigment, confounded with acute hepatitis 669 pysemic abscess of 678 red atrophy of 707 simple induration of 707 sylphilitic 689, 694 confounded with cancer of liver 694 table of diseases of 666 torpor of 680 tropical abscess of ... . 667, 687 waxy 688, 692 confounded with cancer . . 692 diseases confounded with . . 689 Lock-jaw. See Tetanus. Locomotor ataxia . . . 129, 135, 159 arthropathies of, distinguished from rheumatic arthritis . 902 crises in 162 diminution or loss of muscular sense in 161 distinguished from diseases of the spinal cord 163 from general paralysis of the insane 162 eruptions in 162 gait in 81, 160, 161 of syphilitic origin . . . 160, 165 resembling hysteria 165 station in 32 Lumbago 895 Lumbar region, tumors of . . . 727 Lungs, actinomycosis of .... 381 acute affections of 384 confounded with tubercular meningitis 188 68 1086 INDEX. Xiungs, acute affections of, in typhoid fever 927 cancer of 375 cirrhosis of 425, 426 collapse of 359, 426 diseases of 299, 329 fistulous opening into .... 427 gangrene of ... . 339, 355, 380 gray hepatization of 392 hydatids of 421 hypostatic congestion of . . . 654 inflammation of 388 cedema of 393, 796 scrofulous disease of 383 syphilitic disease of 375 tuberculosis of 344, 385 See also Phthisis. Lupus 1016 erythematodes 1016 verrucosus 1016 vulgaris 1016 Lymphadenoma . 137, 420, 508, 866 distinguished from lymphatic cancer 867 Lymphatic glands, cancer of, 727, 867 sarcoma of 867 system, disease of 1018 Lymphomas, local gland . . . 868 distinguisied from Hodgldn's disease 868 of mediastinum 508 Maculse 1015 Malaria, appearance of tongue in 961 chronic 95, 967 examination of blood in . . . 960 poisoning by 787 Malarial cachexia 960 changes in kidneys 967 cirrhosis 706 corpuscles in blood 968 fever, distinguished from den- gue 996 hsematuria, 776 neuralgia 968 palsy 968 poisoning, chronic, ... 95, 967 septicsemia 876 symptoms, in pneumonia . . 402 Malformations of heart con- founded with valvular af- fections 490 Malignant pustule 1045 Mania, acute 192 alcoholic 194 associated with mumps . . . 534 with typhoid fever .... 919 Mania, confounded with acute meningitis ....... 193 with delirium tremens ... 193 ursemic 798 Marasmus 243 Measles 95, 398, 981 anomalous forms of 984 associated with acute bronchitis 983 with pneumonia 984 catarrh In 262, 982 complications of 398, 983 distinguished from miliary fever 984 from rubella 986 from scarlet fever .... 980 from smallpox . 980, 982, 992 from typhus fever .... 983 eruption in . , 982 German 985 malignant, confounded with cerbro-spinal fever . . . 942 Mediastinum, abscess of ... . 508 fluid in 420 inflammatory thickening of . 509 tumor of 420 Megrim. See Migraine. Melsena 651 Melancholia, acute 194 Melasma 1015 Memory, disordered 67 Meniere's disease . . 84, 85, 98, 681 Meningitis, acute 179, 378 confounded with acute mania 193 with acute softening of brain 181 . with apoplexy 199 with cerebritis 181 with delirium tremens . . 193 with head-symptoms of acute rheumatism . . 184 of acute ulcerative endo- carditis 185 of continued fevers . . 182 of pericarditis .... 185 of pneumonia .... 185 of remittent fever . . . 958 of typhus fever .... 932 with typhoid fever ... 927 cerebro-spinal 189, 937 diseases confounded with ; . 940 distinguished from purpura . 887 sporadic 942 chronic, distinguished from tu- mor 242 epidemic 937 idiopathic 942 of the base of the brain ... 180 of the convexity of the brain . 180 ordinary 186 purulent 705 INDEX. 1087 Meningitis, spinal 131 sporadic cerebro-spinal .... 942 tubercular 185, 942 distinguished from acute hy- drocephalus 187 from cerebro-spinal fever . 942 from chronic hydrocepha- lus 187 from hysteria 189 from inflammatory affec- tions of the lungs . . . 188 from typhoid fever . . . 188 rose-spots in 188 Meningo-encephalitis 246 Mensuration of chest 300 Mental faculties, diseases charac- terized by gradual impair- ment of 235 Mercurial tremor 1041 Merycism 565 Metritis confounded with acute cystitis 816 with peritonitis 615 Migraine 82, 256, 260, 802 Miliaria papulosa .... 1005, 1024 vesiculosa 1024 Miliary fever 984 Milk-leg. See Phlegmasia alba dolens. Milk-sickness 1047 Mind-blindness 98, 209 Mollities ossium 904 MoUuscum contagiosum .... 1024 epitheliale 1024 fibroma 1024 Monoplegia , 120 brachiofacial 120, 121 crural 122 facial 120 facio-lingual 122 oculo-motor 122 Morphine habit 1038 Morphoea 1020 Morton's disease 897 Morvan's disease 153, 175 Motion, deranged 103 voluntary diseases marked by sudden loss of 194 Motor path of Gowers 64 Mouth, diseases of 519 gangrene of 520 inflammation of . 519 morbid appearances of . . . . 519 Mucus, vomiting of 561 Multiple neuritis, 128, 164, 528, 833, 1044 See also Neuritis. Mumps ......... 523, 534 See also Parotitis. confounded with erysipelas . . 999 Mumps, diplococeus in .... 534 Murmur, respiratory 314 vesicular 313 absence of 316 changes in 314 Murmurs, cardiac 439 endocardial 439, 461 from lung changes 492 from misdirection of current . 492 functional valvular 491 in the course of fevers .... 463 musical 493 over thyroid gland 457 pericardial 444 without valvular lesion . . . 492 Muscse volitantes 87 Muscle, rectus, contraction of . 722 Muscles, appearance of, in pa- ralysis 108 morbid states of, paralysis from 105 overuse of 152 Muscular contraction, paradoxi- cal 103 movements, irregular forms of 164 rigidity 131 sense 64, 79 diminution or loss of ... 164 Myalgia ....... 253, 409, 896 Myasthenia gravis pseudo-para- lytica 105 Myelitis 126, 132 acute, contrasted with acute as- cending paralysis .... 129 contrasted with multiple neu- ritis 129 central 134 disseminated 134 from compression 134 hemorrhagic 134 transverse 134 Myocarditis 476 acute 477 associated with gonorrhoea . . 477 chronic 478 rheumatic 892 Myoclonus multiplex 222 Myopia 88, 96 Myotone 234 Myxoedema .... 251, 834, 1019 distinguished from acute ne- phritis . , 834 from contracted kidney . . 834 from scleroderma 1019 uterine hemorrhage in ... . 834 Myxomata of larynx 294 JT. Nails, appearance of, in disease, 363, 417, 427, 1039 1088 INDEX. Nails in typhoid fever relapses . 923 shedding of 1013 Narcolepsy distinguished from trance 205, 214 Narcotics, insensibility from . . 202 poisoning by 1032 Nasal catarrh 262 hydrorrhoea 262 polypi 265 Nausea as a symptom 558 Neck, cellulitis of 634 Nematoda 1050 Nephralgia 785 confounded with colic . . 602, 786 from passage of calculi . . . 785 Nephritis 784 acute, parenchymatous . . . 791 confounded with acute Bright's disease .... 794 with acute cystitis .... 815 with myxoedema 834 bacillosa inierstitialis primaria 793 chronic consecutive 805 distinguished from Bright's disease 805 , infectious 705, 793 interstitial 810 suppurative 794 Nerve-storm 256 cardiac 453 Nerves, diseases of 57 paralysis from affections of . . 104 wounds of 174 Nervous affections, classification of 177 deranged nutrition and se- cretion in 174 centres, diseases of, anaesthesia a symptom of 75 paralysis from 104 system , diseases of . ..... 67 Nettle-rash 1004 Neuralgia 252 abdominal 605, 733 due to aneurism 733 as a cause of headache .... 82 cerebral 256 confounded with aneurism . . 733 with pain of rheumatism, 253, 894 dorso-intercostal .... 174, 605 epiletiform 255 facial 254 distinguished from painful anaasthesia of fifth nerve 255 from spasm of face . . . 255 hepatic 601 in Bright's disease 801 intercostal 410, 451 confounded with acute pleu- risy 410 Neuralgia, lumbo-abdominal . . 605 of frontal sinus disease .... 261 of kidney 786 of spinal nerves confounded with colic 605 of stomach 566 ovarian 604 reflex 253 supra- orbital 260 Neurasthenia 240 associated with neuralgia . . . 254 Neuritis 252, 257, 921 acute progressive 127 ascending 105, 137 multiple . 128, 164, 528, 833, 1044 distinguished from acute ascending paralysis . .129 from acute myelitis ... 129 from locomotor ataxia . . 129 from rheumatism .... 129 optic ... 95, 141, 180, 241, 244 Neuroses, reflex 96 Neurosis, cardiac 450 cutaneous 1012 Night-blindness 96 Night palsy 840 terrors 69 Nodules, connected with rheuma- tism 893 in leprosy 1017 subcutaneous flbrous 462 syphilitic, in paralysis .... 143 of lung 375 of tongue 521 Nose, diphtheria of 262 diseases of . - # 260 foreign body in 261 gonorrhoeal infection of . . . 264 hemorrhage from .... 263, 706 Numbness of extremities ... 80, 164 Nutrition, deranged 1 74 Nystagmus 119, 173, 222 O. Occlusion, vascular .... 201, 237 Occupation neurosis 223 (Edema, angio-neurotic .... 176 distinguished from erysip- elas 998 myxoid 276 of forehead and eyelids . . . 243 of the ankles 584, 830 of the lar3'nx 277 diagnosticated from croup . 278 pulmonary . . ^^ . . . . 393, 796 mistaken for pneumonia . . 393 occurring in Bright's disease 796 (Esophagus, auscultation of . . 540 cancerous narrowing of . . . 589 INDEX. 1089 (Esophagus, cicatrices of ... . 539 compression of 539 dilatation of 539 diseases of 519, 537 injBammation of 538 rupture of 539 stricture of 514, 538, 586 spasmodic 538 thicliening of, from alkaline poisoning ....... 1029 Omentum, cancer of ... . 590, 696 tumor of 589 Ophthalmia 90 Ophthalmoplegia 94 Ophthalmoscope in diseases of the nervous system .... 89, 94 Opisthotonus 229, 232 Opium poisoning .... 1032, 1038 Optic nerve, atrophy of ... . 95 neuritis . . 95, 141, 180, 241, 244 tract, diseases of the 118 Orthopnoea 30, 331 Orthotonos 229 Osteitis deformans 251 Otitis from inveterate smoking . 1040 Ovarian cysts 700, 711 dropsy confounded with ascites 711 fluid, chemical character of . 713 inflammation 604, 627 neuralgia 605 tumors simulating renal growths 728 Oxalate of lime in the urine, 575, 757, 786 Oxaluria 758, 795 Oxyuris verraicularis 1051 Pachymeningitis, hemorrhagic, 181, 199 spinalis interna 132 Paget's disease 251 Pain as a symptom 55 abdominal, in enteritis .... 607 in typhoid 918 cardiac 448 from organic structural disease 894 gastric, as a symptom .... 565 in appendicitis 623, 625 in diseases of the liver . . 661, 702 in laryngeal affections .... 267 paroxysmal, diseases character- ized by 252 Palate, paralysis of 528 Pallor of malignant disease . . 862 Palpa:tion of the chest 303 Palpitation, cardiac, diseases at- tended with 452 Palsy. See Paralysis. associated with typhoid fever . 921 Bell's 121, 144 by compression 146 cerebral 156 facial 140, 144 double 146, 148 functional 76, 126 hysterical 139 lead 141 limited 121, 138 local 144 motor ■ 121 shaking 167, 248 wasting . 149 Pancreas, abscess of 615 calculous disease of 722 diseases of 721 fatty diarrhoea in 653 ulcerating 565 uniform simple hardening of . 721 Pancreatic fat necrosis 721 Pancreatitis, acute 614 confounded with peritonitis . 614 chronic 721 hemorrhagic 614, 641 suppurative 721 Papillitis 95, 244 Papilloma 264, 272, 294 Papular diseases 1005 Paracentesis 423 Parjesthesia 80 Paralysis .... 64, 65, 66, 75, 103 See also Palsy. ascending 126 contrasted with acute myelitis 129 with multiple neuritis . . 129 acute atrophic 155 agitans 167, 248, 902 distinguished from chorea . 222 from general paralysis . . 248 from rheumatism .... 902 bulbar 147, 152 from compression 146 clinical investigation of . . . 107 convulsions in 117 crossed 114, 116 diphtheritic .... 141, 164, 528 from multiple neuritis' . . . 142 electro-muscular contractility in 109 sensibility in 112 essential 155 eye symptoms in 91, 116 facial 144 following measles 982 from affection of nerves at their extremities 104 from apoplexy 194 from chronic softening .... 235 1090 JNDEX. Paralysis from interference with the circulation 105 from lead poisoning . 105, 141, 151 from lesion in the course of a nerve 104 from lesion of crus cerehri . . 117 from lesion of nervous centres . 103 from lesion of spinal. cord . . 124 from morbid state of the mus- cles .......... 105 from poisoning 105 from progressive muscular atrophy 149 from reflex action 104 functional 104, 106 general 103, 246 distinguished from other pal- sies 247 of insane 162, 247 glosso-labio-laryngeal .... 148 hereditary 104 hyperpyrexia in 116 hysterical 104, 138 infantile 155 intermitting 106 local 144, 149, 151 malarial . 106 motor, from exposure to cold . 104 of individual muscles .... 288 of nerves of the arm .... 146 of leg only 122 of arms 121, 184 of vocal apparatus . . . 289, 333 partial 103 periodic 106 peripheral 104 pseudo-hypertrophic muscular, 31, 154,478 reflex 104 rheumatic 140 spastic spinal 135 spinal, general 125, 151 sudden, distinguished from apoplexy 125, 204 syphilitic 137, 142 from inherited taint .... 144 tabular view of 167 tremor in 167 vaso-motor 115 with muscular wasting . . . 149 without coma 204 Paramyoclonus multiplex . . . 173 Paramyotone 234 Paraplegia 124, 133 ataxic 163 cervical 134 following accidents 140 from hypnotic suggestion . . 140 from spinal hemorrhage ... 1 25 gradual 130 Paraplegia, hysterical 75 reflex, from intestinal worms . 137 seat of lesion in 124 spastic 163 sudden 125 Parasites 1027, 1048 animal 595, 1050 diseases caused by 1020 fly 1056 in hsematuria 777 in sputum 341 in stomatitis 520 Intestinal 855 vegetable 1049 Paresis 103 spastic 153 spinal 126 Parotitis 534 associated with pneumonia . . 390 secondary 523, 534 See also Mumps. Patellar tendon reflex 101 Pectoriloquy, whispering . . . 325 Pellagra 1020 Pelvic cellulitis 728 hsematocele 628 Pemphigus 74, 1010 foliaceus 1010 syphilitic 1010 Peptonuria in phosphorus poi- soning 1029, 1045 Percussion 803 auscultatory 307 clearness of, as a diagnostic sign 348 dulness of, diseases accom- panied by 361 in pneumonia 896 mediate 803 of abdominal viscera .... 544 of healthy chest 309 respiratory 308 sounds elicited by 804 Percussion hammer 306 Perforation, intestinal, confound- ed with colic 600 Periarteritis 836 nodosa 836, 1064 Pericardial eflftision . . "422, 469, 488 diagnostic signs of ... 470 mistaken for dilatation of heart ' . 488 murmurs 444 Pericarditis, acute 464, 468 caused by scurvy 885 diagnosticated from endocar- ditis 471 from gastric irritation . . . 473 from inflammation of brain . 473 from pleuritis ...... 471 INDEX. 1091 Pericarditis, cancerous 474 friction sounds of 464 head-symptoms of, confounded with meningitis 185 hemorrhagic 474 in Bright's disease 796 indurated mediastino- .... 475 tubercular 474 Pericardium, adhesions of . . . 475 dropsy of 473 effusion of, confounded with chronic pleurisy .... 422 ulcerative perforation of . . . 476 Perihepatitis 668 Perinephritis 818 distinguished from inflamma- tion of psoas muscle . . . 819 Periosteum, rheumatism of . . . 897 Periostitis 256 Peripheral irritation 105 Peritoneum, abscess of .... 730 carcinoma of 715, 729 colloid cancer of 730 diseases of 593, 714, 730 fatty tumor of 730 hydatid disease of 730 perforation of 600 sarcoma of 730 Peritonitis, acute 606, 609 associated with acute pancre- atitis 614 confounded with abdominal hysteria 619 with acute enteritis . . . 614 with acute gastritis ... 613 with colic 606, 620 with cystitis 615 with distention of bladder 615 with inflammation and ab- scess- of abdominal mus- cles 616 with intestinal obstruction 631 with metritis ...... 615 with rheumatism of ab- dominal walls .... 618 with typhoid fever . . . 926 chronic 621, 708, 714 attended with ascites ... 622 cancerous deposits in . . . 622 distinguished from dropsical effusion 714 from collections of pijs in the cavity 617 from extravasation into the sac 611 local 612 perforative 611 puerperal 612 tubercular 589, 622, 714 Perityphlitis 626 Pernicious anaemia 857 Pernicious ansemia associated with alterations in spinal cord . 861 confounded with Addison's dis- ease 872 with contracted kidney . . 862 with disease of heart . . . 862 with organic disease of stomach .. , 862 distinguished from ordinary ansemia 863 from chlorosis 863 from leukaemia 863 from pseudo-luksemia . . . 863 state of blood in 859 Petit mal 215, 218 Pettenkofer's test 761 Phantom tumors 723 Pharyngeal fever 999 tonsil 263 Pharyngitis 275 confounded with diphtheria . 529 Pharyngo^mycosis 537 Pharynx and oesophagus, diseases of 519, 537 adenoid vegetations in . 857 Phlebitis 477, 624, 839, 878 Phlegmasia albadolens, 831, 839, 856, 857, 878 associated with chlorosis . . 891 confounded with rheumatism . 890 Phosphates in the urine .... 752 Phosphatic diathesis 753 Photophobia 337, 900 Phtheiriasis . . . 1005, 1006, 1020 Phthisis 361 See alsoTuberculosis of Lungs. acute 384, 396, 928 distinguished from menin- gitis 387 from typhoid fever . 387, 928 acute pneumonic 387 bronchial 337 cavity from 379 distinguished from pulmo- nary abscess 380 chronic 613 confounded with actinomy- cosis 381 with bronchial dilatation . . 377 with chronic bronchitis . . 369 with chronic pleurisy . 374, 418 with chronic pneumonic con- solidation ..... 370, 872 with emphysema 369 with phthisis of old people . 370 with pulmonary abscess . . 378 with pulmonary cancer . . 375 with pulmonary gangrene . 380 with syphilitic disease of the lungs 375 1092 INDEX. Phthisis, cough in 361 fibroid 425 laryngeal 292 of old people 370 pneumonic 373, 387 pulmonary 338, 418 rapid progress of 388 retrogression of 882 symptoms of 368 temperature in 363 Physical diagnosis .... 297, 299 signs 297 Picric acid test 770 Pigment in the blood . . . 883, 960 liver 669 Pityriasis capitis 1023 maculata et circinata .... 1013 rosea 1013 rubra ........ 1008, 1013 versicolor .871, 1022 Plague distinguished from ty- phus fever ....... 936 from yellow fever 973 Plasmodium malarisB . . . . . 876 Pleura, cancer of 420 etfusion into 422 fistula of 427 friction sound in 472 liquid in 472 Pleurisy, acute .... 360, 396, 404 confounded -with acute Bright's disease .... 796 with acute pneumonia . . 407 with intercostal neural- gia 410 with pericarditis . . 422, 472 with pleurodynia .... 409 bilious 403 chronic 374, 415, 423 confounded with abscess in thoracic walls 422 with cancer .... 420, 424 with chronic interstitial pneumonia 424 with cirrhosis of lung . . 425 with collapse of lung, 359, 426 with emphysema . . . . 419 with enlargement of liver 421 with enlargement of spleen 421 with fistula of pleura . . 427 with hydatid cysts ... 421 with hydrothorax .... 422 with intra-thoracic tumor 419 with pericardial effusion . 422 with phthisis .... 418, 425 with pneumothorax ... 415 with tubercle .... 416, 424 diseases confounded with . . 419 circumscribed 420 Pleurisy, diaphragmatic, con- founded with acute hepa- titis 670 double 374 dry 405, 426, associated with typhoid fever 928 different forms of 418 fluid . of, microscopical and bacteriological examina- tion of 418 Pleuritic eff"usion . 358, 374, 405, 685 Pleurodynia 316, 409 confounded with acute pleurisy 409 Pleurothotonos 229 Plica polonica 1024 Pneumatometry 303 Pneumococcus of Praenkel . 344, 398 of Friedlaender 400 Pneumo-hydro-pericardium . . 476 Pneumonia acute 388 confounded with acute bron- chitis 396 with acute phthisis . . . 396 with acute pleurisy . . . 407 with appendicitis .... 630 with biUious pneumonia . 403 with cerebro-spinal fever . 942 with hypostatic congestion 'Ii94 with pulmonary apoplexy 394 with pulmonary engorge- ment in fevers .... 393 with pulmonary oedema . 393 with typhoid pneumonia . 401 head-symptoms of, confound- ed with meningitis . . . 185 apex 399 associated with measles . . . 983 with typhoid fever .... 928 with typhus fever 934 with ulcerative endocarditis 399 auscultation in , . 390 bilious 401 broncho .... 351, 360, 396, 934 following hemorrhage from cavities 398 caseous 338 catarrhal 351, 396 chronic, confounded with phthisis 370 catarrhal 373 croupous 388, 398 deglutition ^ 398 delirium in 68 dissecting 380 double 399 gangrenous 294 hypostatic 394 interstitial 424 latent 400 lobar 360 INDEX. 1093 Pneumonia, malarial 403 massive 408 migratory 400 physical signs of 390 respiration in 330 tuberculous inspiration bron- cho- 398 typhoid 401 articular symptoms of . . . 402 Pneumothorax . . 411, 476, 580, 686 chest sounds in 413 diagnosticated from chronic pleurisy 419 from diaphragmatic hernia . 414 from emphysema 358 from pneumo-pericardium . 476 without perforation 415 Pneumotyphus 934 Podelcoma .' 1049 Poisoning, aconite 1086 acute . . 1027 alcohol 1033, 1039 urinary test for 1034 alkaline 1029 aloes . 1031 ammonium 538, 1029 aniline 1035 antimony 664, 1030 antipyrine 1036 arsenic .... 128, 609, 1030, 1043 atropine 1034 belladonna 1034 benzene 1033 bromine 1029 brucine 1037 by poisonous exhalations . . . 1047 by ptomaines 1047 Calabar bean 1087 cantharides 1030 carbolic acid 1034 carbon disulphide 1044 monoxide or carbonic oxide, 762, 1035 charcoal fumes 1035 cheese, egg, millc 1031 chloral 1033, 1039 chlorine 10^9 chloroform . . 202, 664, 1088, 1039 chronic 1038 coal gas 1035 colchicum 1081 colocynth 1031 conium . , 1034 copper .... 598, 664, 1030, 1048 corrosive sublimate 1030 cream puif . 1081 diazobenzene 1031 digitalis 1036 elaterium 1031 ergot 1031, 1040 Poisoning, ether . . 664, 1033, 1039 from alkaloids 1047 from animal eflSuvia .... 1048 fungi 1081 hydrochloric acid 1028 hydrocyanic acid .... 203, 1085 hyoscyamus 1034 iodine 1029 iron 1030 irritant 656, 660, 1028 lead, 287, 598, 609, 810, 1030, 1041 lobelia 1031 malarial 831 mercurial .... 609, 1030, 1041 muscarine 1031 mushroom 1032 narcotic 287, 797, 1032 insensibility from, distin- guished from alcohol- ism 1033 from apoplexy . . .201,1082 from uraemia .... 797, 1082 nitric acid 538, 1028 nitrobenzole 202 nitro-glycerine 1036 opium 1032, 1038 oxalic acid . . . 1029 paraldehyde 1039 petroleum 1036 phosphorus, 664, 679, 780, 1029, 1044 picrotoxin 1037 potassium hydroxide .... 1029 iodide and nitrate 1029 producing anaesthesia .... 74 coma 71 headache 83 paralysis 105 prussic acid 1035 sausage 1031 savin 1031 sewer-gas 791 silver 1080 slow, by metals 1041 sodium hydroxide 1029 strychnine 1037 confounded with epilepsy . 1037 with hydrophobia . . . .1087 with tetanus .... 232, 1037 sulphuric acid 538, 1028 tobacco 1031, 1040 tyrotoxicon 1031 veratrum viride 1037 zinc 1080, 1044 Poisons 1027 animal , diseases caused by . .1045 irritant 1028 Poliomyelitis 184, 174 acute anterior 156 Polysesthesia 79 1094 INDEX. Polyarthritis 278 Polypi, nasal 264, 265, 332 of larynx 294 Polyuria 826 chronic, distinguished from true diabetes 827 Porencephalus 250 Porrigo larvalis , . . . , . . .1011 Portal veins, inflammation of, confounded with acute hepatitis ■. . 669 with cirrhosis of liver . . 708 inflammation of, with coagula 708 thrombosis of . 709 Position as a symptom 30 Posterior sclerosis 135, 160 Potassium ferrocyanide test . . 770 Pregnancy, extra-uterine, mis- taken for appendicitis . . 628 Presbyopia 88, 89 Pressure-points 233 Progressive muscular atrophy, 149, 156 distinguished from bulbar pa- ralysis 152 from cerebral hemiplegia . 150 from general spinal paraly- sis 151 from idiopathic atrophy . . 154 from infantile paralysis . . 156 from local paralysis . . . 151 from pseudo-hypertrophic muscular paralysis ... 154 from syringo-myelitis ... 152 from unilateral atrophy of the face 152 Prostate gland, hemorrhage from 778 Prurigo 1006 Pruritus 1006, 1025 hiemalis 1025 Pseudo-disseminated sclerosis . . 169 Pseudo-leuksemia ....... 863 Pseudo-scarlatina 981 Pseudo tabes mesenterica . 556, 724 Psoas muscle, inflammation of • 819 Psoriasis ..... 1006, 1013, 1014 distinguished from eczema squamosum 1014 from lichen planus . . 1006,1014 syphilitic 1014 Ptomaines 83, 641, 676 Ptosis 92 Puerperal malarial fever .... 953 Pulmonary affections, eon- founded with typhoid fever 927 disease, physical signs of . . . 299 engorgement in fevers .... 393 Pulsation, abdominal 731 aortic . 731 Pulsation, aortic, confounded with aneurism of abdomi- nal aorta 733 Pulse, condition of, in disease . 85 dicrotic 38, 922 frequency and rhythm of . . 35, 36 irregular . . . ^ 36 resistance of 37 respiration-ratio, perverted . . 388 strength and volume of . . . 36 Pulsus alternans 36 paradoxus 475 Purging, diseases attended by, 643, 653 Purpura 886 acute, distinguished from cere- bro-spinal meningitis . 887 from haemophilia .... 887 from scurvy 896 hsemorrhagica and rheumat- ica 886 Purulent urine 794 diseases associated with . . . 814 Pus in internal cavities .... 951 In stools 593 in urine 779 in vomit 562 presence of, in appendicitis . . 624 Pustular diseases 1011 Pustule, malignant 1045 Pyaamia 872 arterial ........... 875 associated with myocarditis . . 477 chronic or relapsing 875 confounded with acute affec- tions of liver 874 with acute glanders or acute farcy 874 with intermittent fever . . 952 with rheumatic fever . . . 874 with typhoid fever .... 873 idiopathic 875 joint-affection of 892 metastatic or embolic abscesses of 874 spontaneous septico- 875 Pyelitis 780, 794, 819 catarrhal or rheumatic .... 821 from irritation of calculi ... 821 tuberculous . 821 Pylorus, cancer of 586 fibroid thickening of 587 Pyonephrosis 821 confounded with abscess of the kidney 822 with suppurative nephri- tis .... ; 822 Pyopneumothorax, subphrenic, 580, 686 Pyrosis ; . . . 561 INDEX. 1095 Quinsy, distinguished from sec- ondary parotitis 523 from tonsillitis 522 R. Kaehitis 249 Eadial nerve, paralysis of ... 146 Eales 321, 390 varieties of 322 Eash, mulberry, of typhus . . . 930 of scarlet fever 977 rose 467 Eaynaud's disease 776, 840 mistaken for chilblains .... 841 Eecords of cases, plans for ... 29 Eed gum of infants 1024 Eeflex, abdominal 99 arc 99 cremaster 99 epigastric 99 excitability 112, 133 irritability 184 paraplegia 137 tendo Achillis ..... 100, 247 Eeflexes, aural 100 cranial 100 crossed 101 deep 100, 132 derangements of 99, 150 laryngeal and pharyngeal, 100, 272 nasal 100 reinforcement of 102 superficial 99 tendon 99 Eegurgitation of fluid or food . 565 Eelapsing fever 944 bilious typhoid form of . . 946 distinguished from typhoid and typhus fever 947 from Weil's disease .... 672 from yellow fever . . . 947, 973 renal disease in . 946 spirilla of 947 Eemittent fever 954 bilious 974 distinguished from acute con- gestion of the liver . , . 956 from acute meningitis . . . 958 from intermittent fever . . 956 from typhoid fever .... 957 from yellow fever 974 infantile 961 sequelse of 959 Eenal abscess 794 artery, multiple aneurisms of . 823 asthma 334 colic . 786, 822 concretions, forms of .... 786 Eenal concretions, passage of, 602, 789 cysts 823 disease in relapsing fever . . . 946 enlargements 700 growths simulated by ovarian tumors 728 hsematuria 774 Inadequacy 806 vein, thrombosis of 828 Eespiration, amphoric . . . 320, 476 bronchial 313, 318 broncho-cavernous ...'.. 320 cavernous 319 Cheyne-Stokes . . . 195, 335, 449 feeble 314 harsh 317 in children, peculiarities of . . 328 jerking 316 metallic 320 metamorphosing breath-sound 320 prolonged 316 puerile 314 sounds of, in health 313 supplementary 314 vesiculo-bronchial 317 vesiculo-cavernous 320 Eespiratory movements .... 299 percussion . 308 Eetina, embolism of central ar- . tery of 95 Eetinal hemorrhage 94, 95 Eetinitis, albuminuric .... 95, 801 anaemic 95 diabetic ... 95, 824 leuksemic 95 pigmentosa 94 Eetropharyngeal abscesses . 283, 537 Eheumatic arthritis 900 fever distinguished from pyae- mia 874 gout 900 paralysis 140 Eheumatlsm 129, 253, 889 acute articular 461, 889 confounded with acute syno- vitis 890 with cerebro-spinal fever . 943 . with milk-leg 890 with rickets 905 head-sj'mptoms of, con- . founded with meningi- tis 184, 892 heart-symptoms in .... 892 cerebral 893 chronic 894 confounded with abdominal aneurism 733 with neuralgia . . . 253, 894 with pain of organic struc- tural disease ..... . . 894 1096 INDEX. Kheumatism, chronic, con- founded with paralysis agitans 902 with sciatica 258 in Bright's disease .... 802 distinguished from dengue . . 996 from gout 898 feigned 897 gonorrhoeal 477, 891 hyperpyrexia in 893 muscular 894 distinguished from aohillo- dynia 897 ifrom Morton's disease . . 897 from myalgia 896 from tetanus 230 from trichiniasis . . 897, 1063 of abdominal walls 618 of cervical muscles 943 of scalp 256 periosteal 897 relations of, to chorea .... 220 subacute 893 Eheumatoid arthritis 900 Khinitis 262, 332 caseosa and fibrinosa 262 membranous 634 oedematosa 262 scrofulous 264 Ehinoliths 261 Ehinoscleroma 265 Rhinoscopy 273 Bhythm of respiration, changes in 316 Eickets 250, 513, 902 combined with scurvy .... 905 confounded with craniotabes . 905 with hereditary syphilis . . 904 with mollities ossium . . . 904 with rheumatism 905 Eigidity, local, confounded with tetanus 230 Eisus sardonicus . 228 Eomberg symptom ...... 161 Eose-cold 262, 354 Eoseola 1004 Eothelu 985 Eubella 985 distinguished from measles . . 986 from scarlet fever 986 from typhus fever 988 Eubeola notha 984 sine catarrho 982 Eumination 565 Eupia 1012 S. Salaam convulsions 224 Salivation 519 Sapraemia 877 Sarcinse ventriculi . . . 339,561,591 Sarcoma, mediastinal . . . 420, 608 of kidney 804 of larynx 294 Scabies 1009, 1021 Scalp, cedema of 201 rheumatism of, confounded with hemicrania . . . 256 Scarlatina 90, 976 anginose 978 associated with rheumatism . 978 complications and sequelae of . 979 distinguished from cerebro-spi- nal meningitis 942 from dengue 981, 996 from laryngeal diphtheria, 532, 980 from erysipelas 998 from measles 980 from membranous croup . . 980 from rubella 986 from smallpox .... 980, 992 from typhoid fever .... 980 exhaustion in 980 followed by dropsy 979 nervous symptoms in .... 978 pseudo- 981 rash of 977 sine exanthemate 977 sore throat of 977 surgical 981 tongue in 978 urine of 979 Scarlet fever. See Scarlatina. Sciatica 77, 256 distinguished from hip-joint afl'ections 258 from irritation of the kidney 258 from rheumatism 258 feigned 259 pressure of fluid on nerve in . 258 rheumatic 257 Scirrhus 582 Scleroderma or sclerema .... 1018 distinguished from erysipelas . 1019 from morphoea 1020 from jnyxoedema 1019 Sclerosis, cerebro-spinal . . 167, 248 diffused 239 disseminated 135, 167 lateral amyotrophic 135 multiple 167 eye-symptoms in 168 posterior 135, 160 Scrofula 34, 1005 associated with disease of in- testines 647 with disease of lungs . . . 383 abscess from 628 INDEX. 1097 Scrofulous glands distinguished from lymphadenoma . . . 868 Scurvy 346, 646, 884 combined with rickets .... 905 confounded with purpura . . 886 hemorrhage in 564 infantile 885 sore mouth of 519 Seborrhiea 1008, 1023 Secretion, deranged ... 174, 204 Senile dementia 248 Sensation, deranged 72 gnawing, in vertebrae .... 516 Sensations of patients 55 tests of 77 Senses, special, derangement of . 87 Sensibility, electrical ..... 74 impairment of 64 perverted 79, 466 Sensory centres 63 Septiccemia 876 from absorption of toxines . . 877 malarial 876 puerperal 878 typhoid 876 Shock 38 Sight, dimness of 61 Sinus, frontal, diseases of . . . 260 Skin, atrophies of 1019 condition of, as a symptom . 34 discoloration of, following fe- vers 871 from lactation and preg- nancy 871 hereditary 871 in Addison's disease .... 870 in psoriasis 872 of hands and feet in typhoid 919 diseases 1000 bullous 1010 constitutional 1002 erythematous 1003 from altered gland^ecretion 1023 nervous 1025 papular 1005 parasitic 1020 pustular 1011 squamous 1013 syphilitic 1006, 1025 vesicular 1007 glazing of 74 hypertrophies of ..... .1017 maculie of 1015 new growths of 1016 pigmentation of 902 Sleep, protracted, distinguished from apoplexy 204 Sleeping sickness 214 Smallpox 988 bacillus of . 991 Smallpox, confluent 989 distinguished from erysipelas 998 from measles 992 from scarlet fever, 980, 982, 992 from varioloid 993 eruption of 989 invasion of 988 malignant 991 Softening of the brain 235 acute, confounded with acute meningitis 181 with apoplexy 204 chronic 235 discriminated from abscess . 238 from atrophy 239 from congestion 236 from exhaustion of brain- power 239 from neurasthenia .... 240 from tumor 240 paralysis from 236 red 235 relations of, to hemorrhage . 236 white 235 of spinal cord 135 Sore throat 522 chronic 535 chronic rheumatic 536 clergyman's 535 follicular 535 in scarlet fever 977 syphilitic 536 Sound, bronchial 313, 317 elicited by percussion . . 304, 412 Hippocratic, or succussion . . 303 in chest, adventitious .... 320 oesophageal 540 splashing, in stomach .... 591 tympanitic 305 Spasm, asthmatic or bronchial . 331 facial, distinguished f r o m chorea 223 masticatory, of the face . . . 230 of arterioles 840 ofbladderconfounded with colic 603 of glottis in croup 279 of vocal cord tensors .... 288 Spasmodic dorsal tabes .... 135 Spasms 171 See also Convulsions. clonic and tonic 171 diseases marked by 214 functional 233 mobile 157, 223 of acute cerebral disease . . . 222 saltatory 173 Spectroscope 773 Sphygmo-chronograph .... 43 Sphygmogram 41 in gouty heart . 482 1098 INDEX. Sphygmogram of aortic insuffi- ciency 498 of contracted kidney .... 811 of mitral regurgitation . . . 498 of thoracic aneurism .... 509 Sphygmograph .... 39, 433, 482 of Dudgeon 40 of Marey 39 Spinal anemia 131 cord, congestion of 131 degeneration of columns of , 861 diseases of 57 gout of 900 Hemorrhage into ..... 125 inflammation of 131 distinguished from epi- demic cerebro - spinal meningitis 941 morbid conditions of, as a cause of paraplegia ... 125 sclerosis of 79, 135 softening of 135 sylphilis of 143 from inherited taint . . . 144 table of diseases of .... 177 tumors of 136 curvature 251 irritation . , 131 localization 65 meningitis 126, 131 acute 132 paresis 126 sclerosis 135 disseminated 135 lateral amyotrophic .... 136 primary 135 Spine, concussion of 134 deviation of 153 in chronic pleurisy .... 416 disease of, confounded with aneurism 733 with colic 606 irritable 131 Spirals ■ • • 832, 340, 355 Spirilla of relapsing fever . . . 946 Spirometer 302 Splanchnoptosis 592 Spleen, affections of 719 displacement of 725 enlargement of . . .421, 689, 998 chronic 719 confounded with chronic pleurisy 421 distinguished from cancer of , liidney 720 gastric hemorrhage in ... . 564 infarct in 467 inflanamation of 719 in typhoid fever 918 percussion of 546 Spotted fever 937 Sputa 338 albuminous • . . 423 constituents of 339 crystals in 341, 355 elastic fibres in 340 fibrinous coagula in 340 microscopical examination of, 339, 342 nummular 361, 378 of acute pneumonia 388 of bronchitis 353 of phthisis 362 parasites in 341 resembling currant-jelly . . , 508 spirals in 332, 340, 355 Squamous diseases 1013 Staphylococcus, 398, 467, 529, 816, 873 Starvation from stricture of oesophagus 538 Station 31 Stenosis, bronchial 296 laryngeal 293 of pylorus 589 Stethometer 301 Stethoscope 311 Stomach, acidity of ... . 556, 584 acute diseases of 571 cancer of 582, 696 contrasted with chronic gas- tritis 585 with cirrhosis of liver . . 708 with gastric ulcer .... 582 catarrh of 573 chronic affections of 574 cirrhosis of 621 cramp of 566 dilatation of 590 associated with nervous symptoms 591 confounded with dilatation of large intestine .... 592 connected with tetany . 231,591 dislocation of 590, 592 distention of 503, 591 examination of contents of, 552, 575, 584, 591 fibroid thickening of .... 589 gout in . 899 hemorrhage from, 563, 677, 609, 1028 inflammation of 571 inspection of interior of . . . 551 irritation of, confounded with pericarditis 473 lithsemic pain in 900 membrane of, absorptive ac- tivity of 555, 589 secondary inflammation of . 574 INDEX. 1099 Stomach, motor activity of . . . 555 neuralgia of 666 organic disease of, confounded with pernicious anaemia . 862 pain in, as a symptom . . 565, 571 palpation of 543 percussion of 547 perforation of 612 distinguished from irritant poisoning 1028 peristaltic disturbance of . . . 600 physical examination of, in- struments for 551 rupture of 172 softening of 574 suppurative inflammation of . 574 tests in diseases of, 551, 576, 583, 589, 592 ulcer of 346, 576 Stomatitis, aphthous . , . 520, 1047 gangrenous 520 mercurial 519 ulcerative, confounded with diphtheria 529 Stools as symptoms 593 examinations of 595 fat in 653 Strabismus ...... 91, 206, 654 Streptococcus ....... 467, 529 erysipelatis 998 pyogenes 398, 873 Streptocytus of Schottelius . . . 1047 Stricture of the oesophagus . 514, 538 Stridor, laryngeal 266, 514 Strongylus gigas 1055 Strychnine poisoning 1037 confounded with tetanus, 232, 1037 Stupor 67, 70 as result of poisoning .... 70 in uraemia 797 St. Vitus's dance. See Chorea. Sugar in the urine 762 tests for .763 by fermentation 766 by phenylhydrazin .... 765 Sugar of milk 766 Sulphates in urine, pathology of 756 Sun-bronzing confounded with Addison's disease .... 870 Sun-stroke 210 distinguished from apoplexy . 210 Supra-renal capsules, disease of . 872 Surface thermometry 45 Sweat-glands 1024 Sweating, bloody .... 175, 1024 excessive 176, 507 Sycosis 1012, 1022 Symptoms, feigned 23 pathognomonic 21 Symptoms, similarity of, in dis- eases 25 Syncope 71 distinguished from apoplexy . 203 Synovitis, acute, confounded with acute rheumatism . 890 Syphilis combined with laryngitis 292 constitutional . : 1014 hereditary 34, 904 distinguished from rhinoscle- roma 266 Syphilitic disease of the bowels . 638 of the brain . 142, 245, 827, 953 of the kidney 804 of the liver 689, 694 of the lungs 362, 375 of the skin, 871, 1006, 1010, 1014, 1025 of the spinal cord 137 of the throat 536 fever confounded with inter- mittent fever 953 stenosis 539 ulcers of fauces , 536 Syphiloderm 1006 Syringo-myelitis 152 T. Tabes dorsalis 160, 164 See Locomotor Ataxia. distinguished from diphtheritic paralysis 164 mesenterica 724 pseudo-mesenterica . . . 556, 724 spasmodic dorsal 135 Tachycardia 453 Tactile sense, impairment of . . 78 Taenia lata 1054 mediocanellata 1053 solium 1052 Tape-worms 1051 of pork 1052 Temperature of body as a symp- tom 43 cerebral 45, 123 extraordinary range of ... . 51 in acute encephalitis 238 in apoplexy 195 in cerebro-spinal fever .... 939 in children 49 in cholera 659 in hydrophobia 233 in intermittent fever 950 in measles 50, 981 in phthisis 363 in pneumonia 50, 389 in pyaemia 873 in relapsing fever 945 in remittent fever 954 1100 INDEX. Temperature in rheumatism . . 893 in scarlatina 50, 966 in smallpox 989 in spinal injury 51 in tetanus 51, 229 in trichiniasis 1060 in typhoid fever 60, 914 in typhus fever .' 931 in yellow fever 50, 972 of surface 45 epigastric 679 over gall bladder 602 of tetanus 61 Tenderness as a symptom ... 66 Tenesmus 635, 639 Tetanus 126, 172, 228 confounded with hydrophobia 232 with local rigidity 230 with muscular rheumatism . 230 with spasms in scarlet fever 230 with strychnine poisoning, 232, 1037 distinguished from cerebro- . spinal fever .... 230, 941 from chorea 222 hysterical 229 idiopathic 228 symptomatic 280 traumatic 228 Tetany 206, 231, 591 associated with laryngismus . 279 Thermal impressions, paths of . 64 sense 79, 1^7 Thermometer, clinical use of . . 43 See also Temperature. Thermometry, cerebral . . 45, 123 general 46 surface 45 Thirst as a symptom 656 Thomsen's disease 234 gait in 31 Thoracic aneurism 606 confounded with abscess of the mediastinum 608 with chronic laryngitis . . 514 with dilated auricle .... 512 with insufficient aortic valves 510 with intra-thoracic morbid .growth. 507 with malformation of the chest 513 with malposition of the aorta 513 with pulsating empyema . . 61 1 with pulsation of pulmonary artery 512 eructations in 658 Throat, inflammation of . . 522, 535 soreness of, in scarlet fever . . 977 rheumatic 586 syphilitic ulcers of 686 Thrombosis 877 cerebral 201 from chlorosis 879 from exhaurting diseases . . . 879 of brain sinuses 242, 878 of cerebral arteries 200 of renal vein 828 Thrombus, changes in 884 Thrush 620, 530 Thyroid gland 261, 466 swelling of 456 Tic douloureux 73, 265 Tinea 1020 circinata 1020, 1022 decalvans 1023 favosa 1022 kerion 1022 sycosis 1022 tonsurans 1020, 1022 versicolor , 1016, 1022 Tinnitus aurium 98 Tobacco amblyopia 96 Tongue, cancer of ...... . 621 coating of 54 condition of, in disease . 52, 521 dryness of 53 inflammation of 521 movements of 52 syphilis of 521 Tonsil, abscess of 285 cancer of : 528, 586 enlargement of 523 herpes of 630 pharyngeal 268 Tonsillitis 276, 285, 522 acute follicular 524 confounded with diphtheria . 629 Torticollis 896 Toxines, absorption of 877 Trachea, affections of . . . 266, 278 foreign body in 285 morbid growths in 295 narrowing of 295 symptoms of diseases of . . . 267 ulcers in 295 Tracheal tugging 509 Trance distinguished from nar- colepsy 213 Tremor 166 alcoholic 169 arsenical 170 asthenic 170 convulsive 222 essential 170 functional , 169 hereditary 171 hysterical 170 in exophthalmic goitre . 170, 456 in spasmodic tabes 169 lead 170, 1042 INDEX. 1101 Tremor, mercurial . . . .170, 1041 post-hemiplegic 169 senile 169 tobacco 170 Trial meal 552, 575, 583 Trichina spiralis 1057 Trichiniasis 897, 1059 distinguished from Bright's dis- ease 1065 from cardiac disease .... 1065 from cholera morbus .... 1064 from irritant poisoning . . 1064 from periarteritis nodosa . . 1064 from rheumatism . . .897, 1063 from sausage poisoning . . 1064 from typhoid fever .... 1061 from typhus fever 1061 fever of 1060 muscular symptoms of ... . 1062 oedema in 1061,1065 pulmonary symptoms in . . . 1063 Trichloracetic acid test .... 770 Trichocephalus dispar 1051 Tricuspid regurgitation . . 502, 602 Trismus 229, 941 Tube-casts in the urine . . 809, 946 Tubercle ....... 348, 364, 372 associated with scrofula . . . 383 bacilli 342 tests for 342 calcareous transformation of . 382 in brain 245 in intestines 387, 646 Tubercular meningitis . . . 185,942 pleurisy 374 Tuberculosis of kidney .... 804 distinctive signs of 804 Tuberculosis of lungs . . . 344, 383 See also Phthisis. acute miliarv 385, 928 bacillus of " 342, 368 combined with laryngitis . . . 292 Tuberculous inspiration broncho- pneumonia 398 Tumors, abdominal 718 confounded with colic . . . 606 in hypochondria 718 aneurismal 333, 357 dyspnoea in 333 cerebral 240 distinguished from abscess . 241 from apoplexy 199 from chronic meningitis . 242 from softening 241 from thrombosis of sinuses 242 nature of 245 seat of 243 syphilitic 24-) unilateral symptoms of . . 244 in hypogastric region .... 729 Tumors in iliac and lumbar re- gions 727 in umbilical region 724 intra-thoracic, confounded with chronic pleurisy . . 419 mediastinal 420, 508 non-aneurismal, confounded with abdominal aneurism 734 with thoracic aneurism . 509 of epigastrium 721 of larynx 293 of liver 697 of spinal cord 136 of spleen 719 ovarian 728 phantom 723 retro-peritoneal 715 tuberculous 241 Tympanites 636, 717 chronic, confounded with ascites 716, 717 Typhlitis 625 Typhoid conditions confounded with typhoid fever . . . 925 Typhoid fever 913 abortive 672, 928 bacillus of 877, 917 colic in 600 confounded with acute atrophy of liver 678 with appendicitis 626 with cerebro-spinal fever . . 940 with enteritis 925 with general debility . . . 92;t with meningitis .... 188, 927 with peritonitis 925 with pulmonary affections . 927 with pyaemia 873 with relapsing fever .... 947 with remittent fever .... 957 with scarlet fever 980 with trichiniasis 1061 with typhoid conditions . . 925 with typhus fever 934 with ulcerative endocartitis, 467, 927 convulsions in 920 delirium in • • • 920 diarrhoea in 915 distinguished from yellow fever 973 enlargement of the spleen in . 918 epistaxis in 921 eruption in 921 febrile symptoms of 914 mild form of 928 nervous symptoms in .... 919 pain a symptom in 918 palsy in 921 relapses in 922, 929 septicsemic 877 69 1102 INDEX. Typhoid fever, sequelsB of . . . 923 spinal symptoms in 921 temperature in 914 ulcers of 647 urine of 915 walking 924 Typhoid septiosemia 876 Typho-malarial fever . . . 957, 968 Typhus fever 929, 988 acute tubercular deposits in . . 934 cerebral symptoms in .... 931 cerebro-spinal 937 coma-vigil of 931 compared with typhoid fever . 934 complications in 934 confounded with measles . . . 988 with yellow fever 974 distinguished from acute men- ingitis 932 from cerebro-spinal fever . . 943 from plague 936 Irom relapsing fever .... 947 from rubella 988 eruption in 930 exanthematic 930 gastric hemorrhage in ... . 564 maculated or spotted 930 physiognomy of 930 pulse in 933 temperature in 931 urine in 933 Tyrosine 679, 745, 759 V. Ulcer of duodenum 581 gastric 346, 576, 590 confounded with chronic gastritis 576, 585 with gastric cancer . 582, 585 with ulcer of duodenum . 581 laryngeal 293 of the bowel, follicular . . . 646 syphilitic 638 of the stomach 577, 588 of typhoid, unhealed .... 647 peptic 581 perforating, of the foot, 162, 175, 1049 stercoral 643 Umbilical region, tumors of . . 724 Uraimia . ." 796,1032 associated with cholera .... 660 convulsions in 798 delirium in 68, 798 distinguished from cerebo- spinal fever 943 mania in, acute ....... 798 Ursemiccoma distinguished from apoplexy 203 Ursemic coma distinguished from narcotic poisoning .... 797, 1032 Urates, pathology of 7.')0 tests for 750 Urea, pathology of . . ... 744 table for estimation of ... . 748 tests for 745 Ureometer 746 Ureter, inflammation and ulcera- tion of. 786 Urethra, hemorrhage from . . . 778 Urethral fever confounded with intermittent fever .... 952 Uric acid in gout 898 detection of 898 in lithsemia 864 murexide test for 749 pathology of ........ . 747 Urinary organs, diseases of . 736, 784 Urine 736 abnormal substances in . . . 757 acetone in 766, 824 acidity of 742 albumin and other proteids in . 767 principal tests for 768 albuminous condition of, dis- eases marked by . . 791, 811 alkalinity of 743, 816 analysis of 736 bile in 760 biliary acids in 761 blood in 672, 772 guaiacum test for 772 blood-corpuscles in 774 blood-extractives in 767 calcium oxalate in, 575, 767, 776, 786 casts, mucous, in 809 chlorides in .... 390, 590, 755 chylous 781 color of, changes in 740 constituents of, changes in quantity of 744 cystine in 786 diacetic acid in . . ..... 766 diazo-reaction of 771 estimate of solids in 741 fat in 780 fibrin in 781 hsemoglobin in . . . 664, 772, 777 in Bright's disease ....'. 791 in carbolic acid poisoning . . 1034 increased discharge of ... . 823 in diabetes 823 indican in 623, 639 in gastric disease ...... 590 ingredients of 738 in hooping-cough 337 in jaundice 664, 760 inosite in 766 kreatin and kreatinin in . . . 757 INDEX. 1103 Urine, kyestein pellicle on . . . 781 lactic acid in 904 leucine in 679, 745, 759 mucin or nucleo-albumin in, 767, 771 nitrogen in 746 normal 737, 767 of the insane 826 oxalate of lime in . . 575, 757, 786 paraglobulin in 770 peptones in 767, 771 pigment in 740, 933 phosphates in . . 575, 752, 786, 816 alkaline and earthy . . 752, 754 purulent, confounded with acute Bright's disease . . 794 diseases associated with . . 814 pus in 779, 814, 816 quantitative examination of . 745 reaction of 742 retention of 829 sediments in 782 specific gravity of 740 sugar in 704, 762, 823 sulphates in 756 suppression of 822, 828 table showing action of tests upon 782 tyrosine in 679, 745, 759 urates in 750, 786, 956 urea in 744, 776, 933 uric acid in 747, 786 xanthine in 786 Urinometer 741 Urobilin 705, 740, 857 pathological 740 Urochrome 740 Uroerythrine 740 Urticaria, pigmentosa 1004 Uterus, colic of 604 gravid, confounded with ascites 716 hemorrhage from, in myxcE- dema 834 tumor of 628 Vagrants' disease 871 Valve, aortic, disease of ... . 497 insufficiency of . . . . 510, 602 mitral, disease of 503 ' sigmoid, rupture of 465 tricuspid, affections of . . 496, 602 Valvular affections of the heart . 489 confounded with functional car- diac disorder 491 with malformations of heart 490 with misdirection of current 492 diagnosis of, before develop- ment of murmur .... 504 Valvular affections of the heart from rupture of a valvulet or of a papillary muscle . 504 table of 499 Varicella 993 followed by gangrene .... 994 Varicocele 804 Variola. See Smallpox .... 988 Varioloid 993 Veins, diseases, of 889 enlargement of 704 portal, inflammation of . 669, 708 thrombosis of 709, 878 renal, thrombosis of . .... 828 Vena cava, occlusion of ... . 517 Venous enlargement 517 hum 338 pulsation 43 Vertigo- 83, 223 aural 85 cerebral 84, 86, 241 essential 86 from overwork of brain ... 86 laryngeal 86, 280 lithaemic 85 of malassimilation 85 precursor of epilepsy .... 86 stomachal 84 syphilitic 142 Vesicular murmur, absence of . 316 changes in 314 Vessels, amyloid degeneration of 590 Vibrio proteus 655 Viscera, abdominal percussion and auscultation of . 544, 550 Vision, derangement of . . 87, 900 double 91 Vocal cord, cysts of 294 diseases of 290, 291 extirpation of . . 291 fremitus, absence of 326 paralysis of 333 resonance 325 Voice, altered 266, 291 amphoric 326 auscultation of 325 cavernous 325 changes in, in laryngeal dis- eases 266 loss of 289 metallic 290 strain of 287, 289 whispering 290 without vocal cords 291 Vomit, black 563, 612, 971 coffee-ground 564, 583 different forms of 560 sarcinie and fungi in .... 561 Vomiting as a symptom .... 558 disease accompanied by . 571,653 1104 INDEX. Vomiting, fiiecal 562, 631 gastric 580 in brain diseases 580 nervous 559 of bile 562, 655 of blood . ,563, 579 in irritant poisoning .... 1028 of food or liquid 560 W. Water-brash 561 Weil's disease 671 bacillus of 672 bloody urine in 672 Whitlows, painless 153 Windpipe, foreign bodies in . . 285 Wool-sorters' disease 1046 Word-blindness 61, 208 Word-deafness 61,208 Worms, intestinal . . 137, 855, 1050 Wrist clonus 103 Writer's cramp 228 Wry-neck 896 X. Xanthelasma 698, 1001 Xanthine 786 Y. Yellow fever 947, 969 confounded with Asiatic chol- era 973 with atrophy of liver . . . 678 with bilious remittent fever 974 with dengue 996 with hemorrhagic malarial fever 966 with plague 973 with relapsing fever . . 947,978 with typhoid fever .... 973 with typhus fever 974 examination of urine in . . . 974 walking 972 Zinc poisoning 1030, 1044 THE END.