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Cornell University Library 
 RC 73.S351911 
 
 Pain; its causation and *agno^^^^^^^^^^^^^ 
 
 3 1924 003 505 611 
 
Cornell University 
 Library 
 
 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/cu31924003505611 
 
PAIN 
 
 ITS CAUSATION AND DIAGNOSTIC SIG- 
 NIFICANCE IN INTERNAL 
 DISEASES 
 
 BY 
 
 Dr. RUDOLPH SCHMIDT 
 
 PHYSICIAN TO THE ROYAL EMPRESS ELIZABETH HOSPITAL, VIENNA 
 
 TRANSLATED AND EDITED FROM THE SECOND 
 ENLARGED AND REVISED GERMAN EDITION BY 
 
 KARL M. VOGEL, M.D, 
 
 ASSISTANT PROFESSOR OF CLINICAL PATHOLOGY, COLLEGE OF PHYSICIANS AND 
 
 SURGEONS, COLOMBIA UNIVERSITY ; CLINICAL PATHOLOGIST AND 
 
 ASSISTANT ATTENDING PHYSICIAN, ST. LUKE's HOSPITAL 
 
 HANS ZINSSER, A.M., M.D. 
 
 PROFESSOR OF BACTERIOLOGY, LBLAND STANFORD JR. UNIVERSITY 
 
 SECOND EDITION 
 
 PHILADELPHIA &• LONDON 
 
 J. B. LIPPINCOTT COMPANY 
 
Copyright, 1908 
 
 BT J. B. LIPPINCOTT COMPAKY 
 
 Copyright, 1911 
 
 By J. B. IiIPPINCOTT COMPAMY 
 
 ManvfadMred hy J. B. Lippmcott Company 
 The Washington, Square Press, Philadelphia, V. S. A. 
 
Preface to the Second Edition 
 
 'In the preface to the first edition I expressed 
 the wish that the book might serve as a guide in 
 the rapid and correct interpretation and successful 
 treatment of the pain occurring in internal diseases. 
 The necessity for a second edition, and the trans- 
 lation of the work into English and Italian may be 
 taken as showing that this hope has been fulfilled. 
 In preparing the new edition it seemed to me 
 that ' it would be advantageous to illustrate the 
 abstract discussions by introducing here and there 
 short case histories bearing on the topics under con- 
 sideration. In many sections, for example in the 
 chapters on headache and on gastralgia, further 
 observation has made it possible to treat the subject 
 matter more broadly and at greater length. 
 
 May this new presentation of the subject also 
 receive a favorable reception and useful applica- 
 tion. 
 
 Schmidt. 
 
Translators' Preface 
 
 In undertaking a systematic analysis of pain 
 Dr, Schmidt has performed a useful service. The 
 great diflSculties attending such an analysis hardly 
 need to be emphasized to the general practitioner, 
 who is so often called upon to interpret the sub- 
 jective complaint in terms of the temperament and 
 individuality of the patient. In fulfilling his task 
 the author has throughout tempered his deductions 
 from actual pathological processes with a careful 
 critical consideration of the functional elements 
 which, in the phenomena of pain, so frequently 
 cloud the clinical picture. Wherever possible, how- 
 ever, he has based his conclusions upon the more 
 exact factors of anatomical structure and patholog- 
 ical change. It is self-evident that in the considera- 
 tion of a symptom so purely subjective, composed of 
 such complex psychological and pathological ele- 
 ments, the final interpretation can be made only on 
 the basis of careful clinical observation. The subtle 
 differences, too, which may exist between individual 
 cases of similar conditions preclude the possibility 
 of formulating absolute rules. The author can but 
 point the way to correct analyses and logical deduc- 
 tion. Dr. Schmidt, in the performance of his task, 
 calls upon the experience of many years with a huge 
 clinical material. The thoroughness and concise- 
 
 5 
 
6 TRANSLATORS' PREFACE 
 
 ness with which he has presented his subject have 
 seemed to the translators to justify the preparation 
 of the little volume for the use of American mem- 
 bers of the profession. For the sake of complete- 
 ness they have added a chapter (X) embodying 
 a brief presentation of Head's researches on re- 
 ferred pains and a series of diagrams showing some 
 of the commoner seats of pain or tenderness in 
 visceral disease. 
 
 In preparing the second enlarged edition of the 
 book Dr. Schmidt has performed the work of 
 revision with more than ordinary thoroughness. 
 Some of the chapters have been almost entirely 
 rewritten, and in nearly every section more or less 
 radical changes are to be found. The interest of 
 the text has been greatly increased by the addition 
 of numerous case histories illustrating the discus- 
 sions of the theoretical questions involved, and in 
 many other ways the author has sought to make 
 the work still better adapted to the needs of the 
 practitioner and the student. 
 
Preface to the First Edition 
 
 The manifestations of disease that are apparent 
 to the senses of the examiner, and therefore sus- 
 ceptible of objective estimation, are, naturally, espe- 
 cially valuable for diagnostic purposes. Modern 
 medical research accordingly strives to facilitate 
 the solution of diagnostic problems by investigations 
 tending in this direction, such as the study of serum 
 pathology and radiology. It may therefore appear 
 almost like a step backward to lay as much stress 
 on a phenomenon that is so purely objective in 
 nature, and so dependent on the observations of the 
 patient himself, as wUl be done in the following 
 discussion of the symptom of pain. 
 
 In this undertaking I have been actuated by the 
 following considerations: In the first place, the 
 objective evidences of disease often do not appear 
 untU the malady has reached a certain degree of 
 development, whereas pain is not rarely present at 
 its very inception. Furthermore, under the condi- 
 tions of actual practice a comprehensive investiga- 
 tion of all the objective symptoms is frequently a 
 matter of great difficulty owing to the absence of the 
 necessary facilities, and therefore a careful consider- 
 ation of the patient's own sensations is absolutely 
 essential. Lastly, it is frequently this very symp- 
 tom of pain that impels the patient to seek medical 
 
 7 
 
8 PREFACE 
 
 advice, and it will therefore be the starting point 
 of the diagnostic train of reasoning, while its correct 
 interpretation is the first requisite to the institution 
 of a suitable form of treatment. 
 
 On the other hand, both during the ten years of 
 my service in the clinic of my honored instructor, 
 Hofrat von Neusser, which brought me in constant 
 contact with the younger members of the staff, and 
 in the course of my long-continued activity as a post- 
 graduate instructor, I have convinced myself that 
 even among those having satisfactory command of 
 the methods of objective examination there is a great 
 deficiency in the ability to make use of the infor- 
 mation conveyed by the manifestations of pain, A 
 realization of this lack was another reason for the 
 preparation of the present volume. 
 
 The work is intended especially to afford a gen- 
 eral view that will enable rapid orientation in the 
 individual case, and I therefore did not deem it 
 advisable to impair its continuity by the introduction 
 of references to the literature or of polemical dis- 
 cussions. The adoption of a more or less dogmatic 
 method of presentation seemed justified by my long- 
 standing hospital connection, which has also involved 
 much experience in teaching. 
 
 In discussing the manifestations of pain it has 
 seemed to me that in addition to the organic proc- 
 esses to which they were due and the topographical 
 factors underlying their projection externally, their 
 relationship to function was especially important 
 
PREFACE 9 
 
 from the standpoint of facilitating diagnosis. The 
 investigation of painful conditions from this point 
 of view leads to- a more* iatimate. comprehension of 
 their pathogenesis and therefore to greater success 
 in treatment. 
 
 May the book fulfil the purpose for which it was 
 written, of serving as a guide in the rapid and 
 correct interpretation and successful treatment of 
 the pain occurring in internal diseases. 
 
 Schmidt. 
 
Contents 
 
 PAGE 
 
 Preface to the Second Edition 3 
 
 Translators' Preface. 6 
 
 Preface to the First JEdition 7 
 
 CHAPTER I. 
 The Sensation of Pain 15 
 
 CHAPTER II. 
 
 The Functional Modification of Pain 24 
 
 The Influence of Position 24 
 
 The Influence of Motion 28 
 
 The Influence of Pressure 32 . 
 
 The Influence of Food 36 
 
 The Influence of Drugs and Chemicals,,^ 41 
 
 The Influence of Organic Function 44 
 
 CHAPTER III. 
 
 Topography in its Relation to Pain 50 
 
 The Shoulder -; 51 
 
 Retrosternal Region 53 
 
 Scapula and Interscapular Region 54 
 
 The Epig£kgtrium 56 
 
 The Abdomen below the Umbilicus. . , 60 
 
 The Lumbar Region (Symmetrical) 61 
 
 The Lumbar Region (Unilateral) and the Flanks 63 
 
 Atypical Abdommal Fains 63 
 
 CHAPTER IV. ' 
 
 Quality and Time of Occurrence, 71 
 
 Colicky Pains , 71 
 
 Nocturnal Pains 73 
 
 CHAPTER V. 
 
 The Nervous System 76 
 
 Headache 76 
 
 Due to Elevations of Intracranial Pressure 79 
 
 Caused by Chemical Poisons 85 
 
 Of Reflex Nature 88 
 
 Neuralgias Involving the General Nervous System 97 
 
 The Face 102 
 
 The Occipital Region and Nape of the Neck 104 
 
 The Arm 105 
 
 Intercostal Spaces, Including Upper Abdomen 107 
 
 Flanks and Lower Abdominal I^egion 109 
 
 Lower Extremities 110 
 
 Neuralgias, Sympathetic System and Vagus 113 
 
 11 
 
12 CONTENTS 
 
 CHAPTER VI. 
 
 Organs of Motion 119 
 
 Joint Pains or Arthralgias 119 
 
 Muscular Pains or Myalgias 124 
 
 Bone Pains or Ostalgias 131 
 
 CHAPTER VII. 
 
 Digestive System 140 
 
 Gastralgias 140 
 
 Imtable Weakness of Nervous System 144 
 
 Direct Causes 144 
 
 Reflex Causes 147 
 
 Gastric Ulcer 154 
 
 The Colic of Pyloric Stenosis 175 
 
 Gastric Cancer 187 
 
 Intestinal Ulceration j 197 
 
 Diseases of the Appendix 206 
 
 Lead Colic 217 
 
 Malignant New Growths of the Intestine 224 
 
 Liver 233 
 
 Gail-Bladder Colic 236 
 
 Pains without Colic 254 
 
 Distention and Inflammation of Capsule 256 
 
 Pancreas 268 
 
 CHAPTER VIII. 
 
 Ubinabt System and Spleen 277 
 
 Kidney 277 
 
 True Kidney Pains 277 
 
 Muscular Spasm, Urogenital Tract 291 
 
 Urinary Bladder 302 
 
 Spleen 306 
 
 CHAPTER IX. 
 
 Respiratory and Cibculatoby Systems 312 
 
 The Lungs 312 
 
 Aorta 322 
 
 Peripheral Vessels ■ 345 
 
 CHAPTER X. 
 Cutaneous Tenderness in Visceral Disease 350 
 
List of Illustrations 
 
 (At End of the Text) 
 na. 
 
 1. Diagram, anterior view of the human body showing seg- 
 
 mental distribution of referred pain and tenderness in 
 visceral disease. 
 
 2. Diagram, posterior view of the human body showing seg- 
 
 mental distribution of referred pain and tenderness in 
 visceral disease. 
 
 3. Diagram, lateral view of the human body showing seg- 
 
 mental distribution of referred pain and tenderness in 
 visceral disease. 
 
 4. Diagram of head and neck, showing areas of referred pain 
 
 and tenderness related to visceral disease or to affections 
 of the head and neck. 
 
 5. Possible areas of pain or tenderness in diseases of the nervous 
 
 system, etc. 
 
 6. Possible areas of pain or tenderness in diseases of the nervous 
 
 system, etc. 
 
 7. Possible areas of pain or tenderness in diseases of the abdom- 
 
 inal organs, etc. 
 
 8. Possible areas of pain or tenderness in diseases of the abdom- 
 
 inal organs, etc. 
 
 9. Possible areas of pain or tenderness in diseases of the abdom- 
 
 inal organs, etc. 
 
 10. Possible areas of pain or tenderness in diseases of the abdom- 
 
 inal organs, etc. 
 
 11. Possible areas of pain or tenderness in diseases of the abdom- 
 
 inal organs, etc. 
 
 12. Possible areas of pain or tenderness in diseases of the lungs 
 
 and pleiura. 
 
 13. Possible areas of pain or tenderness in diseases of the lungs 
 
 and pleura. 
 
 13 
 
14 LIST OF ILLUSTRATIONS 
 
 na. '■ 
 
 14. Possible areas of pain or tenderness in diseases of the lungs 
 
 and pleura. . 
 
 15. Possible areas of pain or tenderness in diseases of the heart 
 
 and vessels. 
 
 16. Possible areas of pain or tenderness in diseases of the heart 
 
 and vessels. 
 
 17. Possible areas of pain or tenderness in diseases of the heart 
 
 and vessels. 
 
 18. Possible areas of pain or tenderness in diseases of the heart 
 
 and vessels. 
 
PAIN 
 
 ITS CAUSATION AND DIAGNOSTIC SIGNIFICANCE 
 IN INTERNAL DISEASES 
 
 CHAPTER I. 
 
 The Sensation of Pain. 
 
 In order to combat successfully a painful sen- 
 sation manifested by a patient, of whatever sort it 
 may be, it is necessary first to obtain a clear insight 
 into its sources of origin. The more deeply we are 
 able to penetrate into these the more successful and 
 to the point will be our therapeutic measures. A 
 fundamental principle in such an objective study is 
 the analysis of the painful sensation into its various 
 elements, its relations to space and to time, its <;har-' 
 acteristic qualitative shading, its area of distribu- 
 tion, associated manifestations, etc. 
 
 ToPOGEAPHT. — The analysis of a pain may most 
 suitably be commenced by determining its topo- 
 graphical characteristics. In order to do this it 
 should be made a rule always to have the patient 
 point out exactly the spot or the region in which 
 the pain is felt, and specify whether it is superficial 
 or deep seated. Vague statements, such as pain in 
 the stomach, in the liver, etc., are of little value and 
 are frequently associated with totally erroneous con- 
 
 15 
 
16 PAIN 
 
 ceptions regarding the situation of the organ in 
 question, so that they serve only to lead astray. 
 
 Where the pain is a radiating one it is necessary 
 to differentiate between the painful focus and its 
 peripheral radiations. In such cases it will usually 
 be found that the focus— often from the diagnostic 
 point of view the most important point — coincides 
 with the area in which the pain was localized at the 
 beginning of the attack. Of no less significance than 
 the location of the painful focus, which ordinarily 
 is at least in proximity to the etiological point of 
 origin, are the radiations of the pain, especially in 
 cases in which there is no ground for assuming a 
 neuropathic tendency in the patient. If the opposite 
 should be the case, however, it is advisable not to 
 attach undue importance to the direction of radia- 
 tion from the standpoint of differential diagnosis. 
 Under these conditions one must be prepared to 
 encounter atypical and wholly irregular, bizarre radi- 
 ations. The extent of the area involved by the 
 radiation of the pain in paroxysms such as those of 
 biliary and ureteral colic, etc., frequently appears 
 to be directly proportional to the intensity of the 
 neuropathic tendency. Under such conditions pain 
 in unrelated regions may easily appear. For ex- 
 ample, biliary colic may be associated with pseudo- 
 angina, and thus present the anomalous picture of an 
 attack of colic with apparent radiation into the left 
 upper extremity. 
 
 In considering the topography it is also essential 
 to take into account multiplicity or symmetry of the 
 
ANALYSIS OF THE SENSATION 17 
 
 pain, if present. These features in connection with, 
 neuralgias, arthralgias, and ostalgias iudicate a 
 broader etiological basis, such as a disorder of metab- 
 olism, and speak against a purely local causation. 
 
 Time. — ^A natural sequel of a consideration of 
 the location of the pain is that of the time of its 
 appearance. Not infrequently the onset of the pain 
 is associated with some definite hour of the day, or 
 exhibits a regular dependence on certain occur- 
 rences, such as the ingestion of food. Or it may 
 appear at some stated time of the day (for example, 
 nocturnal pain), and it is then our task to determine 
 the factors underlying this regularity in recurrence. 
 Now and then a relation to larger units of time, such 
 as the seasons, or distinct phases in bodily develop- 
 ment, may be ob^rved and open up perspectives 
 in the direction of the manner of causation. The 
 duration of the painful sensation must also receive 
 due attention. 
 
 Intensity. — The purely quantitative variations, 
 of course, depend on the intensity of the stimulus 
 in question, but not less so on the sensitiveness of 
 the registering apparatus, that is, the patient's 
 psychical characteristics, so that the same etiologi- 
 cal stimulus may appear endurable to one, but may 
 seriously disturb the psychical equilibrium of an- 
 other. This double dependence of the intensity of 
 the painful sensation on stimulus and irritability, 
 and the impossibility of projecting externally the 
 physicochemical events in the sensory nerve sub- 
 stance that take place when pain is experienced, ren- 
 der illusory attempts at the quantitative estimation 
 
 2 
 
18 PAIN 
 
 of the sensation for diagnostic purposes. None the 
 less, we are not entirely without means of control, 
 and can make use of these in cases in which doubt 
 arises regarding the credibility of the patient. 
 
 Simulation- and Exaggeration. — While in some 
 cases there may be an actual attempt to mislead the 
 examiner, more frequently one encounters individ- 
 uals whose neuropathic constitution causes every 
 painful stimulus to be perceived in greatly magnified 
 form. With such persons the hypersusceptibility 
 of their receptive centres may result in even the 
 slightest disturbances, possibly vasomotor or nutri- 
 tional in nature, being recorded as painful sensa- 
 tions. This is probably the explanation of the vague 
 "rheumatoid" pains so frequently complained of 
 by neurasthenics. Neuropathic individuals like to 
 speak of their sensations in the superlative, even 
 when these are actually of slight intensity. In such 
 cases it is well to avoid much questioning and to 
 pay more attention to the facial expression while 
 testing for sensitiveness — of the abdomen, for ex- 
 ample — at the same time distracting the patient's 
 mind by conversation, etc. One then often notes the 
 absence of the troubled expression and general rest- 
 lessness that characterize the existence of pain in 
 normal persons. Due consideration must be given 
 to the reflexes of expression in endeavoring to esti- 
 mate the severity of pain. 
 
 Experience shows that intense and persistent 
 pain in the course of time nearly always leads to 
 more or less serious disturbances in the condition 
 
ANALYSIS OF THE SENSATION 19 
 
 of the body as a whole, so that disorders of nutrition 
 are produced and loss of weight results. In some 
 cases, therefore, systematic observations of the 
 patient's weight may serve as a means of control in 
 this regard. If there is no loss of weight, and espe- 
 cially if there should be a gain, the existence of per- 
 sistent intense pain is extremely unlikely. When 
 paroxysmal pain is complained of, the determina- 
 tion of the pulse rate and of the blood-pressure is 
 to be recommended. This should be done both in the 
 interval when the pain has subsided and at the height 
 of the paroxysm. Fluctuations either upward or 
 downward may give a useful hint, but as it is largely 
 a question of vasomotor control, which is subject to 
 great individual variations, hard and fast rules 
 cannot be laid down. 
 
 I have seen attacks of lead colic which were attended by a rise 
 in blood-pressure, but this is not necessarily the case. In one case 
 of biliary colic there was during the seizure a fall in blood-pressure 
 from 85 nun. of Hg. (Gartner) to 55 mm. without the patient's 
 going into collapse. 
 
 In dealing with patients suspected of malingering 
 I would suggest that if pain is complained of on 
 pressure, the size of the pupils be observed in 
 order to detect any possible increase in dilatation 
 that may follow the painful stimulus (sympathetic 
 reflex). If this reflex is present there is no doubt 
 of the veracity of the patient in stating that he 
 is experiencing pain. It is advisable, however, to 
 obtain some insight into the patient's susceptibility 
 to reflexes of this sort by the production of an 
 artificial pain, e.g., by pinching. Theoretically, 
 
20 PAIN 
 
 this procedure even offers the possibility of obtain- 
 ing an insight into the intensity of the original pain 
 by observing the degree of stimulation necessary to 
 evoke the same reflex, assuming that equal stimuli 
 produce reflexes of equal intensities. Eeflex phe- 
 nomena may be used in other ways as means of 
 control in this direction. Such a one is the unilateral 
 increase in the abdominal reflex which leads to the 
 symptom of muscular rigidity (defense musculaire) 
 occurring in abdominal conditions. True pressure 
 tenderness, due to acute appendicitis, is never accom- 
 panied by an increase in the superficial abdominal 
 reflex on the right side. If a patient complaining 
 of such tenderness also exhibits a marked increase 
 in this reflex he is probably neuropathic and not 
 suffering from an acute inflammatory process about 
 the appendix. 
 
 Quality. — Patients accustomed to close self- 
 observation often supply information in regard to 
 the quality of their pains. Not infrequently light 
 may be thrown on the pathogenesis or nature of 
 these pains through the description which the patient 
 gives of them as being boring, piercing, colicky, etc. 
 Pain resulting from muscular spasm is often experi- 
 enced as a "cramp" or "griping." In cases of 
 overdistention of hollow muscular organs this phe- 
 nomenon may give its characteristic shading to the 
 pain, and the pain of aneurysmal erosion, for ex- 
 ample, is often described "as if something was 
 boring" or as being "pounding" in nature. Ab- 
 dominal pains must always be considered with re- 
 
ANALYSIS OF THE SENSATION 21 
 
 gard to the presence of a colicky character. The 
 distinctive feature of this lies in its wave-like in- 
 crease and decrease, frequently accompanied by a 
 sensation of griping, "tying up in a knot," or a 
 feeling of overdistention. 
 
 Modifying Factoes. — The exact analysis of the 
 pain furthermore demands the accurate determina- 
 tion of all of the factors which influence the inten- 
 sity of the sensation, either in the positive or the 
 negative sense. Such modifying factors are inti- 
 mately connected with the causative condition and 
 are therefore of the greatest importance from the 
 diagnostic point of view. In this connection stimuli 
 of general nature must especially be considered. 
 
 a. Psychical. — ^Excitement, diversion of atten- 
 tion, suggestion dther in the waking condition or 
 under hypnosis, etc. It is evident that painful sen- 
 sations that have what may be termed a psychical 
 origin and from this centre are projected to some 
 one zone of the periphery, such as some of the pains 
 of hysteria, are particularly susceptible to psychical 
 modification. The same thing is true of pains which 
 are peripheral and organic in origin but which are 
 brought prominently into the foreground only as the 
 result of abnormal irritability of the central recep- 
 tive organs. In such cases diverting the attention 
 through suitable occupation or pastimes, change of 
 surroundings, etc., has an anodyne action. Such 
 "negative" psychical modifications, i.e., diminution 
 in the pain effected by these means, may if well 
 defined have some differential value, and indicate a 
 
22 PAIN 
 
 psychical component in the condition. On the other 
 hand, a "positive" psychical modification, mani- 
 festing itself in increase of the pain, is hardly ever 
 of service in distinguishing between functional and 
 organic disorders. The effect of unpleasant emo- 
 tions is to increase the susceptibility to disagreeable 
 impressions, and all painful stimuli are therefore 
 experienced with greater intensity. Furthermore, 
 the various organic functions, such for example as 
 that of digestion, are largely subject to such influ- 
 ences. It is not astonishing therefore to see the 
 symptoms attending a gastric ulcer increase under 
 excitement, or to note that an attack of biliary colic 
 may follow a fit of anger. It would be quite wrong, 
 however, to conclude in such cases that the symp- 
 toms were purely functional in nature. At the most 
 it is justifiable only to assume the existence of a 
 contributing component of this character. 
 
 b. Mechanical. — Position of the body, motion, 
 solid food, percussion, massage, pressure, concus- 
 sion, etc. 
 
 c. Thermic. — Changes of weather, draughts, etc. 
 
 d. Electrical. 
 
 e. Chemical. — 1. Dietetic. 
 
 2. Remedial: local or general. 
 Whenever the pain appears to be dependent on 
 certain organic conditions or organic functions it 
 will nearly always be possible on careful considera- 
 tion to discover the primary causative factor, either 
 in the group of the mechanical or of the chemical 
 cell stimuli. 
 
ANALYSIS OF THE SENSATION 23 
 
 Accompanying Manifestations. — Finally, it must 
 not be forgotten that attention should be directed 
 to any possible associated manifestations, whether 
 these are of a purely subjective nature or are also 
 susceptible of objective study. Frequently, of 
 course, these are only remote in nature, such for 
 example as the vomiting or constipation accompany- 
 ing painful abdominal seizures of the most varied 
 types, but sometimes they may also be interpreted 
 as actual local symptoms (peristalsis, diarrhoea, 
 dysuria, icterus, bleeding from the genitals, etc.). 
 
 By following the preceding scheme it will often 
 be possible to make a rapid diagnosis and to obtain 
 a point of departure for therapeutic measures. At 
 least the diagnostic possibilities will be narrowed 
 and the physical examination or the laboratory 
 investigations may be concentrated in a smaller 
 domain. This is as it should be, for not only accu- 
 racy but also promptness is desirable in diagnosis. 
 
CHAPTER II. 
 
 The Functional Modification of Pain. 
 
 THE INFLUENCE OF POSITION. 
 
 In discussing the pain associated with the 
 various organs it is often desirable to emphasize 
 its dependence on definite positions of the body, 
 such as the dorsal, the lateral, etc, which fre- 
 quently appear to bear a distinct relationship 
 to the sensation. Observations of this sort lead 
 to the characterization of certain "positions of 
 maximum pain," which term may be applied to 
 those positions which give rise to a pain which 
 previously did not exist or which increase the inten- 
 sity of a paia already present. In so far as the 
 painful position depends on tenderness to pressure 
 of superficial structures, as in joint affections, etc., 
 it has little diagnostic interest, and only those in- 
 stances are to be discussed in which such external 
 causation of the pain is not involved. In gastric 
 ulcer the existence of a painful position has been 
 accorded a somewhat unjustifiable degree of im- 
 portance from the standpoint of differential diag- 
 nosis, and for this reason the interpretation of the 
 symptom is not always clear cut. This subject will 
 be discussed later on in its proper place. 
 
 As a matter of fact, painful positions may be 
 discovered in connection with the pain complexes 
 of the most varied organs, and this therefore points 
 
 24 
 
FUNCTIONAL MODIFICATION 25 
 
 to uniformity in tlie mechanism of their origin. For 
 example, in the discussion of special organs refer- 
 ence will be made to the occurrence of painful posi- 
 tions in diseases of the gall-bladder, of the appendix, 
 in abdominal tumors, aneurysms, pericarditis, etc. 
 In the majority of cases the most general cause of 
 pain is to be sought for in a change of position of 
 the diseased organ, such as occurs in certain posi- 
 tions of the body. All the organs, including new 
 growths, are rather loosely packed ia the body cavi- 
 ties, and the firmness of their fixation is very vari- 
 able, as is shown in enteroptosis for example. 
 
 Painful traction on diseased organs is likely to 
 result (especially in cases of inflammatory processes 
 in the immediate neighborhood of the structures 
 involved, as in perigastritis, appendicitis, periaor- 
 titis, etc.) in those positions of the body in which the 
 organ is deprived of its firm support. This is ordi- 
 narily the case in the position on the side opposed to 
 the lesion, and the resulting pain will depend on 
 the degree of sensibility caused by the inflammation 
 and on the intensity of the traction, i.e., on the weight 
 and mobility of the displaced mass. Of course other 
 factors also come into play, such as pressure on 
 neighboring nerve trunks, as in aneurysms, tumors, 
 etc., as well as secondary pressure effects on mus- 
 cular hollow organs like the stomach, intestine, 
 ureter, etc. A special mechanism depending on 
 the local peculiarities of the tissues involved under- 
 lies the position of maximum pain in certain diseases 
 of the aorta or the coronary arteries. It is well 
 
26 PAIN 
 
 known that in some cases of these the horizontal 
 position may give rise to the onset of painful attacks 
 of angina pectoris. In these affections the causa- 
 tive factor is probably to be found in the alterations 
 in the circulation produced by the change in position, 
 such as the slower but more powerful cardiac con- 
 tractions with a possible rise in arterial pressure 
 and greater lateral tension of the chronically in- 
 flamed aorta. 
 
 What light is thrown on the problem of differ- 
 ential diagnosis by the discovery that there is in 
 a given case a position of maximum pain? 
 
 1. If the problem presenting itself for decision 
 is whether the pain is organic or functional in 
 nature, the existence of a painful position is in favor 
 of an organic lesion. Thus in cases of mediastinal 
 new growth, including carcinoma of the cesophagus, 
 aneurysm of the thoracic and abdominal aorta, gas- 
 tric ulcer, etc., the nature of the attendant pain is 
 not rarely misunderstood and is considered as being 
 a functional manifestation of a neurosis. Under 
 these conditions the demonstration that there is a 
 distinct position of increased pain may be of deci- 
 sive moment. 
 
 2. The presence of a painful position always in- 
 dicates the advisability of a search for the organ 
 or new growth causing it, and the location of the 
 sensation attending the painful position will corre- 
 spond to the situation of the organ or new growth 
 in question. The detection of deeply situated 
 tumors involving, for example, the pancreas or 
 
FUNCTIONAL MODIFICATION 27 
 
 oesophagus, is often a matter of difficulty and in 
 these cases the presence of a painful position may 
 be taken as confirming the results of the examination 
 by palpation. Careful attention to this symptom 
 may sometimes aid considerably in establishing an 
 otherwise doubtful diagnosis. 
 
 In one case under my observation the oecurrenee of a painful 
 position, together with glycosuria, seemed of significance. At the 
 autopsy the symptoms were explained by the discovery of a carcinoma 
 of the pancreas. 
 
 The occurrence of a painful position points 
 toward a localized process, especially in dealing with 
 the abdomen, even when the pain appears to be 
 diffuse, as in appendicitis, intestinal cancer, chole- 
 lithiasis, nephrolithiasis, etc., and so may be of 
 service in differentiating an ordinary intestinal 
 colic from similar painful sensations originating in 
 appendicular disease or localized malignant new 
 growths. 
 
 The lateral posture is a painful position par ex- 
 cellence, for it involves the most favorable condi- 
 tions for abnormal displacement and traction. The 
 dorsal position {e.g., retroperitoneal processes) or 
 the sitting posture may also come into question, 
 however. In the latter case the symptom is usually 
 difficult to interpret. Pain in the small of the back 
 and in the flanks is not infrequently caused after 
 long sitting, especially if the body is inclined for- 
 ward, by swollen abdominal organs like the kidney, 
 spleen, liver, etc. These pains do not, however, 
 appear very promptly, but only after long oontin- 
 
28 PAIN 
 
 uanee of the position, and the pain may sometimes 
 also be explained as being the result of fatigue of 
 the dorsal musculature. 
 
 THE INFLUENCE OF MOTION. 
 
 Under this heading only those forms of pain will 
 be discussed that are modified in clearly recognizable 
 fashion through bodily motion, either general or 
 local. In these cases the pain may be produced 
 or aggravated as if by carefully planned experi- 
 mentation, and the differential diagnosis is facili- 
 tated by tests in this direction. A more or less 
 superficial connection between pain and bodily mo- 
 tion in the sense that rest has a beneficial effect 
 is very widespread and may, to some extent, be 
 explained through the steadiness of the circulatory 
 conditions (headache), and in the absence of me- 
 chanical insults (gastric ulcer) when the body is at 
 rest. On the other hand, there is a group of painful 
 sensations that appear on motion as the inevitable 
 result of the general pain mechanism. 
 
 1. Disorders op the Organs of Motion. — These 
 are maladies usually involving the extremities, which 
 are accessible to careful and extensive physical ex- 
 amination so that special difficulties are not likely 
 to be encountered. The greatest source of error is 
 to be found in the fortunately comparatively rare 
 diffuse diseases of the osseous system, such as osteo- 
 
FUNCTIONAL MODIFICATION ' 29 
 
 malacia and disseminated lesions of the bone- 
 marrow. These possibilities must therefore always 
 be kept in mind. 
 
 2. DiSOBDEBS 0¥ THE ClBCXJLATOBY APPABATUS. — 
 
 The intimate relationship existing between the vas- 
 cular and muscular systems has as a result, that in 
 disorders both of the central and peripheral portions 
 of the circulatory system, motions may appear as a 
 potent source of pain. The circulatory system is 
 also one of the channels through which the physical 
 and objective act of motion transforms itself into 
 the subjective sensation of pain. Every muscle, 
 whether it is striated or smooth, when in action 
 makes increased demands on the vascular system as 
 a whole, and also on its own peripheral district. In 
 this way it is easy to understand on the one hand 
 the possibility of the causation of local pain on 
 locomotion in local disorders (crural, mesenteric, and 
 coronary vessels), and on the other hand it is clear 
 that muscular action may produce pain indepen- 
 dently of peripheral demands through the indirect 
 effect on the central portions of the circulatory sys- 
 tem, as in aortitis, aneurysm, etc. It is therefore an 
 easily explainable fact that all of the symptoms 
 produced by aneurysm or chronic inflammation of 
 the aortic walls, and especially pain, may be in- 
 creased or brought about by bodily motion. If, for 
 example, retrosternal or epigastric pain is caused 
 
30 PAIN 
 
 as the result of severe muscular exertion, such as 
 climbing stairs, running, or battling against the 
 wind, the possibility of the presence of disease of 
 the circulatory system must always be suspected 
 (atheroma of the thoracic and abdominal aorta, scle- 
 rosis of the coronary arteries, hepatic congestion). 
 The same is true in regard to pain in the shoulder, 
 or brachial neuralgia (aneurysm). 
 
 3. Abdominal Disoedees. — ^In these there is not 
 rarely an exquisite interdependence between pain 
 and motion. This is especially true of acts that are 
 accompanied by simultaneous exercise of the ab- 
 dominal muscles, such as lifting weights, stooping, 
 raising the head, defecation, backward or lateral 
 inclination of the body, coughing, sneezing, etc. Un- 
 doubtedly it is the accompanying elevation of intra- 
 abdominal pressure that gives rise to the painful 
 paroxysms in already congested organs (ureteral 
 and biliary colic, etc.), either directly or through 
 the interference with the venous flow. Before the 
 onset of typical attacks of pain and also after the 
 subsidence of these the appearance of distinctly 
 localized pain as the result of efforts of the sort just 
 mentioned may direct attention to a local disorder 
 in the nature of latent appendicitis or cholecystitis, 
 etc. Pain in the neighborhood of the appendix, for 
 example, is not rarely elicited during defecation, 
 in drawing on the shoes, lifting the head, bending 
 
FUNCTIONAL MODIFICATION 31 
 
 the trunk to the left, on sitting down, etc. Pain in 
 the epigastrium on bending the body backward would 
 suggest the presence of an epigastric hernia. 
 
 The pain produced through forcible motion at 
 the hip joint in inflammatory and suppurative proc- 
 esses in the neighborhood of the ileopsoas muscle 
 involving the appendix, caecum, kidney, and para- 
 metrium finds its explanation in the local pressure 
 caused. Under these conditions it is important not 
 to make the examination in the horizontal position, 
 in which the abdominal muscles are relaxed, but to 
 have the patient standing, as then the pressure 
 effects are more pronounced. Of course it is also 
 necessary to think of inflammatory processes involv- 
 ing the joint itself. The pain accompanying certain 
 movements of the thigh in incarcerated hernia (ob- 
 turator hernia) must not be overlooked in this con- 
 nection. The jar communicated to the abdomen 
 along the lower extremity on putting the foot to 
 the ground may give rise to pain ; for example, in the 
 neighborhood of an inflamed appendix, a movable 
 kidney, or in cholecystitis. This pain appears when 
 the foot on the same side strikes the ground, and 
 is more pronounced in walking down hill owing to 
 the greater force of concussion. 
 
 Motion and any change of position is especially 
 likely to give rise to pain in cases of acute suppura- 
 tive peritonitis. The patient usually anxiously main- 
 tains the dorsal position and avoids turning to either 
 
32 PAIN 
 
 side. This point is of importance, for in certain 
 other conditions that sometimes simulate peritonitis, 
 such as intestinal ulceration and meteorism, hys- 
 teria, colic due to intestinal stenosis, etc., this symp- 
 tom is conspicuous by its absence. In enteroptosis 
 a careful study of the effect of position on pain is 
 of value. Even extreme degrees of enteroptosis 
 are sometimes unaccompanied by pain. In neuro- 
 pathic, over-excitable persons, however, usually 
 women, suffering from this condition, exertion may 
 induce attacks of spasmodic pain that are difficult to 
 distinguish from biliary or renal colic. Two points 
 aid in the differential diagnosis : 1. The attacks are 
 often promptly relieved on assuming the recumbent 
 position. 2. The application of an abdominal binder 
 is effective. 
 
 THE INFLUENCE OF PRESSURE, 
 
 The influence of pressure, especially pressure 
 from within, is of great importance in the mech- 
 anism of spontaneous attacks of pain. An elevation 
 of intracranial pressure gives rise to most severe 
 headache. A rise of tension in the arterial system 
 may produce extremely painful paroxysms; in- 
 crease in the internal pressure in the liver, spleen, 
 or kidney may cause acute pain through the tension 
 of the capsule of the organ, and the same thing is 
 true of localized distention in the gastro-intestinal 
 canal. 
 
 Pressure from without exerted for the purpose 
 of testing a painful condition is usually not effective 
 
FUNCTIONAL MODIFICATION 33 
 
 from all directions, as in tlie above instances, but 
 only from a given point. Nevertheless, under some 
 conditions spontaneous pressure effects in all direc- 
 tions may be experimentally imitated and made use 
 of for differential diagnosis ; for example, in dealing 
 with the digestive tract. I remember one case in 
 wMcb the nature of a tumor below the left costal 
 arch was in doubt until the colon was inflated. At 
 once pain, localized strictly to the tumor region, ap- 
 peared, and at the autopsy carcinoma of the splenic 
 flexure of the colon was revealed. In a similar way 
 in cases of carcinoma of the oesophagus with stenosis 
 the administration of effervescent draughts may 
 give rise to localized pain, evidently caused by the 
 tension from within. 
 
 Peessube feom Without. — ^When applied for 
 diagnostic purposes this may be used in order to 
 obtain more exact informaition in regard to the 
 location of already existing pain, or it may be re- 
 sorted to to discover a hitherto unrevealed area of 
 hyperalgesia. This is especially true of the abdo- 
 men. In doing this it is well to remember that, even 
 under physiological conditions and according to the 
 degree of individual susceptibility, strong pressure 
 may be more or less painful, and it is advisable 
 always to compare similar areas on the two sides. 
 It is further desirable always to outline the zones of 
 hyperaesthesia to pressure as accurately as possible. 
 The more deeply the pressure is carried the greater 
 is the loss of the resulting pain in localizing value, 
 and this is particularly true of the abdominal cavity. 
 
 3 
 
84 PAIN 
 
 Peectjssion. — By means of this it is possible to 
 obtain an accurate estimate of the effect of pressure 
 and this method of examination should never be 
 omitted, especially in examining the abdomen. Posi- 
 tive results will generally be obtained by this proce- 
 dure in dealing with organs that touch the abdomi- 
 nal wall with even only a portion of their surfaces, 
 as the stomach, intestine, liver, and spleen in the 
 anterior parts and the kidney in the posterior parts. 
 The examination of the linea alba in this way for 
 its whole length, from the xiphoid process to the 
 symphysis, is especially to be recommended. If 
 there is any diastasis of the recti, pressure or per- 
 cussion in this region is not transmitted through the 
 abdominal musculature, as is the case over the recti, 
 but causes distinct manifestations of pain if one 
 of the organic lesions in question is present. 
 
 In general it may be said that at every examina- 
 tion of the abdomen for purposes of rapid orientation 
 it is wise to test the sensibility to pressure of the 
 region of the pylorus and gall-bladder, the three 
 flexures of the colon, the neighborhood of the appen- 
 dix, and the hernial openings. Any local sensitive- 
 ness to pressure in the rectum or vagina should also 
 be noted. The testing of local sensibility to pres- 
 sure also forms a useful method of rapid orientation 
 in cases in which accurate palpation is rendered 
 impossible owing to tension of the abdominal walls 
 as in ascites. 
 
 Among the pathological processes of a general 
 nature that underlie pressure or percussion pain in 
 
FUNCTIONAL MODIFICATION 35 
 
 the abdominal region the first place must be given to 
 peritoneal irritation, either circumscribed or diffuse. 
 In addition, increase in the internal pressure also 
 plays an important role ; for example, in such con- 
 ditions as hepatic congestion, and circumscribed or 
 diffuse gastro-intestinal distention, especially when 
 accompanied by ulcerative or peritonitic lesions. 
 Thus the hypersesthesia of the congested liver dimin- 
 ishes in proportion to its decrease in size, and the 
 tenderness of gastric ulcer may decrease from an 
 excessive degree to a very slight amount within a 
 few hours owing to the subsidence of gastric disten- 
 tion. The sensitiveness of an inflamed appendix 
 may ia the same way diminish suddenly on the expul- 
 sion of faeces and gas. While in most cases it is 
 natural to associate any existing abdominal tender- 
 ness with the topographically related organs the 
 rarer possibilities must also be kept in mind. For 
 example, the symptom may have its seat in the ab- 
 dominal musculature itself, as in the epigastric 
 tenderness due to fatigue of the origins of the recti 
 following persistent attacks of coughing. If the 
 seat of the pain is situated behind the muscle the 
 contraction of the latter usually diminishes or abol- 
 ishes the effect of the pressure, and this may be of 
 value in differential diagnosis. The vascular system 
 of the abdominal cavity, particularly the aorta, may 
 also be the seat of tenderness in the epigastrium. 
 Furthermore, the possibility of neuralgic tenderness 
 of the sensory tracts should not be forgotten, as in 
 lead colic, gastric crises, etc. Sometimes in abdom- 
 
36 PAIN 
 
 inal neuralgias of this sort intense pressure, over 
 the epigastrium for example, may seem to have the 
 effect of relieving pain. This sign may sometimes 
 be made use of in diagnosis, though caution is neces- 
 sary, as the same thing exceptionally occurs in 
 organic diseases. 
 
 I am inclined to consider the accurate localiza- 
 tion of tenderness of the sympathetic nerve fibres 
 and plexuses running deep down along the spinal 
 column as theoretically highly desirable but prac- 
 tically impossible, and the same thing may be said 
 in regard to the determination of tenderness of the 
 solar plexus. 
 
 THE INFLUENCE OF FOOD. 
 
 While the importance of the exact determination 
 of the alimentary causation or modification of pain 
 phenomena is very great, the difficulties attending 
 the demonstration of a relationship of this sort are 
 no less so. This is especially the case when the 
 evidence consists only of the biased or inaccurate 
 observations of the patient himself. Frequently the 
 connection between the two events is denied with the 
 statement that pain is present also when food is not 
 being taken and that the composition of the ingesta 
 has no noticeable effect. It is evident that both of 
 these conclusions are erroneous. In the first in- 
 stance, it is permissible to draw only the inference 
 that the ingestion of food is not the only pain-produc- 
 ing factor, and in the second that the quality of the 
 food is of slight importance. The difficulty of estab- 
 
FUNCTIONAL MODIFICATION 37 
 
 lisMng a relationship of cause and effect is also 
 increased through the fact that in most cases the 
 pain, at least as far as it involves the gastro-intes- 
 tinal tract, appears only several hours after the 
 ingestion of food. 
 
 If the pain begins during the taking of the food 
 itself a deep-seated stenosis of the oesophagus, par- 
 ticularly carcinomatous, should be thought of even 
 in. the absence of well-defined dysphagia and though 
 the pain be localized in the epigastrium. The pain- 
 ful sensations caused by the food masses that become 
 impacted above the stenosis are not infrequently 
 referred to the epigastrium, are accompanied by a 
 feeling of pressure, and usually disappear suddenly 
 at the moment that the bolus passes the obstruction. 
 Alimentary modification of the pain is ordinarily to 
 be taken for granted only when the pain follows the 
 ingestion of food with great regularity and after the 
 lapse of a uniform interval of time. In these cases 
 it is always advisable to determine the relationship 
 experimentally by modifications in the amount and 
 composition of the food. 
 
 The ingestion of food may serve to produce pain 
 in several ways, among which the most important are 
 as follows: 
 
 1. The increase in gastro-intestinal peristalsis 
 following the taking of food may serve mechanically 
 to induce pain. In this connection the effect of cold 
 appears to be especially noteworthy, as when cold 
 water is taken. The colicky pain sometimes appear- 
 ing in acute enteritis or appendicitis a short time 
 
S8 PAIN 
 
 after a drink of cold milk, for example, is certainly 
 caused in this way. When inflammatory ulceration 
 exists in the oesophagus, pylorus, intestine, etc., it 
 is natural to assume that the muscular contrac- 
 tions set in motion for the purpose of carrying 
 along the contents of the viscus form the cause of 
 the pain, so that it is easy to understand that the 
 composition of the food itself may not be of any 
 particular importance, 
 
 2. Chemical stimuli in the form of ingested acids, 
 spices, etc. The decomposition products resulting 
 from bacterial action on carbohydrates and fats must 
 also be included under this head. 
 
 3. Local irritation due to the mechanical action 
 of substances like hard bits of meat and similar 
 bodies, distention of the gastro-intestinal wall 
 through the formation of gas due to the fermentation 
 of farinaceous foods, fruits, etc. This mode of 
 causation seems to play an especially important role 
 in cases of gastro-intestinal ulceration. 
 
 The factors mentioned above have a positive 
 action ; that is to say, cause* increase in pain, but 
 there is also the possibility of an influence in the 
 opposite direction. It is a fact that not only in 
 gastric neuroses but also in cases of ulcer and some- 
 times in gastric carcinoma the iagestion of food may 
 alleviate or entirely relieve previously existing pain. 
 Two possibilities must be considered in this connec- 
 tion: 1. The excessive and painful peristalsis is 
 relieved by the entrance of food into the stomach 
 (the growling of a hungry stomach). In cases in 
 
FUNCTIONAL MODIFICATION 39 
 
 which the nature of the food seems to be miimpor- 
 tant, so that even a piece of bread, for example, has 
 an anodyne effect, this appears to be the most nat- 
 ural explanation. 2. The food consumed, such as 
 milk, for example, combines with acid after the fash- 
 ion of an alkali. 
 
 In regard to the time of appearance of alimen- 
 tary pain phenomena the variability of the causes 
 explains the differences observed in the period of 
 their appearance, although in the same individual 
 the time intervals in cases of organic disease are 
 often very uniform. The painful attacks attending 
 lesions of the pylorus, for example benign stenosis, 
 appear with great regularity two or three hours 
 after the midday meal, probably in connection with 
 the expulsive period of digestion. Cases are ob- 
 served often enough, however, in which the interval 
 is as much as five or six hours. I consider that 
 attempts to draw inferences from such observations 
 regarding the position of the lesion, for example, 
 that it is a duodenal ulcer, are entirely unwarranted. 
 On the one hand the appearance of the pain of 
 pyloric ulcer may be much delayed as has been men- 
 tioned, and on the other, in duodenal ulcer and intes- 
 tinal affections including those of the colon (cancer 
 of the sigmoid flexure, appendicitis, etc.), the pain 
 may be felt a very short time after the food has been 
 taken. It is interesting that in some cases of pyloric 
 ulcer the onset of the pain is delayed if the quantity 
 of food taken is very large. This is probably due 
 to the fact that the expulsion of the gastric contents 
 
40 PAIN 
 
 is retarded. When there is a clearly demonstrable 
 connection between the ingestion of food and the 
 pain, internal gastro-intestinal lesions, especially 
 those of an ulcerative and stenotic character, must 
 be thought of. In addition, the somewhat rarer 
 perigastritic processes should be kept in mind, such 
 as adhesions between stomach and liver in syphilis 
 of the latter organ, adhesions between stomach and 
 colon in carcinoma of the splenic flexure, etc. En- 
 largement of the organs in the neighborhood of the 
 stomach must also be considered, such as echino- 
 coccus of the liver or spleen, pancreatic cysts, etc., 
 but these lesions are more apt to be accompanied by 
 a sensation of uncomfortable pressure rather than 
 by direct pain. 
 
 Organic lesions are particularly likely to be pres- 
 ent in cases in which there are no fluctuations in the 
 intensity of the symptoms, in which the effect of 
 psychical factors is slight or entirely absent, and the 
 alimentary factor is characterized by great consist- 
 ency. Owing to the close interrelationship between 
 the gastro-intestinal tract and the large abdominal 
 glands, the liver and pancreas, it is natural to expect 
 a priori that on account of the circulatory changes 
 in these organs attending the digestive act pain 
 from these districts also should be subject to alimen- 
 tary modification. Such interdependence is very 
 irregular in its maJiifestation, however, and fre- 
 quently cannot with, certainty be demonstrated at 
 all. Equally irregular is the alimentary relation- 
 ship of the pain often observed after the subsidence 
 
FUNCTIONAL MODIFICATION 41 
 
 of lead colic or gastric crises. In the former con- 
 dition painful attacks are not rarely tlie result of 
 a diet that tends to gas formation. 
 
 Pain resulting from disease of the circulatory- 
 system is also susceptible of modification by the in- 
 gestion of food, as will appear later. Attacks of 
 angina pectoris may follow meals excessive in 
 amount or composed of food causing gastric and 
 intestinal distention. The phenomenon may prob- 
 ably be explained in part by the rise in blood pres- 
 sure and increased demand upon the heart. The 
 influence of food ingestion may also be observed in 
 cases of atheroma involving the gastro-intestinal 
 vessels. 
 
 "Eheumatic" pain (gout and allied diatheses) 
 appears sometimes to be increased by the consump- 
 tion of dark or underdone meat. 
 
 THE INFLUENCE OF DRUGS AND CHEMICALS. 
 
 All forms of pain exhibit a wide-spread suscepti- 
 bility to modification by the admiaistration of drugs, 
 quite independently of the effects of the narcotics. 
 Furthermore, there may be in some cases a specific 
 susceptibility obviously depending on more or less 
 fundamental factors in the mechanism of production 
 of the pain in question, and which may be made use 
 of for the purposes of differential diagnosis. It is 
 well known with what regularity the paroxysms of 
 angina pectoris respond to the administration of the 
 vasodilators. For this purpose I should especially 
 recommend erythrol tetranitrate given in tablet form 
 
42 PAIN 
 
 in doses of from 0.01 g. to 0.03 g. In a case present- 
 ing indefinite pain in the neighborhood of the heart 
 or in the epigastrium and where there are other 
 reasons for suspecting vascular disease, the resort 
 to an erythrol tetranitrate test may be of great diag- 
 nostic value, especially if the effect is more or less 
 sudden and the same result always follows a repe- 
 tition of the test. Obscure neuralgic pains in the 
 left upper extremity may also be unmasked in this 
 way and be found to depend on an irregular form of 
 angina. Eeflex pain of this sort in the arm is some- 
 times relieved by cold to the precordium. 
 
 Local ansesthetics may be used for the purposes 
 of differential diagnosis in order to determine 
 whether the cause of the pain is peripheral or cen- 
 tral. The subcutaneous injection of cocaine has 
 been recommended for this purpose in trigeminal 
 neuralgia and a 5 per cent, ointment of morphine 
 has been used with a similar object. In testing the 
 gastric mucosa the use of ansesthesin in 0.5 g. doses, 
 or of cocaine (about 16 drops of a 1 per cent, solu- 
 tion), may be recommended. The pain of gastric 
 ulcer or of ulcerating carcinoma of the oesophagus 
 usually ceases within about a quarter of an hour 
 after the administration of these amounts of anaes- 
 thesin or cocaine. If this occurs in a case under 
 consideration, duodenal ulcer is improbable, and I 
 therefore suggest this anaesthesin test as a means of 
 differential diagnosis between gastric and duodenal 
 ulceration. A prompt result following the anaes- 
 thesin treatment in cases of epigastralgia usually 
 
FUNCTIONAL MODIFICATION 43 
 
 indicates a lesion of tlie gastric mucosa such as ulcer 
 or carcinoma and justifies the assumption of a local 
 causation of the pain. If the pain is accompanied 
 by evidences of stenosis, such as increased gastric 
 peristalsis or dysphagia, a positive result of the test 
 would point to internal stenosis with changes in the 
 mucous membrane. 
 
 In order to decide the question whether a gastric 
 pain is partly or entirely caused by hypersesthesia 
 to hydrochloric acid this may be given while fast- 
 ing in doses of 1-5 drops of the dilute acid to a 
 tablespoonful of water. The administration of 
 alkalies such as sodium bicarbonate forms the coun- 
 terpart to this test. It must be borne in mind, how- 
 ever, that sodium bicarbonate may bring relief and 
 cessation of pain by causing the stomach to expel 
 any gas that may be present. Furthermore, an 
 anodyne effect of alkalies does not necessarily indi- 
 cate hyperacidity — the amount of acid may even 
 be quite small and the patient be suffering from 
 hydrochloric hypersesthesia. Epigastric tenderness 
 due to hepatic congestion is usually very amenable 
 to digitalis treatment. If it shows a tendency to 
 increase while the other evidences of congestion sub- 
 side the complication of gastric ulcer must be sus- 
 pected (ulcer in a congested stomach). 
 
 The rapid relief of headache or neuralgic pain 
 by the administration of iodine and mercury of 
 course suggests syphilis. In cases of headache, tri- 
 geminal neuralgia, sciatica, etc., accompanied by con- 
 stipation, it is advisable to resort to purgation in 
 
44- PAIN 
 
 endeavoring to obtain insight into the etiology of 
 the pain. While the intestinal condition is not very 
 frequently the sole cause of the pain, there is no 
 doubt that it sometimes is an important factor, and 
 the diagnostic and therapeutic aims may be united. 
 In gastric ulcer, the colic of pyloric stenosis, lead 
 colic, etc., an important role in the pain formation 
 is often played by stagnation of the fecal masses. 
 Paroxysms of abdominal pain of the most varied 
 nature (gall passages, ureters, etc.) frequently re- 
 spond very directly to the cautious evacuation of the 
 intestine either through cathartics given by mouth 
 or through the rectum. 
 
 The hypodermic injection of distilled water may 
 be of diagnostic value in obscure pain, especially in 
 cases in which the patient's suffering is completely 
 or in part the result of autosuggestion. Even if 
 the pain diminishes there is always the possibility 
 that in addition to the functional element there is 
 also an organic causative factor, and in this wa.y it is 
 possible to form an idea of the intensity of the latter. 
 Obscure pain about the thorax (shoulder, interscapu- 
 lar space, etc.) which is increased by the injection 
 of tuberculin probably is related to an underlying 
 tuberculous process. 
 
 THE INFLUENCE OF ORGANIC FUNCTION. 
 The coincidence of certain pain phenomena with 
 one or another organic function may form the start- 
 ing point of a diagnostic analysis. Sometimes such 
 a conjunction may afford appreciable assistance, but 
 
FUNCTIONAL MODIFICATION 45 
 
 it must be confessed tliat often there is danger of 
 its leading into error. 
 
 Defecation. — The act of defecation, for example, 
 may exhibit the most varied relationships to pain 
 phenomena of widely differing origin. Coprostasis 
 of long .duration causes stagnation and abnormal 
 decomposition in the entire digestive tract, includ- 
 ing the stomach, and it is not surprising, therefore, 
 that the pain accompanying many gastro-intestinal 
 conditions, such as appendicitis, intestinal stenosis, 
 lead poisoning, ulcer, stenosis of the pylorus, 
 etc., may be favorably affected by the cautious 
 production of an evacuation, a fact which de- 
 serves careful consideration from the standpoint 
 of therapeutics also. In dealing with inflammatory 
 lesions in the abdomen care must be taken, however, 
 that the act of defecation does not involve too great 
 a degree of exertion of the abdominal musculature. 
 Otherwise precisely during the act of defecation 
 strictly localized pain may be caused corresponding 
 to the position of the inflamed appendix or diseased 
 gall-bladder, or in the neighborhood of a carcinoma 
 of the colon or gastric ulcer. Such an occurrence 
 may have diagnostic value in determining the posi- 
 tion of the process in question. This localized pain, 
 accompanying abdominal straining, may be spoken 
 of by the patient and be of assistance in the diag- 
 nosis in cases of quiescent appendicitis, or on the 
 other hand, in the early stages of the disease. Back- 
 ache resulting from gastro-intestinal distention (in- 
 testinal stenosis, etc.) is usually perceptibly relieved 
 
46 PAIN 
 
 after a movement of the bowels. If the movement is 
 regularly preceded by pain immediately before the 
 act, deep-seated ulcerative processes such as carci- 
 noma of the rectum should be suspected. 
 
 In cases of latent angina pectoris severe abdom- 
 inal straining during defecation may cause the onset 
 of a paroxysm, or slight retrosternal premonitory 
 sensations may be induced. The favorable effect 
 of defecation is often indubitable and even aston- 
 ishing in many cases of headache, especially, it 
 appears to me, in those types which are accompanied 
 by an elevation of intracranial pressure. A laxa- 
 tive frequently is much more effective than are 
 antineuralgics, even in cases of severe organic 
 lesions like brain tumors. In these cases the im- 
 provement must depend on alterations in the intra- 
 cranial circulation, for the effect is often very sud- 
 den. Meteorism may lead to stasis in the superior 
 vena cava and in the cerebral veins through the 
 restriction of the respiratory venous aspiration, and 
 the important part played by normal intestinal peri- 
 stalsis in facilitating the venous circulation in the 
 portal district must also be considered. In these 
 cases, too, the act of defecation may give rise to 
 temporary increase in the headache if it is accom- 
 panied by undue straining efforts. 
 
 The onset of gastric crises in tabes not rarely 
 occurs in conjunction with defecation and the evacu- 
 ation of fluid stools. It is likely, however, that the 
 act of defecation is in these cases only indirectly to 
 be associated with the gastric symptoms (increased 
 
FUNCTIONAL MODIFICATION 47 
 
 gastro-intestinal peristalsis). The phenomenon is 
 of interest, however, as attacks of colic of other 
 sorts are usually attended by obstinate constipation. 
 In enteroptosis, intestinal atony and neuropathic 
 conditions persistent constipation sometimes ap- 
 pears rather to have the effect of deferring the 
 onset of functional pains, such as gastralgias. 
 
 Vomiting. — If vomiting accompanies abdominal 
 pain the coincidence of the latter with this common 
 symptom is more apt to lead astray than to be of 
 direct diagnostic service, unless it happens that the 
 nature of the vomitus (blood, sarcinae, lactic acid 
 bacilli, hyperchlorhydria, etc.) gives the necessary 
 clue. One may easily be deceived by the vomiting 
 in chronic intestinal stenoses, for example in tu- 
 berculous ulceration of the small intestine, and in 
 the absence of peristaltic movement be led to 
 assume a gastric lesion such as stenosis of the 
 pylorus as the starting point of the pain. Slight 
 alleviation of the pain after vomiting is sometimes 
 observed in painful seizures of the most varied 
 nature, such as angina pectoris, renal infarct, chole- 
 lithiasis, etc. Prompt and often complete relief to 
 the pain is particularly characteristic of attacks of 
 colic due to stenosis of the pylorus. 
 
 Deglutition. — Pain accompanying the act of 
 swallowing may depend on internal or external 
 causes. If the source of the sensation is in the 
 upper part of the oesophagus its detection will ordi- 
 narily not prove difficult. If the patient has fever the 
 possible existence of laryngeal tuberculosis should 
 
48 PAIN 
 
 not be forgotten. If the dysphagia is due to ulcer- 
 ation of some portion of the oesophageal mucosa an 
 increase in the pain is usually caused on taiing acids 
 or spiced articles of food. On the other hand, the 
 administration of local anaesthetics like ansesthesin 
 will prove beneficial. This effect of food or drugs 
 is generally absent if there are other causes for the 
 disturbance m deglutition, unless secondary ulcera- 
 tions have been caused. The deglutition pain of 
 aneurysm frequently radiates into the left shoulder 
 or below the clavicle. 
 
 Menstruation. — While it is natural to refer to 
 the genital apparatus pains occurring together with 
 menstruation — or at least, if they involve regions at 
 a distance such as headache or gastralgia, to asso- 
 ciate them with this function — it must always be 
 borne in mind that the menstrual process leads to 
 increased irritability of the system in general. 
 Therefore, whenever there is already present an 
 irritative condition, such as cholelithiasis, appen- 
 dicular disease, ulcer of the stomach, etc., attacks of 
 pain may be brought on in these regions of lessened 
 resistance. This is especially true of the appendix, 
 owing to its topographical relationships and its 
 circulatory connections. In distinction to this many 
 obstinate abdominal pains such as gastralgias seem 
 to be checked during pregnancy. This is particu- 
 larly the case in enteroptosis, probably in part owing 
 to the diminution of the abnormal mobility of the 
 abdominal organs. Menstruation sometimes acts in 
 a similar way. 
 
FUNCTIONAL MODIFICATION 49 
 
 Eespibation. — In dealing with shoulder pains in- 
 duced by respiration, it is always advisable to think 
 of the possible presence of apical tuberculosis with 
 secondary perineuritis of the brachial plexus (ten- 
 derness on pressure). Thoracic pain may of course 
 be purely myogenic in nature in spite of its depend- 
 ence on the respiratory act. Pleural pain is likely 
 to be axillary in location. The retrosternal paiu 
 sometimes produced by deep respiration in cases of 
 atheroma of the aorta may be explained by the 
 traction on the vessel. Both local and diffuse peri- 
 tonitic lesions such as perihepatitis, perigastritis, 
 etc., as well as lesions of movable abdominal viscera 
 in general, are frequently the seat of pain on the 
 inspiratory descent of the diaphragm in deep breath- 
 ing. In appendicitis the pain caused by deep inspi- 
 ration is sometimes more significant than local 
 tenderness. 
 
CHAPTER III. 
 
 Topography in its Eelation to Pain. 
 
 While in external diseases the site of pain nearly 
 always corresponds to the lesion, this is true of 
 internal affections only with certain reservations 
 and in this connection there is found an unending 
 source of diagnostic errors. Even the general ques- 
 tion of whether the presence of local pain indicates 
 the existence of any disease of an internal organ and 
 is not due to an external lesion, may sometimes be 
 difficult to answer. Before arriving at the conclu- 
 sion that a certain painful sensation is caused by 
 internal disease, it will be found practically useful 
 to exclude the possibility of an affection of the 
 organs of motion — ^joints, muscles, or bonesi — as well 
 as of disorders of the nervous system {v. Neural- 
 gias). The patient's own sensations and his de- 
 scription of the pain as being deep seated may some- 
 times, but not always, point to the existence of an 
 internal lesion. 
 
 The following discussion of pain in connection 
 with topography will be devoted only to those mani- 
 festations that are the result of disease of the inter- 
 nal organs. The inclusion of disorders of the 
 organs of motion and of the nervous system would 
 lead too far afield. Even with this restriction, how- 
 ever, completeness of exposition is out of the ques- 
 tion and therefore only certain districts of the body 
 
 60 
 
TOPOGRAPHY 51 
 
 will be considered, which may be regarded as nodal 
 points for painful sensations emanating from dif- 
 ferent directions. The obvious will be omitted ajid 
 only more unusual and easily overlooked phenomena 
 will be discussed, particularly from the therapeutic 
 standpoint. For the purposes of practical differen- 
 tial diagnosis it will not do to hold too closely to 
 purely topographical considerations. It is espe- 
 cially desirable to study the factors that influence 
 the pain; that is to say, the examination must in- 
 clude a test of function as well as of the accompany- 
 ing symptoms, as has already been pointed out in 
 detail in the section on the analysis of pain. In the 
 following pages I wUl be as brief as possible, as a 
 more detailed discussion of the various organic pains 
 may be found in the chapters devoted to each of 
 these. 
 
 I. THE SHOULDER. 
 
 The internal organs coming in question under 
 this head are as follows: 
 
 a. Lung. — ^Affections of the pulmonary apices, 
 especially tuberculosis and new growths, not infre- 
 quently cause spontaneous shoulder paiu as well as 
 tenderness of the brachial plexus, probably through 
 the development of perineuritis or direct involve- 
 ment of the branches of the plexus. I have found 
 that tenderness is particularly apt to occur at the 
 junction of the outer and middle thirds of the upper 
 border of the trapezius. When pain in the shoulder 
 is complained of by persons of tuberculous appear- 
 ance this possibility skould be kept in mind. 
 
52 PAIN 
 
 b. Thoracic Aorta. — Aneurysm and atheroma of 
 the thoracic aorta not infrequently are accompanied 
 from the very first by persistent shoulder pain. 
 This may be either bilateral or only on one side. 
 In addition to spontaneous pain there is frequently 
 also tenderness over the brachial plexus as well as 
 in the upper intercostal spaces in front. Of great 
 diagnostic importance is the fact that the pain is 
 increased by exertion, such as stair climbing, etc., 
 as well as its coincidence with increased heart action. 
 Quieting cardiac activity by bodily rest and the 
 application of cold compresses generally relieves 
 this aortic shoulder pain. Motion at the shoulder 
 joint may be free and painless, but lifting the upper 
 arm from the side above the horizontal line is likely 
 to evoke pain (traction on the subclavian artery?). 
 It must be remembered that, especially in athero- 
 matous disease of the subclavian artery and in cases 
 of the arthritic diathesis, aneurysm of the aorta and 
 chronic aortitis may coexist with more or less inde- 
 pendent disease of the shoulder joint (rheumatic 
 joint lesions). 
 
 c. Subdiaphragmatic Organs. — Inflammatory 
 processes occurruig in the liver, spleen, or stomach, 
 or in their subphrenic surroundings. Shoulder 
 pains transmitted in this way through the phrenic 
 nerve of the same side usually do not attain particu- 
 lar intensity. The causative lesion, such as echino- 
 coccus of the liver, subphrenic suppuration, peri- 
 splenitis in leukaemic spleens, perigastritis in ulcer 
 of the stomach, etc., ordinarily causes much more 
 
TOPOGRAPHY 53 
 
 acute local symptoms, so that if the possibility of 
 this connection is kept in mind the danger of misin- 
 terpreting the shoulder pain is not very great. The 
 shoulder pain may sometimes be latent and appear 
 only on pressure on the brachial plexus or on the 
 above-mentioned pressure point at the upper edge 
 of the trapezius. 
 
 II. RETROSTERNAL REGION. 
 
 a. Circulatory' Apparatus. — The pain accom- 
 panying such affections as aortic aneurysm, chronic 
 aortitis, and sclerosis of the coronary arteries, which 
 are the ones most often concerned imder this head- 
 ing, is accompanied by a pronoimced sense of con- 
 striction, and has the further peculiarity of being 
 promptly influenced and increased on exertion such 
 as running, climbing stairs, etc. The very intense 
 retrosternal pain that is sometimes seen in cases of 
 pericarditis is not paroxysmal but is persistent. 
 
 b. Mediastinum. — Bifurcation of the trachea and 
 local affections of the mediastinum. The retroster- 
 nal pain often accompanying the cough in acute 
 bronchitis is usually to be explained by the inflam- 
 matory condition at the bifurcation of the trachea. 
 In some cases similar changes in the neighboring 
 lymph glands may contribute to its causation. The 
 more or less severe and persistent retrosternal pain 
 not rarely accompanying severe dyspnoea of long 
 duration may have a similar origin, and I have found 
 this symptom a not infrequent accompaniment in 
 cases of miliary tuberculosis. Mediastinal new 
 
64 PAIN 
 
 growtlis, such as lymphosarcoma, etc., also not infre- 
 quently cause retrosternal pain that may be relieved 
 to some extent by leaning forward. Such pain may 
 be increased by rapid walking, etc., probably through 
 the forced inspiration and consequent increase in the 
 motility of the trachea and traction on the surround- 
 ing structures. This observation may lead to the 
 erroneous diagnosis of angina pectoris. 
 
 c. (Esophagus, Stomach, and Liver. — Fairly se- 
 vere retrosternal pain may be due to stretching of 
 the wall of the oesophagus on taking food if the lower 
 portion of the tube is stenosed. Pain of this nature 
 exhibits marked dependence on alimentary condi- 
 tions. There may also be persistent sternal pain, 
 possibly modified by changes in position and accom- 
 panied by tenderness of the sternum and of the 
 spine or of the left dorsal region. Eetrosternal 
 radiation of the pain is not rare in ulcer of the 
 stomach and pyloric stenosis, although in these con- 
 ditions the pain is rarely found only in this situa- 
 tion. The same thing is true of hepatic affections. 
 
 In the preceding, retrosternal sensations have 
 been considered only in so far as they reach the 
 point of actual pain. Sensations such as the feel- 
 ing of oppression sometimes occurring in nervous 
 asthma, tuberculosis, dilatation of the right heart, 
 or tabes, are not within the limits of the discussion. 
 
 III. THE SCAPULA AND INTERSCAPULAR REGION. 
 
 More than in any other part of the body pain in 
 this district suggests the possibility of disease of 
 the organs of motion (spinal column, dorsal muscles) 
 
TOPOGRAPHY 66 
 
 as well as neuralgia. Only after these have been 
 excluded or on the demonstration of corresponding 
 organic lesions is it justifiable to consider the latter 
 as being responsible for the pain. In general the 
 possibilities are the same as those relating to shoul- 
 der pains, and here also pulmonary affections 
 like tuberculosis are not unimportant. Sometimes 
 chronic inflammatory changes in the pleura leading 
 to the formation of adhesions or glandular changes, 
 acting like the retroperitoneal glands in causing 
 backache, may manifest themselves subjectively by 
 interscapular pain. Secondary neuralgic conditions 
 of the intercostal nerves must also be thought of; 
 at any rate pains of this sort always indicate an 
 exhaustive examination of the lung. 
 
 Aortic lesions (aneurysm, chronic aortitis) also 
 not rarely give rise to pain in the interscapular 
 region, especially on the left side. Frequently there 
 is also a feeling of painful pressure and sometimes 
 a dependence on particular positions of the body. 
 Exertion naturally often increases such pain. The 
 intimate relationship of the liver and gall-bladder, 
 spleen, and stomach to the shoulder blade of the 
 same side is well known, and reference may be made 
 to what has been said above. 
 
 Of gastric disorders it is particularly stenosis 
 of the pylorus that gives rise to painful attacks with 
 radiation into the left, or more frequently, both 
 shoulder blades. This radiation of the pain seems 
 to some extent to run parallel with the intensity of 
 the distention of the stomach during the paroxysm. 
 
56 PAIN 
 
 The shoulder pains previously described repre- 
 sent a spatial prolongation of the radiation which 
 ordinarily rarely passes upward beyond the spine 
 of the scapula. It may also be mentioned that the 
 radiation of headache into the interscapular space is 
 generally associated with an increase in intracranial 
 pressure, as in brain tumor, meningitis, etc. 
 
 IV. THE EPIGASTRIUM. 
 
 The series of organic lesions manifesting them- 
 selves through pain ui the epigastrium is so great 
 that from the standpoiat of practical differential 
 diagnosis it seems more suitable in each case to 
 abandon promptly the purely topographical factor 
 and to turn the attention to certain characteristic 
 features of each type of epigastralgia, such as those 
 comprised in the modifying factors, accompanying 
 manifestations, etc. In this way more rapid orien- 
 tation is possible and the diagnostic possibilities may 
 rapidly be narrowed. Here again, as was pointed 
 out at the beginning of the chapter, lesions of the 
 organs of motion, such as the muscular pain follow- 
 ing persistent cough, muscular haematoma, etc., and 
 diseases directly concerning the nervous system, like 
 the neuralgia of spondylitis, the girdle pains of 
 tabes, or gastric crises, will not be discussed at 
 length. 
 
 The most important differential points to be dis- 
 cussed are as follows : 
 
 a. Tenderness to Pressure and Percussion. — It is 
 true that most of the spontaneous pains in this dis- 
 
TOPOGRAPHY 67 
 
 trict are axjcompanied by tenderness to pressure, but 
 the exact localization of this, and particularly the 
 determination of the point of maximum tenderness, 
 may be of importance. This is true, for example, 
 for the tender gall-bladder in cholelithiasis, pain on 
 pressure under the left costal arch in gastric ulcer 
 or carcinoma, or in syphilis of the left lobe of the 
 liver, sharply circumscribed tenderness in ulcer and 
 epigastric hernia, the relation of the sensitive point 
 to the edge of the liver, and so on. The absence of 
 tenderness in spontaneous attacks of pain would 
 suggest, though not without reservation, the diag- 
 nosis of gastric crises, essential gastralgia, or lead 
 colic. Its presence, however, is not sufficient to 
 exclude the latter affection. 
 
 b. Colic. — In addition to the common paroxysms 
 of biliary colic and gastralgia, such conditions as 
 intestinal stenosis, new growths of the small intes- 
 tine, tuberculous intestinal ulceration, etc. — as well 
 as particularly appendicular disease, pancreatic 
 colic, and angina pectoris — ^must also be considered. 
 
 c. Collapse. — The evidences of collapse may ap- 
 pear at the acme of any attack of colic, but such 
 severe general symptoms are especially suggestive 
 of perforation, as in gastric or duodenal ulcer, 
 acute intestinal obstruction, gastric crises, pancre- 
 atic necrosis, and angina pectoris. 
 
 d. Causation through the Ingestion of Food. — 
 Under this heading may be included gastro-intes- 
 tinal lesions, processes in the neighborhood of the 
 stomach accompanied by progressive increase in 
 
58 PAIN 
 
 size, such, as ecliinococcus of the liver, splenic tumor, 
 deep-seated stenoses of the oesophagus, and more 
 rarely, angina pectoris and cases of painful intermit- 
 tent dilatation of the abdominal aorta. 
 
 e. Causation through Exertion. — ^In this class 
 may be grouped diseases of the circulatory appa- 
 ratus, like sclerosis of the coronary arteries and 
 chronic aortitis. The sensation of painful pressure 
 due to hepatic congestion of course is also consid- 
 erably increased on motion. 
 
 f . Position. — The existence of a position of maxi- 
 mum pain {v. p. 24) generally may be taken as indi- 
 cating an organic origin for the symptom. 
 
 g. The Influence of Drugs {v. p. 41). — This con- 
 cerns particularly the internal administration of 
 local anaesthetics, of hydrochloric acid and alkalies, 
 as well as of erythrol tetranitrate. 
 
 h. Vomiting and Regurgitation. — ^Whenever pain 
 is due wholly or in part to distention of the stomach 
 walls by stagnating fluids or by gas relief is afforded 
 when the contents are ejected. This is particularly 
 the case in pyloric stenosis. Primary gastralgias 
 are sometimes relieved by the belching of gas and 
 thus show themselves to be not entirely of functional 
 character. It goes without saying that the vomitus 
 should be carefully examined. 
 
 Of much more importance than localization in the 
 epigastrium is asymmetrical distribution of the pain. 
 If this is more manifest on the right or the left 
 
TOPOGRAPHY 59 
 
 either spontaneously or on pressure, an organic con- 
 dition is a priori more likely. One must be sure, 
 however, that one is not dealing with an individual 
 presenting general unilateral hyperesthesia as in 
 hysteria. Tenderness just below the costal borders 
 may easily be misinterpreted since it may be caused 
 by processes actually in some other region. Pleurisy 
 and pneumonia must always be thought of, and 
 pelvic processes may also come in question. 
 
 A. Localization on the Right Side. — Below the 
 right costal arch : Spontaneous pain and tenderness 
 in disease of the gall-bladder, of the pylorus, the 
 duodenum (ulcer!), the hepatic flexure of the colon, 
 as in carcinoma or flatulence, renal infarct, etc. In 
 appendicular disease Jthe tenderness is usually lower 
 down ; in pleurisy and pneumonia of the lower lobe 
 there is usually only tenderness. 
 
 B. Localization on the Left Side.^Below the left 
 costal arch: Here both in spontaneous pain as well 
 as in tenderness to pressure ulcerative conditions 
 in the stomach should always be thought of first, 
 particularly as occurring in the middle region of the 
 organ, although gastric crises sometimes, even if 
 rarely, are distinctly left-sided. Furthermore, intes- 
 tinal carcinoma, particularly of the descending colon 
 ( radiating to the anus), should Be thought of. When 
 there is a tendency to flatulence pain in this region 
 is also not uncommon. Lesions of the pancreas 
 (cysts), affections of the spleen, and painful cardiac 
 conditions (angina pectoris) must also be considered. 
 
60 PAIN 
 
 V. THE ABDOMEN BELOW THE UMBILICUS. 
 
 In order to avoid error, it should always be taken 
 into account that in cases of enteroptosis organs 
 situated in the upper part of the abdomen, such as 
 the kidney, stomach, or gall-bladder with a corset 
 liver, may give rise to pain in the lower abdomen. 
 On the other hand, viscera originally situated in the 
 pelvis may in some conditions develop upwards 
 (urinary bladder, ovarian cysts, extrauterine preg- 
 nancy, etc.). If the patient is a woman and there 
 is tenderness over the lower part of the abdomen 
 extending to either side the possibility of some pel- 
 vic process must be taken into account. A bimanual 
 vaginal examination is then necessary in order 
 to determine the condition of the uterus, tubes, and 
 ovaries, exudate in the cul-de-sac of Douglas, etc. 
 The neighboring hernial openings are also to be in- 
 vestigated and rectal examination should not be 
 omitted. Pain on the left side suggests the various 
 affections of the sigmoid flexure, including carci- 
 noma, dysentery, membranous enteritis, volvulus, 
 foreign bodies introduced through the anus, etc. 
 In chronic constipation the region of the sigmoid 
 flexure is frequently painful or tender on pressure, 
 and relief follows an evacuation of the bowels. If 
 on the right side, attention is directed to lesions in 
 the neighborhood of the caecum and the appendix, 
 including tuberculous glands or ulcerations, intes- 
 tinal perforation in typhoid fever, distention of the 
 caecum in atonj^ of the colon, etc. 
 
TOPOGRAPHY 61 
 
 VI. THE LUMBAR REGION (SYMMETRICAL). 
 
 Symmetrical lumbar pain is but little adapted to 
 furnish decisive diagnostic information. After ex- 
 cluding lesions of the musculature or fascia, such as 
 lumbago and diseases of the spine, like spondylitis, 
 osteomalacia, etc., there is a wide range of possibili- 
 ties in which nearly all the abdominal organs com- 
 pete, including particularly the female generative 
 system. The demonstration of alimentary modifica- 
 tion of the backache is of importance since it occurs 
 in ulcerative processes of the stomach or large intes- 
 tine. In these as well as in disorders of the colon, 
 for example carcinoma, the pain often apears 
 within even a few minutes after the ingestion of 
 cold fluids or solid food. This phenomenon is prob- 
 ably to be interpreted as the result of a reflex stimu- 
 lation of intestinal peristalsis. Accumulations of 
 gas above stenoses appear to be particularly prone 
 to induce backache. In gastric ulcer with distention 
 of the stomach, in pyloric stenosis, and in carcinoma 
 of the colon backache is sometimes observed which 
 disappears promptly when the stomach or intestine 
 empties itself, thus showing its dependence on the 
 distention of these organs. Very deep-seated car- 
 cinomas frequently lead to pain in the neighborhood 
 of the sacrum, and the same may be said of hemor- 
 rhoidal conditions. Backache occurring during preg- 
 nancy and which is particularly severe on walking 
 is of great practical significance, as it is a symptom 
 of osteomalacia. A dependence on motion, particu- 
 
62 PAIN 
 
 larly stooping, is also often present in backache not 
 originating in the apparatus of motion itself, as in 
 hepatic, splenic, and renal processes, new growths 
 of the colon, etc. The backache sometimes com- 
 plained of in leukasmic swelling of the spleen, or 
 other enlargements of abdominal organs, is mani- 
 festly due to the compression of the swollen viscus 
 caused by the position. Persons with pendulous 
 abdomens find that their backache is promptly re- 
 lieved by manual support of the abdomen, and thus 
 suggest the applicability of an abdominal binder. 
 
 The dorsal position is particularly likely to be 
 painful in cases of retroperitoneal tumor formation 
 through enlarged glands, aneurysm, pancreatic cysts, 
 etc., and it seems reasonable to explain this on the 
 ground of the increase in compression accompanying 
 this position. A rather rare condition that I have 
 observed is backache occurring in chronic lead 
 poisoning. This is sometimes accompanied by radia- 
 tion into both thighs and is followed by colicky pain 
 in the neighborhood of the umbilicus. 
 
 Very severe backache together with a doubtful 
 skin eruption suggests the possibility of smallpox, 
 and this symptom is also associated with many other 
 infectious diseases like typhoid fever and meningitis. 
 The following case is of interest in this connection. 
 
 After exposure to cold a man of twenty-five years suddenly, 
 on December 27, 1907, developed severe backache, and pain in the 
 interscapular region. The pain was increased by motion and dis- 
 appeared when at rest. The next day the pain also involved the 
 lower extremities, which became stiff, so that a cane was needed in 
 walking. On the Slst the back was so stiff that the patient could 
 
TOPOGRAPHY 63 
 
 not sit up; there were frequent lightning-like tetanic convulsions 
 and spasm of the masseters. 
 
 Ill this case of "rheumatic" tetanus, which ended 
 in recovery, the backache was the first symptom. 
 
 VII. THE LUMBAR REGION (UNILATERAL) 
 AND THE FLANKS. 
 
 The presence of spontaneous pain or tenderness 
 in the right or left lumbar region or in the flank has 
 much greater diagnostic value and restricts the pos- 
 sibilities much more than backache that is symmetri- 
 cal. Frequently there is no spontaneous pain, but 
 it is necessary to test for tenderness by pressure, or 
 preferably by light blows with the ulnar side of the 
 clenched fist. Under these conditions painful renal 
 affections must always be thought of, particularly if 
 the corresponding flank is also tender. Further- 
 more, on the right side: Appendicitis with retro- 
 csBcal abscess, hepatalgia, and especially choleli- 
 thiasis. On the left side: Gastric ulcer, perisplenitis, 
 and pancreatic lesions. It must not be forgotten 
 that new growths or inflammatory processes of the 
 parametrium may give rise to tenderness in the 
 flanks. 
 
 ATYPICAL ABDOMINAL PAINS. 
 
 While the limits comprised under such a heading 
 as this are necessarily arbitrary, its introduction is 
 justifiable from the practical standpoint. For vari- 
 ous reasons abdominal pains not rarely offer unusual 
 difficulties in diagnosis. Frequently it does not suf- 
 fice simply to observe and to correlate the observa- 
 
64 PAIN 
 
 tions to form diagnostic conclusions, but it is neces- 
 sary to go further and consider even the rarer 
 possibilities. The processes that most often lead 
 to diagnostic errors may perhaps be classified in the 
 following way: 
 
 1. Atypical Attacks of Colic and Thoracic Proc- 
 esses. — The source of the pain is found in a more 
 or less characteristic and anatomically sharply cir- 
 cumscribed organic lesion, but the attacks of pain 
 are rudimentary or there is an absence of localizing 
 symptoms pointing to the organ in question. It is 
 well known, for example, that appendicular disease 
 or lesions of the gall-bladder frequently manifest 
 themselves by pain in the middle of the epigastrium, 
 and that biliary and ureteral colic and the pain of 
 pancreatic disease may appear in paroxysms embrac- 
 ing a wide area. "Wrong diagnoses are to be avoided 
 only by the most careful search for a point of maxi- 
 mum tenderness, such as the testicle, gall-bladder, 
 etc., and possible attendant symptoms such as 
 dysuria, glycosuria, urobilinuria, etc. In this con- 
 nection those cases should also be considered in 
 which the source of the abdominal pain is found out- 
 side of the abdomen, like the epigastric pain of 
 chronic thoracic aortitis or disease of the coronary 
 arteries and the tenderness under the costal arch 
 and in the flank in cases of pleuropneumonic disease 
 of the same side, etc. 
 
 Lesions of the oesophagus, especially deep seated, 
 malignant growths, not infrequently cause epigastric 
 pain. This is also true of the very rare cases of 
 
TOPOGRAPHY 65 
 
 spontaneous rupture of this structure which some- 
 times occur in heavy drinkers while voniiting, the 
 patients going into deep collapse. It is less well 
 known that bleeding from oesophageal varices may 
 lead to intense abdominal pain. 
 
 E.. B., an official, aged thirty-six years, in August, 1900, 
 began to complain of flatulence, diai^rhoea, and loss of appetite. On 
 the 13th of the month moderate enlargement of the abdomen was 
 noted for the first time. Alcoholism was admitted. On August 26, 
 after drinking some milk there was suddenly exceedingly severe 
 pain in the epigastrium, and hsematemesis (about J litre of blood). 
 There was a feeling of great tension in the abdomen, especially on 
 the left side of the epigastrium. Pressure in this region gave re- 
 lief; the pain radiated into the back. The eructation of gas gave 
 some relief. The subcutaneous injection of 0.03 of morphine was 
 without effect. The epigastrium was very prominent, fluid could 
 be demonstrated in the abdomen, and the patient went into collapse 
 with jactitation. Death followed at two o'clock on the same day. 
 At the autopsy cirrhosis of the liver was found, with perforation 
 of an oesophageal varix. The stomach and intestines were filled with 
 blood-clots. 
 
 In a similar way bleeding from a gastric ulcer 
 may lead to sudden diffuse abdominal pain. 
 
 2. Cystic New Growths and Foreign Bodies in the 
 Intestine.— Under this heading cyst formations, such 
 as those of the mesentery, pancreas, and ovaries, 
 must be considered. As wUl be pointed out in de- 
 scribing pancreatic pain the sensations attending 
 these are not susceptible of uniform interpretation. 
 For example, mesenteric cysts may on occasion give 
 rise to pain through the obstruction caused to the 
 passage of gastric and intestinal contents (direct 
 stenosis, volvulus?), or they may give rise to second- 
 
 5 
 
66 PAIN 
 
 ary neuralgia (solar plexus). The latter possibility 
 enters particularly into the question of pancreatic 
 cysts. The obstruction of venous trunks through the 
 torsion of the pedicle may lead to a rapid increase 
 in pressure in the interior of the cysts and therefore 
 give rise to pain through the augmented tension of 
 the cyst wall. 
 
 Pathological processes in the abdominal lymph 
 glands, both mesenteric and retroperitoneal, must 
 be thought of in cases of obscure spontaneous attacks 
 of paiu as well as when tenderness to pressure exists 
 (typhoid, tuberculosis, neoplastic mesenteric glands, 
 etc.). Swollen glands, for example in leukaemia, are 
 particularly likely through compression of neighbor- 
 ing nerve centers, such as the solar plexus, to cause 
 neuralgias of the severest type and resembling 
 attacks of colic. In this group may be included also 
 the pain accompanying the course or termination of 
 a tubal pregnancy {v. the differential diagnosis of 
 appendicitis). 
 
 Intestinal colic may be caused by the presence of 
 a tapeworm in the bowel, and foreign bodies such as 
 particles of bone or fish bones may give rise to 
 inflammatory conditions inducing symptoms resem- 
 bling those of appendicitis, cholecystitis, etc. 
 
 On April 28, 1904, a nineteen-year-old tailor's apprentice was 
 brought into the medical clinic with the diagnosis of " appendicitis." 
 Two days before, the temperature was said to have been 104° F., but 
 on admission it was subnormal. There was marked tenderness in 
 the ileocaecal region and also in the left gluteal region. In the ileo- 
 esecal region a hard, pencil-like body could be felt. The patient 
 denied having swallowed a foreign body, but just before the opera- 
 
TOPOGRAPHY 67 
 
 tion he confessed that a friend had introduced a pen-holder into his 
 rectum. The laparotomy was performed in Hockenegg's clinic. 
 An incision was made over the caecum and the pen-holder was found 
 in the sigmoid flexure with one end pressed against the left linea 
 innominata. The flexure had a very long mesosigmoid, so that the 
 oral end of the foreign body reached the neighborhood of the caecum. 
 An official, aged thirty years, was taken in November, 1903, 
 with pain in the umbilical region, which later centred about the 
 gall-bladder. A Carlsbad treatment caused the pain to disappear. 
 I saw the patient for the first time in May, 1904. He then had 
 pain in the gall-bladder region which was increased on deep respira- 
 tion and on coughing, and on bearing weight on the right foot. 
 Lying on the side was painful. The temperature was subnormal. 
 Taking food did not modify the symptoms. In the gall-bladder 
 region a firm mass the size of a nut could be felt. Cholecystitis? 
 Gumma? The surgeons declined to operate and the patient left 
 the clinic. In June, 1905, I saw him again and he related that in 
 April, 1905, the pain had recurred in the former situation, and the 
 overlying skin had become red. In May, 1905, an incision was made 
 and about two litres of pus were evacuated. In the discharge a 
 portion of a chicken bone the length of a match was found. 
 
 3. Visceral Neuralgias and Disorders of Circular 
 tion. — The cause of the pain lies not in the organ 
 itself, but in its nerve supply or in its vascular 
 system. Experience shows that cases of this sort 
 are particularly liable to misinterpretation because 
 through the law of probabilities lesions of the organs 
 themselves are more likely to be thought of. 
 
 The neuralgiform attacks sometimes occurring 
 in spinal diseases, particularly in tabes, cerebro- 
 spinal syphilis, etc., and manifesting themselves in 
 certain organs, such as the stomach, intestine, blad- 
 der, etc., as well as independent processes in the 
 abdominal sympathetic and its ramifications will be 
 taken up partly in describing the various organic 
 
68 PAIN 
 
 pains and partly in the discussion of the visceral 
 neuralgias. In order to avoid repetition, reference 
 is made to the chapters in question. On the other 
 hand, in the chapter on the vascular system we shall 
 discuss the manner in which anatomical changes ia 
 vessels, like dilatation, constriction, occlusion, embol- 
 ism, and thrombosis, may occasion pain in the corre- 
 sponding organs, and reference will be made to the 
 importance of functional disorders like vascular 
 spasm. It is therefore to be recommended always 
 to keep this possibility in mind in investigating 
 attacks of abdominal pain in which the necessary 
 underlying factor such as mitral stenosis, or athe- 
 roma with cardiac iasufficiency is present. It is well 
 to remember, however, that these are more or less 
 rare and that, on the other hand, circulatory disor- 
 ders may give rise to abdominal pain in other, even 
 though indirect, ways. For example, patients with 
 portal obstruction are prone to meteorism and may 
 suffer from extremely severe pain from flatulent 
 colic, or there may be a secondary nephrolithiasis 
 due to sedimentation of urine in the renal pelvis of 
 a congested kidney, or complications like gastric 
 ulcer or cholelithiasis whose development appears at 
 times to be favored through the congestion. 
 
 4. Acute Intestinal Stenoses, Hernias, etc. — In- 
 testinal affections from the borderland of surgery 
 and iatemal medicine. Here we should first con- 
 sider the pain often suddenly arisiag under severe 
 general manifestations, spontaneously or after ab- 
 domirial straining, and accompanying acute interfer- 
 
TOPOGRAPHY 69 
 
 ence with the passage of intestinal contents, whetlier 
 produced l>y external or internal incarceration, 
 strangulation, volvulus, or intussusception. "WTiere 
 evidence is obtained pointing in this direction, such 
 as increased peristalsis with severe general symp- 
 toms, the subjective sensation of impeded intestinal 
 activity, acute meteorism, etc., the most careful study 
 of the nature of the pain is to be recommended. 
 While the diffuse colic attending these conditions is 
 not characteristic, the search after definite local 
 pain phenomena may be of decisive value. It is 
 above all necessary to determine exactly the region 
 in which the pain began, as this may at least permit 
 conjecture in regard to the site of the lesion. Just 
 as in chronic intestinal stenosis the location of the 
 pain sometimes corresponds to the situation of the 
 obstruction, the same thing may be tru«i in acute 
 cases. It is of equal importance to test for local 
 tenderness to pressure, and in this connection the 
 various hernial openings should of course be most 
 carefully examined. 
 
 Gall-stones or foreign bodies impacted in the ia- 
 testine may also occasion atypical local tenderness 
 which is diflScult to interpret. In considering hernial 
 pain the position of the body must be taken into 
 account as well as the local tenderness, since it may 
 determine the intensity of the trauma acting at the 
 moment on the contents of the hernial canal or her- 
 nial opening. For example, the attitude of "Atten- 
 tion" or bending the trunk backward frequently 
 
70 PAIN 
 
 gives rise to paiA in cases of the extremely small 
 and therefore easily overlooked hernias of the linea 
 alba, while on leaning forward the epigastric pain, 
 which is frequently interpreted as due to ulcer, is 
 relieved. When lying on the back raising the head 
 may cause pain, or also contraction of the abdominal 
 muscles at stool or in whistling. Abduction and for- 
 cible rotation inward of the thigh usually increases 
 the pain of incarcerated obturator hernia. 
 
 This group of easly misinterpreted atypical 
 abdominal pains also includes the more or less pain- 
 ful sensations that accompany abnormal gas accu- 
 mulation in the intestinal canal. The neuropathic 
 constitution, enteroptosis, and the tobacco habit not 
 rarely furnish the underlying groundwork of this 
 condition. The pain often involves the flexures of 
 the colon, is frequently characterized by great sever- 
 ity and a colicky nature, and may also be accom- 
 panied by local tenderness. The occurrence of local 
 distention may explain the circumscribed tenderness 
 not rarely observed in cases of general peritonitis, 
 in regions in which there appears to be no anatomical 
 basis for the pain. (For example, on the left side 
 in appendicitis with perforation.) In other in- 
 stances, when no inflammatory condition exists, 
 external pressure may give relief, obviously by caus- 
 ing the dispersal of a local accumulation of gas. 
 The examination of the stools is of great importance 
 and often reveals a strongly acid reaction and an 
 abnormal flora with the presence of leptothrix-like 
 rod forms which give the starch reaction. 
 
CHAPTER IV. 
 
 Quality and Time of Occurrence. 
 
 Colicky Pains. — The classification of pains from 
 the standpoint of their quality, as a rule, has but 
 little practical diagnostic value. One group stands 
 out distinctly, however, and that is the one compris- 
 ing the pain of colic. This is characterized by a 
 gradual onset and subsidence, that is, a wave-like 
 curve of intensity with summits and valleys, and by 
 the sensation of spasmodic contraction. The first 
 peculiarity is also manifested by the pain of neural- 
 gia, and therefore in abdominal cases the recognition 
 of the nature of the symptom may be attended by 
 considerable difficulty. In such instances the pres- 
 ence of the spasmodic element, as well as possible 
 accompanying- manifestations such as active peri- 
 stalsis or borborygmi, may give the necessary clue. 
 
 Pathogenesis of the Pain of Colic. — ^How does the 
 pain of colic originate? It occurs in regions where 
 there are muscular, hollow organs and is linked with 
 this anatomical structure. In regard to the general 
 pathogenesis of colic, from the purely clinical stand- 
 point I agree with those who explain the phenom- 
 enon by supposing that along the course of a muscu- 
 lar tube a band of spasmodic contraction approaches 
 another fixed contracted ring, driving before it the 
 contents of the organ. As a result of this there must 
 
 71 
 
72 PAIN 
 
 beoverdistentionof the constantly shortening portion 
 lying between the two rings, and I regard this pain 
 of distention as being the chief factor in the mechan- 
 ism of the condition. It is a fact that the paroxys- 
 mal attacks of pain sometimes occurring in lesions of 
 the renal parenchyma (nephritis, tumor, etc.) as the 
 result of acute congestion, haemorrhage, etc., in their 
 qualitative shading are hardly to be distinguished 
 from the pains of colic. Here the distention of the 
 capsule is probably the only active factor. If the 
 stationary ring of contraction relaxes, the formerly 
 distended portion collapses, the tension of the wall 
 subsides and the contents move on. This may be 
 directly observed in cases of gastro-intestinal ste- 
 nosis. The advance of the contents is rendered evi- 
 dent by loud borborygmi, and with their onset the 
 pain usually subsides. Is the stationary contraction 
 ring itself a source of pain? It is a fact that cases 
 may be observed in which a spastic tumor at the 
 pylorus of an entirely empty stomach suddenly 
 appears under the palpating fingers, while at the 
 same time severe pain is felt by the patient. As the 
 tumor vanishes the pain also ceases. It seems out 
 of the question in such a case to assume the existence 
 of distention of the walls in view of the empty con- 
 dition of the stomach, and observations of this sort 
 appear to me to indicate that local spasm of the 
 nature of the ordinary sural cramp is also capable 
 of evoking the pain. In regard to the separate 
 forms of colic, the differential diagnosis, etc., refer- 
 ence may be made to the discussion of the individual 
 
OCCURRENCE 73 
 
 organic pains as well as to the section on atypical 
 abdominal pains. 
 
 For the purposes of rapid orientation in doubtful 
 cases of colic it should be remembered that unilateral 
 tenderness of the testicle to pressure, disorders in 
 the evacuation of urine and m its nature, and pain on 
 pressure in the renal region are found in ureteral 
 colic. Elevation of temperature, ileocsecal pain, and 
 leucocytosis accompany appendicitis. The exami- 
 nation may also require a search for tenderness and 
 enlargement of the liver and gall-bladder, mesenteric 
 or ovarian cysts, extrauterine pregnancy, tenderness 
 about the hernial openings, gastro-intestinal peri- 
 stalsis, sarcinas in the stools and in the gastric con- 
 tents which occur in stenosis of the pylorus, lead line 
 on the gums, abnormalities of the pupillary and 
 patellar reflexes, glycosuria and the absence of indi- 
 can with peritoneal symptoms indicating pancreatic 
 disease, glandular masses in the neighborhood of the 
 solar plexus, menstrual irregularities, and cardiac 
 and aortic lesions pointing to angina pectoris with 
 epigastric localization. 
 
 The time of occurrence of the pain has differen- 
 tial value only if there is regularity in this, or if 
 there is a relationship to the ingestion of food or to 
 organic function. In this connection reference may 
 be made to what has been said above. 
 
 NocTUENAL Pains. — A special group is formed 
 by attacks of pain characterized by more or less ex- 
 clusively nocturnal onset. An undeniable relation- 
 ship in this regard is manifested by: (1) The pain 
 
74 PAIN 
 
 of colic in general. As a physiological example 
 labor pains deserve the first place. With the inactiv- 
 ity of striped muscle there seems to be associated an 
 increased activity of the smooth muscle fibres, and 
 it may be said that at night smooth muscle is in the 
 ascendant. Colicky seizures of the most varied sorts 
 show a pronounced tendency to manifest themselves 
 during the midnight hours. Nocturnal occurrence 
 appears to me to be of differential interest, espe- 
 cially in distinguishing between functional pain and 
 that having an organic basis. If the pain wakes the 
 patient from sleep it is usually organic in nature. 
 (2) Neuralgias. (3) Pains due to a dyscrasia. In 
 this category may be included the ursemic headaches, 
 ursemic cramps of the calf muscles, and gouty seiz- 
 ures. The neuralgic pains complained of by dia- 
 betics also frequently manifest nocturnal exacerba- 
 tions. It seems to me natural to assume that as 
 a result of the diminution in metabolic function 
 through the absence of muscular work and its attend- 
 ant respiratory and cutaneous activity, when a dys- 
 crasia exists the toxsemic curve ascends at night and 
 leads to nocturnal attacks of, pain. Circulatory 
 changes also no doubt come into play. The connec- 
 tion between syphilis and nocturnal pain may accord- 
 ingly be regarded only as a particular example of 
 a connection actually having a much deeper founda- 
 tion. 
 
 Gouty pains sometimes are severest during the 
 morning hours. In such cases it is probably the auto- 
 massage and improvement in the circulation of the 
 
OCCURRENCE 76 
 
 affected joints that causes the pain to grow less as 
 the day wears on. In some forms of pain regular 
 intermissions are due to the fact that the underlying 
 cause is regularly intermittent, as for example fever, 
 or the ingestion of food. Trigeminal neuralgia 
 sometimes appears at definite hours, without depend- 
 ing on a masked malaria. Periodical attacks of pain 
 at certain intervals, as in migraine, essential gas- 
 tralgias, etc., suggest the possibility that the causa- 
 tive factor lies in the accumulation of metabolic 
 products — ^for example those of the glands of inter- 
 nal secretion. 
 
CHAPTEE V. 
 
 The Nebvous System. 
 
 HEADACHE. 
 
 This designation, although it really connotes only 
 a topographical characteristic of the pain, is usually 
 employed when an organic pain is in question, that 
 is, cerebral pain. In order to justify the latter 
 assumption, it is necessary to regard the brain, to- 
 gether with its enveloping membranes, as an entity, 
 a principle that, by the way, will be found per- 
 fectly natural in the description of hepatic, splenic 
 or renal pains, etc. Paradoxical as it may seem at 
 the first blush to draw parallels of any sort between 
 organs that are so different in function and struc- 
 ture, it cannot be denied that the general basis of the 
 phenomena of pain in the organs just mentioned 
 possesses certain characteristics in common. Varia- 
 tions in the volume of the organs with the attending 
 tension of the capsule, and more or less independent 
 inflammatory processes of their enveloping mem- 
 branes, are important factors in the general pathol- 
 ogy of pain involving the organs in question. For 
 example, in proportion as the volume of a congested 
 liver diminishes under the action of digitalis its ten- 
 derness to pressure decreases, to reappear again 
 
 76 
 
THE NEHVOUS SYSTEM 77 
 
 suddenly at a time when auscultation demonstrates 
 tlie onset of a perihepatitis. In this case the condi- 
 tions are plainly evident, for the organ is accessible 
 to direct physical examination. It is different in 
 cases of cephalalgia, for although the ophthalmo- 
 scope may give valuable information, for the most 
 part we are confronted by the rigid bony cranium 
 which sets at naught our efforts in the way of physi- 
 cal examination. We are therefore forced to form 
 an opinion concerning the general mechanism of pain 
 from case to case, taking into consideration the modi- 
 fying factors and the accompanying manifestations. 
 Under these conditions it is hardly possible to avoid 
 reasoning by analogy. The question is further com- 
 plicated by the fact that we are often obliged to 
 assume that certain persons have a predisposition 
 to headache, without which the factors about to be 
 discussed might be ineffective. This may to some 
 extent depend on vasomotor instability, and accord- 
 ingly headache is enormously frequent in neuro- 
 pathic individuals. Local anatomical peculiarities 
 may play a role, such as the size of the foramen of 
 Magendie, and of the emissary and other venous 
 channels. There is also evidence in favor of the 
 view that headache is sometimes related to consti- 
 tutional peculiarities, under which heading metabolic 
 processes are undoubtedly of much importance. 
 Thus the attacks of migraine usually cease with the 
 onset of the climacteric. Then there are interesting 
 cases, of which I remember several, in which the 
 
78 PAIN 
 
 development of leukaemia or carcinoma is attended 
 by the cessation of previously habitual headaches. 
 
 Fundamental Causes or Headache. — ^Assuming 
 the existence of such a predisposition, the following 
 factors of general pathology may be grouped as 
 belonging to the fundamental causes of headache : 
 
 I. Mechanical factors, involving a rise in intra- 
 cranial pressure : (a) Chronic (new growths, hydro- 
 cephalus), (b) Acute. Under this heading vaso- 
 motor disturbances must be considered, such as 
 angioneurotic hydrocephalus and also interference 
 with the venous return, as in sinus thrombosis, 
 paroxysms of coughing accompanying congestion in 
 the superior vena cava in consequence of mediastinal 
 new growths, tricuspid insufficiency, etc. 
 
 II. Chemical factors: AnsBmia, toxaemia, inflam- 
 mation. 
 
 III. Reflex factors. 
 
 The meninges, receiving their innervation from 
 the trigeminal nerve, are to be regarded as the com- 
 mon point of attack of all these, and the peculiar 
 nature of this nerve to some extent explains the 
 especial characteristics of headaches. 
 
THE NERVOUS SYSTEM 79 
 
 I. Headache Due to Chronic or Acute Elevations 
 of Intracranial Pressure. 
 
 By way of preface, it may be pointed out that 
 increased pressure in tlie arterial system sometimes 
 occurs together with intracranial hypertension, and 
 may under certain conditions serve as a predisposing 
 factor. On the other hand, it is evident that intra- 
 cranial tension may also be increased in cases of 
 low arterial pressure. 
 
 Beain Tumob and Hydeocephalus. — The ana- 
 tomical processes to be considered in this connection 
 are in the first place tumors, which may increase 
 cerebral pressure partly per se through the increase 
 in the bulk of the intracranial contents, but which 
 may also do this as a consequence of their relation- 
 ship to important channels such as the veins of Galen 
 or the aqueduct of Sylvius. The latter element par- 
 ticularly serves to explain the fact that of the intra- 
 cranial processes leading to headache tumors of 
 the posterior fossa deserve first place. Cerebral 
 abscesses, of course, behave in the same way. A 
 form of hypertension headache is caused ia those 
 cases of acquired hydrocephalus of adults in which 
 the manifestations of increased cerebral pressure 
 arise, sometimes in stormy fashion with the symp- 
 toms of an infectious disease (serous meningitis), in 
 other cases in a more or less insidious manner, or 
 at least without evidences of acute infection. The 
 etiology of these cases of hydrocephalus runnirig a 
 course like that of brain tumor is far from clear, 
 
80 PAIN 
 
 and the assumption of tlie existence of chronic menin- 
 gitic processes is usually a mere hypothesis. Intes- 
 tinal processes such as constipation with acetonuria, 
 as well as anaemic blood changes like chlorosis, seem 
 to have some causative influence. The headache 
 arising under these conditions resembles, particu- 
 larly in the acute cases, the headache of acute menin- 
 gitis, and also, it is true, the hypertension headache 
 of brain tumors. The headache of acute meningitis 
 may also be included in this category. 
 
 Position of the Head. — On careful observation 
 of such cases of hypertension headache, as I may 
 briefly call them, it is undeniable that the position 
 and motion of the head is of considerable influence 
 on the pain. The patient often succeeds in reducing 
 his suffering to a minimum by bending the head far 
 backward and burying it in the pillow. No doubt 
 this position produces a certain diminution of ten- 
 sion and may be compared to the midposition as- 
 sumed by inflamed joints. On the contrary, bending 
 the head forward appears to increase the pain, and 
 similarly, rotation of the head is often painful, the 
 sensation usually being experienced in the nape of 
 the neck and sometimes apparently on the side oppo- 
 site to that toward which rotation has taken place. 
 On lying down the patients not rarely fix the head 
 with the hand. Swallowing sometimes serves to 
 bring on pain. The patient therefore usually at- 
 tempts to bring the head into a certain "midposi- 
 tion" and to maintain it passively in this attitude 
 without innervation of the neck muscles. Another 
 
THE NERVOUS SYSTEM 81 
 
 set of painful stimuli have iu common tlie fact that 
 through increased heart action the blood supply to 
 the brain is increased but the venous return is in- 
 hibited. Of this description are various mechanical 
 factors like stooping, lifting weights, sitting up 
 rapidly or lying down quickly, the horizontal posi- 
 tion, hard straining at stool, etc. Extreme heat may 
 act in a similar way, and is usually not well borne. 
 Furthermore, various chemical stimuli of a dietetic 
 nature may be mentioned, such as the use of alcohol, 
 tobacco, coffee, tea, etc. 
 
 Headache and Constipation. — ^Finally, I should 
 like to call attention to the frequently very close re- 
 lationship between hypertension headache and con- 
 stipation. Practically this is of the greatest impor- 
 tance, but theoretically it is no less interesting. 
 When hypertension headache appears in conjunction 
 with constipation of long duration, for example, in 
 chlorotic persons, together with other symptoms of 
 intestinal intoxication like urticaria, acetonuria, etc., 
 a causative connection immediately suggests itself, 
 and as a matter of fact calomel is a sovereign 
 remedy in these cases. I can also recall cases of 
 imdoubted hypertension headache in cerebral tumor 
 in which the administration of a laxative gave 
 prompt relief and far surpassed the effect of the 
 antineuralgics prescribed. The connection between 
 constipation and headache is undeniable, but the ex- 
 planation of this is pure theory. The widely sup- 
 ported toxin theory seems to me to be not very satis- 
 factory, or at least not of itself all suflScient, in view 
 6 
 
82 PAIN 
 
 of the extreme suddenness with which the pain often 
 ceases on evacuation of the bowels. Mechanical 
 factors seem to me more significant. In this connec- 
 tion the role played by intestinal peristalsis as an 
 accessory to the portal circtilation might be thought 
 of as well as the interference with circulation in 
 the domain of the superior vena cava that results 
 through constipation and gas accumulation in the 
 abdomen, owing to the pushing upward of the 
 diaphragm. 
 
 Topography and AccoMPANYiiirG Manifestations. 
 A topographical peculiarity of hypertension head- 
 ache appears to me to lie in its preference for the 
 nape of the neck, as well as in its tendency to radiate 
 along the spinal column, particularly in the region 
 between the shoulder blades. The patients fre- 
 quently complain of feeling "as if the head were 
 being split open," "as if the head would burst 
 open, ' ' sensations that may well be in harmony with 
 the underlying condition. Changes in the fundus 
 of the eye are particularly prominent among the 
 accompanying manifestations. They may be partly 
 of purely mechanical nature, such as dilatation of 
 the veins, or hfemorrhages ; partly inflammatory in 
 origin. In these cases there may be lymphatic con- 
 gestion with an accumulation of the products of 
 metabolism, and it may readily be assumed that not 
 only in the optic nerve but also in the trigeminal or 
 occipital nerves similar alterations may develop with 
 secondary neuralgia. Pressure points may often be 
 
THE NERVOUS SYSTEM 83 
 
 demonstrated over the distribution of the occipital 
 and trigeminal nerves. Hiccough, vomiting, and ab- 
 normalities in pulse and respiration may be re- 
 garded as vagus symptoms. Not rarely symptoms 
 due to irritation of the optic and acoustic nerves 
 are observed, such as spots dancing before the eyes 
 or buzzing in the ears, as well as attacks of vertigo. 
 The headache seen in conditions like brain tumor 
 and hydrocephalus which cause changes in the intra- 
 cranial pressure is readily explicable on mechanical 
 grounds, and no element of predisposition need be 
 postulated. The case is different in the much more 
 frequent instances of headache without any anatom- 
 ical basis, the bane of the large family of neuro- 
 paths, and which we are acustomed to term 
 "nervous" headache. This very designation in- 
 volves a confession of ignorance. Since the sufferers 
 are usually persons with undue irritability of the 
 vasomotor system and unstable cardiac equilibrium, 
 the thought suggests itself that here again we are 
 dealing with disturbances of the intracranial circu- 
 lation, so that one might speak of "angioneurotic 
 headaches." All the attendant circumstances fre- 
 quently exhibit the closest analogy to those accom- 
 panying the organically induced "hypertension 
 headaches" of tumor or hydrocephalus. "While in 
 the latter the increase in intracranial pressure is 
 permanent and of maximum degree, in their func- 
 tional counterparts the rise is intermittent and at 
 times only insignificant. The following may serve 
 as an example : 
 
84 PAIN 
 
 A man of thirty-three years, otherwise well and strong, has 
 suffered since a fall on the occiput in his ninth year from attacks 
 of headache recurring on an average of once in three to four weeks. 
 These begin early in the morning with pain about the point of 
 emergence of the left supraorbital nerve. In the evening occipital 
 pain sets in, which is so severe that the patient's eyes fill with 
 tears. Inciting causes are pressure over the back of the head, 
 alcohol, excessive smoking, especially of cigarettes, heat in summer, 
 mental and physical exertion. Relief is afforded by bending the 
 head backward until it is nearly at right angles to the spine. The 
 most efficient antineuralgic has been a combination of codeine with 
 a coal-tar drug, given early in the morning. The application of 
 cold is ineffective. In the case of this constitutionally nervous 
 individual there are no doubt occasional elevations of intracranial 
 pressure, which may have been predisposed to by the accident in 
 childhood. 
 
 The forms of nervous headaclie in wMch. eleva- 
 tion of the head brings relief, and epistaxis often is 
 followed by immediate cessation of the pain are to be 
 included in the category of hypertension headaches. 
 The elevation of blood-pressure which is so often 
 seen in neurasthenics may serve as a favoring factor, 
 and this condition always deserves consideration in 
 the diagnosis and treatment of headache. The vaso- 
 motor origin of the pain is furthermore suggested 
 by such attendant manifestations as redness of the 
 face with a feeling of burning, or pallor. The effect 
 of temperature is sometimes noteworthy, thus exac- 
 erbations often are observed during the summer 
 months. Cold footbaths and similar measures are 
 frequently promptly effectual. 
 
 Headaches of the type next to be discussed 
 depend largely on the action of endogenous poisons. 
 The conditions are not so simple, however, as in 
 the case of the hypertension headache due to tumor 
 
THE NERVOUS SYSTEM 85 
 
 and hydroceplialus. AnsBmia of the severest grades 
 or ursemic states may run their course entirely with- 
 out headache. Individual idiosyncrasies are of 
 moment, and elevation of intercranial pressure is 
 frequently an intermediate factor, so that the dys- 
 crasia in question, uraemia or anaemia, for example, 
 acts not directly but only secondarily through this 
 mechanical means. 
 
 II. Headache Caused by Chemical Poisons. 
 
 Ub^mia. — ^Albuminuric headache or the cephal- 
 algia caused by renal insufficiency may be taken as a 
 paradigm of this type, although here in addition to 
 the toxaemic element no doubt mechanical factors, 
 such as cerebral oedema or hydrocephalus, together 
 with arterial hypertension, frequently play a not un- 
 important role in the pain production. The relief 
 to the pain that frequently follows epistaxis or 
 blood letting at the mastoid process may be ex- 
 plained on this basis. As with the headache of 
 hypertension, the seat of the uraemic headache is not 
 rarely the occipital region but in general it may be 
 said that there are no entirely characteristic fea- 
 tures, so that in every case of obstinate cephalalgia 
 the examination of the uriue for serum albumin is 
 urgently demanded. The prompt effect frequently 
 following large doses of cerium oxalate, (about 
 0.5 g.) is an interesting fact. 
 
 In May, 1906, I was consulted by a lady of about fifty years 
 on account of severe headache. She had never suffered in this way 
 before, but her menstruation had ceased three months ago and since 
 
86 PAIN 
 
 that time the headache had persisted. The pain began over the 
 root of the nose, and was so severe, especially early in the morning, 
 that she had expressed her intention of committing suicide. There 
 was also frequent vomiting. Black cofifee lessened the pain, but 
 wine or beer caused it to become more intense. She complained of 
 loss of appetite and could not take milk or acid foods. It was 
 found that the quantity of urine was increased, especially at night, 
 and that it was light in color. Examination showed high arterial 
 pressure and enormous quantities of albumin in the urine. 
 
 It is difficult to determine to what extent the head- 
 ache occurring in cases of arteriosclerosis with high 
 blood-pressure but without albuminuria. depends on 
 arteriosclerotic renal insufficiency. Here again the 
 high blood pressure may come into play, as appears 
 to me to be shown by the relief not infrequently 
 afforded by an incidental nose bleed, so that the 
 advisability of producing this artificially may even 
 suggest itself. 
 
 Lead Poisoning and Gout. — The basis of the 
 headache in chronic lead and metal poisoning in 
 general is probably not constant, and the same thing 
 is true of the uric acid diathesis and the peculiar 
 type of headache well known to the laity as migraine. 
 It is true nevertheless that Trousseau's classical 
 dictum, "migraine and gout are sisters," deserves 
 full consideration. 
 
 I remember to have seen cases of gout in which the onset of 
 joint pain was accompanied by the cessation or lessened intensity 
 of the attacks of migraine. (Excretion of uric acid into the joints 
 and therefore decrease in the uric acid content of the blood?) 
 
 Infectious Pbocesses.— The relations between 
 infectious processes such as syphilis, malaria, tuber- 
 
THE NERVOUS SYSTEM 87 
 
 culosis, influenza, etc., and their associated head- 
 aclies, are no less uncertain. In part, there may be 
 direct toxic action on the pain-conducting trigeminal 
 tract; in part, transitory elevations of intracranial 
 pressure incited through inflammatory hypersemia 
 of the meninges and the intracerebral blood vessels. 
 This holds also for cases of suppurative or tubercu- 
 lous meningitis. 
 
 In malaria there may be regular attars of headache, even 
 though the fever is irregular. In one case of mine the pain came 
 on every afternoon at four o'clock. Since syphilitica are nearly 
 always also neuropathies, in considering their headache one must 
 think of the possibility of its being nervous in character. This is 
 made more probable if the pain Is not nocturnal. 
 
 Anemia. — ^It is undeniable that patients with 
 blood changes, such" as chlorosis or pernicious 
 antemia, not rarely suffer from headache, and it is 
 equally true that headache is often entirely absent 
 in cases of pernicious anaemia of the most severe 
 sort. It is hardly wise therefore to speak off-hand 
 of an ansemic headache. When headache is espe- 
 cially intense in anaemic patients, the idea of intra- 
 cranial rise in pressure through hydremic hydro- 
 cephalus suggests itself. In such cases elevating 
 the head is frequently of benefit, and the patients 
 often behave ia a manner similar to that discussed 
 under the heading of hypertension headache. Just 
 as hydremia appears to predispose to fluid exudates 
 in general, it seems sometimes to give rise to transu- 
 dation into the ventricles of the brain. This is not 
 intended to deny, however, that anaemic blood 
 
88 PAIN 
 
 changes may not cause headache without an inter- 
 mediate condition of hydrocephalus. These are 
 then susceptible to the same therapeutic measures 
 as the underlying condition and are relieved by a 
 more abundant blood supply, such as is caused by 
 lowering the head. 
 
 III. Headache of Reflex Nature. 
 
 Here irritative stimuli are concerned — particu- 
 larly in the distribution of the trigeminal nerve — 
 which under some circumstances may find an echo, 
 as it were, through radiation in the meningeal dis- 
 tribution of this nerve. Such reflexes are especially 
 likely to occur in cases in which a neuropathic pre- 
 disposition and vasomotor instability exist. Even 
 in cases of restricted localization it may be difficult 
 to distinguish between neuralgia and true cerebral 
 pain. If there is evidence of increased intracranial 
 pressure, as in otitis media for example, all doubt 
 is, of course, removed. At any rate, in making the 
 differential diagnosis of headache, it is advisable 
 not to leave out of consideration any existing mani- 
 festations in the distribution of the trigeminal nerve. 
 
 The Eye, Nose, and Ear. — This is especially 
 true of the eye; the combination of headache and 
 visual disturbances should always lead to the most 
 careful examination of the eye, including iuvestiga- 
 tion of the tension of the eyeball, the visual field, 
 and examination for excavation of the optic disc. 
 Furthermore, there is no doubt that other disturb- 
 ances such as weakness in convergence, hyperme- 
 
THE NERVOUS SYSTEM 89 
 
 tropia or presbyopia, astigmatism, etc., may fumisli 
 the starting poiat of headache, especially in cases 
 in which a general predisposition to headache is 
 already supplied by other factors such as the 
 neuropathic co,nstitution, disorders of nutrition, etc. 
 The following case may serve as an example: 
 
 The patient was an anaemic lady, slender in build and of sensi- 
 tive intellectual type. The vasomotor system was overexcitable, and 
 even slight exertion caused fatigue. There was pain about the 
 tendo Aehillia on rising after sitting for some time. The breasts 
 were tender, especially at menstruation. All the nerve trunks sensi- 
 tive. She was restless and found that the quieter she was the 
 worse she felt. At the menstrual period there was constipation 
 which was relieved by the use of morphine suppositories. Corneal 
 reflex and knee-jerks normal. She was near-sighted and wore glasses. 
 For a long time she had suffered from headaches which were rebel- 
 lious to the usual antineuralgic remedies. The instillation of 
 hematropin always relieved the headache promptly. During the 
 attacks the pupils were contracted. 
 
 More often the relation between the eyes and 
 headache is less direct, since use of the eyes may 
 cause an increase in headache caused by some other 
 factor. This is true especially of "nervous" or 
 "vasomotor" headaches. There is an undeniable 
 relation between headache and inflammatory and 
 suppurative disease or swellings in the nasal pas- 
 sages and their accessory cavities (frontal headache 
 in iodide coryza, etc.). Particularly convincing are 
 those cases in which months of antineuralgic treat- 
 ment of obstinate frontal headache are suddenly 
 permanently terminated by the discharge of a quan- 
 tity of pus through the nose. Processes in the 
 frontal and sphenoidal sinuses are of particular 
 
90 PAIN 
 
 significance in this connection. But here also the 
 relationship is often purely superficial, and the 
 headache depends primarily on the patient's neuro- 
 pathic constitution, while the nasal condition is 
 merely a secondary etiological factor. Overzealous 
 treatment by specialists must therefore be depre- 
 cated and the general predisposing condition should 
 receive full therapeutic attention. That the ear 
 should require full consideration among the organs 
 of special sense is evident through the possibility 
 of otogenous cerebral abscesses, sinus thrombosis, 
 etc. The examination of the mastoid process for 
 tenderness should never be omitted. In case there 
 is a purulent aural discharge the connection is par- 
 ticularly evident, for retention of this causes prompt 
 increase in the often unilateral headache, which sub- 
 sides again when the discharge becomes free. 
 
 Stomach and Intestine. — ^Any existing gastro- 
 intestinal disorders (parasites, constipation, dys- 
 pepsia, latent cholelithiasis) must also be taken iato 
 account. Just as cerebral processes like brain 
 tumors, meningitis, or migraine frequently evoke 
 vomiting, constipation, or other secondary gastro- 
 intestinal disturbances, a similar influence seems to 
 be possible in the opposite direction also. Headache 
 of this variety also frequently has a neuropathic 
 substratum. The following are examples from my 
 experience : 
 
 One neurasthenic patient complained of headache, especially 
 after taking sweet or fatty foods. In another case headache of long 
 duration was relieved on the expulsion of a tape worm. One patient 
 
THE NERVOUS SYSTEM 91 
 
 with entcroptosis and marked pulsation of the ahdominal aorta 
 suffered from pounding in the head after taking starchy desserts, 
 while a woman with a tendency to abdominal distention, found that 
 the headache was lessened when she compressed the abdomen with 
 a massage ball. In a case of nervous achylia the gastric disturbances 
 were always associated with pain in the top of the head. Larger 
 amounts of eggs or bread caused increase in the headache and the 
 patient was accustomed to relieve himself by inducing vomiting by 
 drinking black coffee. Another patient had temporal headache when 
 fasting ("Hunger Headache"). 
 
 Stagnation of fecal masses deserves considera- 
 tion, as has already been indicated. Even though 
 the headache may seldom be caused by constipation 
 alone, this often affords an important contributing 
 cause, the removal of which, as for example in cases 
 of brain tumor, may lead to an immediate and con- 
 siderable improvement in the pain. 
 
 It is chiefly the gastro-intestinal neuroses that 
 are associated with headache, and sometimes alter- 
 nate with it. Organic gastro-intestinal lesions are 
 less often associated with it. 
 
 In one case of carcinoma of the stomach the headache was 
 always lessened on taking food, while in another similar case it 
 was increased when the patient ate meat and bread. 
 
 An intimate etiological relationship between 
 headache and constipation may exist in cases of in- 
 testinal autointoxication. In these several days of 
 constipation are followed by very severe headache 
 frequently associated with stiffness of the neck so 
 that the possibility of meningitis suggests itself. On 
 emptying the bowel prompt relief is usually afforded. 
 Acetonuria, which to be sure may also occur in 
 
92 PAIN 
 
 meningitis, at least in the later stages, and the 
 absence of fever are of assistance in tlie differential 
 diagnosis. 
 
 Tlie genital system also plays an important role 
 in the causation and modification of headaches. 
 Here again overzealous special treatment must he 
 guarded against, for the chief etiological factor 
 usually lies in a general neuropathic tendency, which 
 may it is true be aggravated by sexual excesses or 
 masturbation. The following examples are referred 
 to in brief : 
 
 In one instance severe headache appeared during several months 
 of amenorrhoea and ceased on the return of the menstrual flow. In 
 another case persistent occipital pain invariably stopped when the 
 patient had an erection. In still others " habitual " headaches 
 disappeared after marriage, or after the birth of the first child, 
 and so on. 
 
 Differential Diagnosis. — Since headache, as 
 has already been emphasized, is frequently based 
 on the general constitution of the patient, or dis- 
 orders of metabolism, etc., a thorough general 
 examination is always necessary. On the other 
 hand, consideration of the headache per se often 
 shortens the diagnostic analysis, and especially in- 
 vestigation of its functional relations may afford a 
 clue to the proper treatment. 
 
 Topography. — ^Localization of the pain at the back 
 of the head and the nape of the neck radiating down- 
 ward along the spinal column between the shoulder 
 blades, would suggest particularly hypertension 
 headache or renal headache, if there is no disease 
 of the vertebral column itself or rheumatic affection 
 
THE NERVOUS SYSTEM 98 
 
 of the neck muscles. Involvement of the frontal 
 region, on the other hand, would direct attention 
 to functional disorders of the eye or diseases of the 
 nose and nasal sinuses, particularly the frontal 
 sinus. Headache felt at the vertex is nearly always 
 of neuropathic origin. The depth at which the pain 
 is said to be situated is always of importance. Su- 
 perficial headache points to trigeminal neuralgia or 
 rheumatic disease of the galea. Local tenderness 
 about the top of the head should always be looked 
 for. A fairly reliable indication of * ' nervous ' ' head- 
 ache lies in the fact that superficial contacts, as in 
 combing the hair, are very painful, while deeper 
 pressure causes no discomfort. Local tenderness 
 frequently occurs over cortical tumors — possibly 
 through irritation of the periosteum. Palpation also 
 reveals any existing points of tenderness over the 
 foramina of exit of the sensory nerves, especially 
 the trigeminal and the occipital, or the thickenings 
 of the skull or its coverings caused by syphilis or 
 rheumatic affections. A unilateral headache indi- 
 cates idiopathic migraine, if an appropriate history 
 is obtained of hereditary predisposition, onset in 
 youth, and typical accompanying manifestations 
 like vomiting, scintillating scotoma, etc. If hemi- 
 crania begins later in life, a secondary form such as 
 that due to tumor, nephritis, syphilis, etc., is sug- 
 gested. 
 
 I recall the case of a tabetic with a history of lues, diplopia, 
 and lightning pains, and whose pupillary reflexes were lost while 
 the knee-jerks were present, who suffered from left-sided headache 
 
94 PAIN 
 
 recurring regularly every four weeks. The attacks were accom- 
 panied by vomiting and diarrhoea, which latter symptoms at times 
 also occurred by themselves as gastro-intestinal crises. 
 
 Quality and Intensity. — The quality and sever- 
 ity of the pain also deserve analysis. In general 
 the greatest intensity is exhibited by hypertension 
 headache due to tumor and hydrocephalus, the 
 attacks of migraine, and trigeminal neuralgia. The 
 quality of the pain of the first-mentioned type, which 
 is often described as "splitting," harmonizes well 
 with the underlying process, which frequently no 
 doubt involves a maximum of intracranial pressure. 
 The time of onset, too, may give a clue. Headache 
 that never appears at night is probably not of luetic 
 origin. This is a differential point of considerable 
 value, for syphilitics are especially prone to "ner- 
 vous" headache and the time at which the pain 
 manifests itself is of assistance in determining its 
 nature. The reverse is not true, however, for noc- 
 turnal increases in intensity are also observed in 
 non-luetic cerebral processes, such as brain tumor 
 or uraemia. 
 
 Modifying Factoes. — Most suggestive indica- 
 tions are generally afforded by a careful consid- 
 eration of the conditions under which the pain is 
 modified. In the following paragraphs especial 
 attention will be paid to therapeutic considerations. 
 
 A. Psychical. — ^Less severe forms of "nervous" 
 headache are frequently amenable to mental influ- 
 ences, and diversion by such measures as tennis or 
 piano playing may be of service. Of the drugs, 
 
THE NERVOUS SYSTEM 95 
 
 aspirin in very small doses (0.25 to 0.5 Gm.) appears 
 to work best. 
 
 B. Mechanical. — TMs factor comes into play 
 especially when the pain is induced through eleva- 
 tions of intracranial pressure. This occurs not 
 only in brain tumor and hydrocephalus, but also in 
 some instances of "nervous" headache and of that 
 due to other conditions such as anaemia and uraemia. 
 In such cases of what may be termed "plethoric" 
 headache, a dependent position of the head is usually 
 detrimental. The patients therefore feel more com- 
 fortable when sitting than when lying. Epistaxis or 
 the application of leeches is often beneficial, but 
 stooping increases the pain. Firm bandaging of the 
 head is sometimes effective, possibly through a reflex 
 influence on the circulation. The part played by 
 constipation as a mechanical factor has already been 
 discussed on page 81. 
 
 C. Theemic. — Heat often increases the pain, and 
 the patients suffer more in summer. This happens 
 with especial frequency in cases of "plethoric" 
 headache, the patients often belonging to the neuro- 
 pathic class. In these cases cold footbaths of short 
 duration appear to be particularly beneficial, while 
 cold applications to the head are rather apt to in- 
 crease the suffering even in cases in which a feeling 
 of heat is complained of. Of course precisely in this 
 group individual peculiarities are especially to be 
 reckoned with. 
 
 Z>. Chemical. — This category includes the well- 
 known and frequently abused antineuralgic drugs. 
 
96 PAIN 
 
 It is interesting to note that there are also agents 
 which can give rise to definite cerebral pain. To 
 this class belong the nitroglycerin and erythrol- 
 tetranitrate preparations so much used in the treat- 
 ment of angina pectoris. Thyroid gland and iron 
 preparations appear also to have a similar effect. 
 
 E. Dietetic. — In this connection I would refer 
 particularly to the frequently observed effect of even 
 small amounts of alcohol in increasing or causing 
 headache. The "plethoric" forms of headache are 
 especially susceptible to the action of alcohol. Not 
 rarely the administration of black coffee gives relief 
 to the pain. In neurasthenics with rheumatic ten- 
 dencies the consumption of large quantities of meat 
 may bring on a headache. 
 
 In this way the analysis of the pain itself will 
 frequently guide the examiner in one direction or 
 another, even though the diagnosis does not at once 
 follow. The careful and detailed general physical 
 examination is not to be avoided in this way, but may 
 be shortened. Certain tests are always to be recom- 
 mended for the purpose of rapid orientation: 
 
 1. Estimation of the blood-pressure and of any 
 existing vascular changes (nephritis, angiosclerosis, 
 lead poisoning). 
 
 2. Pulse rate (bradycardia in tumors, hydro- 
 cephalus, meningitis). 
 
 3. Examination of the urine for serum albumin 
 and acetone. In intestinal autointoxication the 
 latter appears early, but in meningitis later. 
 
THE NERVOUS SYSTEM 97 
 
 4, Testing the intra-ocular tension in order not 
 to overlook a case of glaucoma. 
 
 5. Ophthalmoscopic examination of the fundus 
 of the eye. 
 
 6, Testing the patellar reflex, which may be 
 absent in cerebellar tumors or meningitis, 
 
 7. Testing the pupils (syphilis and meningitis). 
 
 Among the cranial nerves the facial and hypo- 
 glossal deserve most attention, as slight disorders 
 of either of these do not give rise to complaint and 
 are therefore easily overlooked. 
 
 In taking the history, attention must be paid to 
 such accompanying manifestations as vomiting, 
 which suggests hypertension headache, migraine, or 
 glaucoma, and acute disturbances of vision indicat- 
 ing migraine, glaucoma, or nephritis. The matter 
 of preceding or still existing nasal or aural dis- 
 orders should alsO' be investigated. Lacrimation 
 or secretory disturbances of the nasal mucosa or 
 salivary glands, accompanying the attacks of pain, 
 arouse suspicion of the existence of trigeminal 
 neuralgia. 
 
 NEURALGIAS INVOLVING THE GENERAL 
 NERVOUS SYSTEM. 
 
 Inasmuch as every stimulus requires transmis- 
 sion by the nerve trunks in order to be experienced 
 as a sensation, it at first seems rather paradoxical 
 to speak of "nerve pains" as a distinct variety. 
 Clinically, however, this term connotes the concep- 
 tion that the source of the pain is not to be found 
 
 7 
 
98 PAIN 
 
 in the parenchyma of an organ, from which it is 
 transmitted to the sensorium through the special 
 nerve trunk belonging to the organ, but rather that 
 it acts upon the sensory trunk itself in its peripheral 
 portion. The first task of the diagnostician is to 
 discover, as far as possible, the seat and variety of 
 this cause. If this attempt is not successful the 
 assumption is warranted that there is present a 
 neuralgia in the more restricted sense; that is, a 
 nerve pain concerning whose etiological basis bio- 
 chemical information is not yet available and histo- 
 logical investigations will probably never enlighten 
 us fully. It is therefore necessary to keep in mind 
 that the diagnosis of neuralgia in its restricted sense 
 is a diagnosis by exclusion and that up to a certain 
 point it remains doubtful. Bepeated reinvestigation 
 in regard to the etiology is accordingly extremely 
 desirable. 
 
 The point of attack of the neuralgia-producing 
 factor is probably in most cases to be found in the 
 course of the peripheral neurone. Nevertheless it 
 is desirable to remember that the central conducting 
 tracts, the medulla, pons, optic thalami, and their 
 surroundings, and probably also the cerebral cortex, 
 as well as the posterior portions of the gray matter 
 of the cord, may be the seat of the disease. In these 
 anatomical districts pain may be produced, not only 
 as the result of organic, but also from functional 
 disturbances. The neuralgias arising in hysteria, 
 cerebral tumors, tabes, syringomyelia, myelitis, etc., 
 are probably to some extent to be interpreted as 
 
THE NERVOUS SYSTEM 99 
 
 having a central origin of this nature. Much more 
 varied are the general and special factors that give 
 rise to neuralgias in the peripheral nervous system. 
 As it seems advisable to pass these in review in 
 every doubtful case, I wish to make at least the 
 attempt to arrange them in classified form. 
 
 A. DiBECT Factobs. 
 
 1. Mechanical. — These are principally pressure 
 effects through new growths, particularly glandular 
 swellings, aneurysms, inflammatory processes with 
 exudation in the neighborhood of nerves, hernias, 
 etc. 
 
 2. Thermic. — This group includes the complex 
 of stimuli comprised under chilling, draughts, etc., 
 the mode of action of which is difficult to analyze. 
 The imderlying cause frequently lies much deeper 
 and the thermic stimuli have only an exciting effect. 
 
 3. Chemical Factors with Secondary Disorders 
 of Nutrition. — Their point of attack is certainly 
 often indirect, involvLug the vascular system. Scle- 
 rotic and spastic conditions in the domain of 
 the vasa nervorum must not be forgotten in this 
 connection. 
 
 (a) Non-infectious exogenous toxins: Proto- 
 plasmic poisons of the most varied nature would be 
 included here, such as arsenic, lead, alcohol, nico- 
 tine, mercury, etc. 
 
 (b) Toxins infectious in nature: Syphilis, ma- 
 laria, influenza, tuberculosis, gonorrhoea, etc. 
 
100 PAIN 
 
 (c) Dyscrasic endogenous toxins: Gont, carci- 
 noma, diabetes, nephritis, anaemia, adiposis dolorosa 
 of Derciun. 
 
 Here may best be included also those local dis- 
 turbances of metabolism that underlie the so-called 
 occupation neuralgias which result from the exces- 
 sive use of certain nerve tracts. Furthermore the 
 attacks of pain involving the distal portions of the 
 extremities and accompanied by vasomotor disturb- 
 ances, such as erythromelalgia, Eaynaud's disease, 
 etc. 
 
 B. Eeflex Factobs. 
 
 The stagnation of fecal masses, intestinal para- 
 sites, various visceral disorders involving the heart, 
 gall-bladder, genital apparatus, kidney, etc., may be 
 concerned in the causation of neuralgias, and it is 
 natural to assume a reflex element under these con- 
 ditions. On the other hand, neuralgias in certain 
 nerve tracts may incite neuralgias elsewhere as 
 through the ■ sympathetic vibrations of musical 
 strings. 
 
 How IS A Neuealgia to be Eeoognized ? — As re- 
 gards the diagnosis of neuralgias as such, the recog- 
 nition of the fact that a pain corresponds topo- 
 graphically to a peripheral sensory nerve tract, and 
 like this exhibits a linear rather than a diffuse dis- 
 tribution, is frequently sufficient to establish the 
 nature of the case. Naturally it is not enough to 
 determine only the spatial limits of the spontaneous 
 pain, but the presence of painful pressure points 
 should also be sought for, This is the more impor- 
 
THE NERVOUS SYSTEM 101 
 
 tant since in this way latent neuralgic conditions 
 not manifesting themselves spontaneonsly may be 
 detected. For example, in angina pectoris I have 
 seen tenderness of the left brachial plexus even be- 
 tween the attacks. The pressure points usually corre^ 
 spend to those portions of the nerves which are sub- 
 ject to trauma through their superficial position, a 
 firm or bony substructure, etc., but as these are not 
 constant there is little wisdom in overloading the 
 memory with ballast of this nature and anatomical 
 knowledge is the best guide. In addition to the me- 
 chanical factor of pressure, traction may be used 
 for evoking the pain experimentally. This is true 
 for the trigeminal nerve (movement of the lower 
 jaw), the occipitalis major (rotation of the head), 
 and the sciatic nerve (flexion at the hip joint with ex- 
 tended knee) . The susceptibility to influence in this 
 way may also, however, lead to confusion with 
 muscle, joint, or bone pains, and caution is necessary 
 ia interpreting the results. The anatomical unity 
 of the pain may be entirely upset through the in- 
 volvement of bone, periosteum, muscle, and joint 
 nerves in the neuralgic process, and these possibili- 
 ties must always be reckoned with. Paroxysmal 
 onset (frequently at night) is a common characteris- 
 tic of neuralgic pains. At any rate, the mere fact 
 of nocturnal occurrence does not justify the con- 
 clusion that syphilis is the underlying factor, 
 although in general the absence of nightly exacerba- 
 tions may be used with some probability as being 
 against syphilis. The periodical onset of the pain 
 
102 PAIN 
 
 and its relief hj quinine may find its explanation in 
 the malarial nature of the neuralgia, but this is not 
 necessarily so. 
 
 Site of the Lesion, whetheb Centeal oe 
 PeeipheeaIi. — After a painful condition has been 
 identified as a neuralgia, it is always necessary to 
 determine the site of the lesion. The possibility of 
 cerebrospinal localization (brain tumor, tabes, 
 syringomyelia, syphilitic spinal meningitis, etc.) 
 must always be thought of, and the reflexes and 
 possible disorders of motility, like flaccid or spastic 
 paralysis, ataxia, vesical or rectal disturbances, 
 should be considered. After determining the 
 peripheral character of the neuralgia the question 
 of etiology arises, and in regard to this reference 
 may be made to the classification given above. It 
 is of the greatest practical importance not to over- 
 look a beginning new growth, to think of the possi- 
 bility of cardiac or aortic lesions, and to guard 
 against failure to recognize some dyscrasic factor 
 by careful examination of the urine. The possi- 
 bility of reflex origin must also always be given due 
 weight. 
 
 The Face. 
 
 In order to determine the causative factor in 
 cases of trigeminal neuralgia, the course of the 
 nerve from the Gasserian ganglion onward should 
 always be kept in mind, so that such conditions as 
 tumors of the nerve itself, aneurysms of the internal 
 carotid, destructive processes of the meninges and 
 at the base of the skull, like tuberculosis, syphilis, 
 
THE NERVOUS SYSTEM 103 
 
 carcinoma, actinomycosis, etc., may not be over- 
 looked. The distribution of the nerve must also 
 be considered and the processes in the eye, teeth, 
 alveolar cavities, nose, ear, etc., that may come in 
 question. In infectious processes the discovery of 
 pronounced tenderness at the point of emergence 
 of the supra-orbital nerve suggests influeiiza, typhoid 
 fever, or malaria. Under these conditions, however, 
 as well as in meningitis, it should not be forgotten 
 that the pain on pressure may be only a part of the 
 general hypersesthesia. Of the reflex etiological 
 factors, reference may be made particularly to the 
 stagnation of fecal masses and disorders of the 
 female genital system. There is no doubt that at 
 times, as in cases of headache, a laxative is the best 
 antineuralgic remedy and dietetic treatment may 
 also be of service. 
 
 I remember the case of an older patient with arteriosderoais 
 and high blood-pressure, who stated that for eight years he had 
 pain almost every other day about the left supraorbital nerve. All 
 sorts of antineuralgic remedies were resorted to, but the only thing 
 that proved effective was black coffee. Caffeine did not give relief. 
 
 Similar conditions also obtain, both in trigeminal 
 neuralgia and in headache, in regard to the general 
 pathological conditions, as is not surprising when 
 one considers that the dura mater is supplied in part 
 by the trigeminal nerve. Accordingly, trigeminal 
 neuralgias, like headaches, are susceptible to mental 
 influences and are not rarely greatly aggravated 
 by excitement. The underlying conditions that give 
 rise to the symptom complex of angina pectoris 
 must also be counted among the reflex visceral 
 
104» PAIN 
 
 factors. It is true, however, that isolated trigeminal 
 neuralgia is unusual under these circumstances, 
 although unilateral radiation in the districts of the 
 third and second branches, with paiu in the teeth, 
 is not of exceptional rarity. It seems that there is 
 great likelihood of the radiation occurring through 
 the vascular channels, perhaps owing to spasmodic 
 conditions due to the sclerosis. 
 
 The Occipitai, Region and Nape or the Neck. 
 
 Of the sensory tracts supplying this region there 
 may be mentioned, toward the midline the occipitalis 
 major, more laterally the occipitalis minor, and still 
 further outward supplying the posterior surface of 
 the ear, the auricularis magnus. Occipital neural- 
 gias may frequently be explained on the basis of 
 the general causes summarized on page 99. The 
 abuse of tobacco is especially significant. Of the 
 organic lesions diseases of the vertebral column and 
 of the meninges of the cervical portion of the cord 
 have a particular etiological bearing. Since the 
 second cervical nerve — ^whose posterior branches, as 
 the occipitalis major nerve, supply sensory filaments 
 to the skin of the occipital region — passes between 
 the atlas and axis, the occurrence of mechanical 
 injuries in this region may be readily understood 
 through the great mobility of the parts. At the 
 same time, the fact is explained that neuralgia of 
 this region may restrict the movements of the head, 
 although the muscles and joints themselves are not 
 involved. Neuralgias in this situation are probably 
 also caused mechanically in cases of elevation of the 
 
THE NERVOUS SYSTEM 106 
 
 intracranial pressure, especially when due to proc- 
 esses encroaching on the posterior cerebral fossa, 
 as in hydrocephalus following serous meningitis 
 (Quincke) or due to chlorosis or tumors of the pos- 
 terior fossa. 
 
 Of the Adsceral diseases chronic nephritis seems 
 to me to be particularly prone to give rise to 
 occipital neuralgia, perhaps through intracranial 
 elevations of pressure. In addition, glandular proc- 
 esses (lymphosarcoma) and more rarely aneurys- 
 mal dilatations of the vertebral artery may come 
 in question. 
 
 The Aem. 
 
 The neuralgias occurring in the brachial plexus 
 and involving especially the ulnar and radial dis- 
 tricts, may be caused either through direct or reflex 
 factors. 
 
 1. Direct Causation. — In addition to spinal dis- 
 orders like tabes, syringomyelia, etc., one should 
 think of vertebral disease, supraclavicular or axil- 
 lary compression by glands, aneurysmal dilatations 
 of the subclavian or innominate arteries, and the 
 presence of cervical ribs. The brachial plexus may 
 also be directly involved in cases of inflammatory 
 processes or malignant growths of the apical pleura, 
 and in this way spontaneous brachial neuralgia — 
 or at least tenderness of the plexus — ^may result. 
 I have formerly directed attention to this symptom 
 of "unilateral plexus tenderness" in incipient 
 phthisis, and have frequently made use of it to 
 
106 PAIN 
 
 good advantage. Abnormal exhaustion of the nerve 
 tracts through local overexertion, as in piano play- 
 ing, and the general causes of neuralgia (page 99) 
 must also be kept in mind. 
 
 2. Reflex Causation. — The neuralgic conditions 
 of the brachial plexus, whether spontaneously pain- 
 ful or existing only as a latent neuralgia manifest- 
 ing itself by tenderness on pressure, may overstep 
 the purely neurological limits since they not rarely 
 are accompanying evidences of visceral lesions. 
 Sometimes, though less often, they present a certain 
 degree of independence, or may be accompanied by 
 mild motor manifestations of a paretic or spasmodic 
 nature. 
 
 The occurrence of neuralgic sensations in the province of the 
 left ulnar nerves is always noteworthy, especially when appearing 
 in conjunction with exertion as in stair climbing or running. A 
 premonition of angina pectoris is suggested. 
 
 A neuropathic constitution undoubtedly affords 
 a favorable soil for radiations of this sort. The 
 thoracic viscera, particularly the heart, pericar- 
 dium, and large vessels, as well as the diaphragm 
 and the abdominal organs coming in contact with it, 
 are likely to be concerned in this way. The side of 
 the organic lesion then usually corresponds to the 
 side of the plexus neuralgia. There is no doubt that 
 the phrenic nerve is the reflex tract in many such 
 cases, and therefore tenderness over the third and 
 fourth spinous processes should always be looked 
 for. 
 
 Particular emphasis may be laid on the fact that 
 sometimes spontaneous pain may be absent while 
 
THE NERVOUS SYSTEM 107 
 
 the pressure tenderness is constant, as in angina 
 pectoris or perisplenitis. In discussing the separate 
 organic pains, these reflex arm and shoulder neural- 
 gias will be explained in detail, and in order to 
 avoid repetition reference is made to the sections 
 in question. 
 
 iNTEECOSTAIi SpACES, INCLUDING THE IJPPEB AbDOMEN, 
 
 The intercostal nerves, whose lower branches 
 send sensory fibres also to the upper portion of the 
 abdominal wall, very frequently cause spontaneous 
 pain, but still more often occasion tenderness to 
 pressure. In addition to localized central processes 
 like spondylitis, tabes, syringomyelia, etc., it is espe- 
 cially internal diseases that are accompanied by 
 either tenderness or spontaneous pain in the regions 
 supplied by the intercostal nerves. 
 
 Diseases of the lung, and particularly of its 
 pleural covering, deserve first place in this connec- 
 tion. In nearly all cases of pneumonia and pleurisy 
 the intercostal spaces are sensitive to pressure, nota- 
 bly in the axillary region, although it must remain 
 an open question whether the tenderness does not 
 depend on direct mechanical trauma to the inflamed 
 pleura and whether there may not also coexist an 
 inflammatory condition of the intercostal muscula- 
 ture transmitted through the lymphatics. It is sug- 
 gestive that the tenderness in cases of pulmonary 
 infarct and tuberculosis frequently corresponds ex- 
 actly to the site of the infarct or infiltration, and 
 shows no relation to the usual pressure points of 
 
108 PAIN 
 
 intercostal neuralgia. Suppurative pleural exu- 
 dates are likely to be accompanied by special 
 tenderness, while pleural processes accompanied 
 by contraction only rarely give rise to severe 
 neuralgias. 
 
 Diseases of tbe circulatory apparatus, such as 
 mitral stenosis, are frequent causes of intercostal 
 neuralgia. Usually the pain is located on the left 
 side in the neighborhood of the apex beat. In acute 
 pericarditis and acute endocarditis similar neu- 
 ralgic sensations may be experienced. In the course 
 of acute articular rheumatism due consideration 
 should always be given to such manifestations in 
 the cardiac region. Acute angina pectoris may 
 begin as a left-sided intercostal neuralgia. Athe- 
 roma of the intercostal arteries with constriction 
 at their origins may give rise to intercostal neu- 
 ralgia. The mode of origin of intercostal neuralgia 
 in dilatation of the aorta and mediastinal new 
 growths demands no explanation ; no doubt in addi- 
 tion to direct trauma reflex stimuli also come into 
 question just as for the brachial plexus, especially 
 for the upper intercostal spaces. The aneurysmal 
 neuralgias of direct causation are not rarely char- 
 acterized by dependence on exercise and position, 
 owing to stronger pulsation of or dislocation of the 
 sac. Diseases of the subdiaphragmatic organs like 
 cholelithiasis, perihepatitis, pyloric ulcer, and peri- 
 splenitis are also prone to cause tenderness of the 
 axillary portions of the lower intercostal spaces on 
 the corresponding side. If the liver or spleen is in- 
 
THE NERVOUS SYSTEM 109 
 
 volved the area of tenderness often coincides with 
 the dulness, and this may be of diagnostic impor- 
 tance. Here, no doubt, reflex stimuli are concerned 
 similar to those cansiag the hyperaesthesia of cer- 
 tain spinous processes that is frequently also 
 present. In pyloric ulcer and cholelithiasis this 
 tenderness to pressure and percussion often occurs 
 over the twelfth thoracic vertebra. In cases of sud- 
 den intense intercostal neuralgia the imminent 
 onset of herpes zoster should be thought of. The 
 intercostal neuralgia frequently accompanying 
 kyphoscoliosis also deserves mention. This may 
 lead to the erroneous diagnosis of pleurisy, for at 
 the site of the pain atelectatic crackles suggesting 
 friction sounds are often heard. 
 
 The Flanks and Lowbb Abdominal Eegion. 
 
 Leaving aside the neuralgias of spinal origin 
 which have already been spoken of several times, 
 idiopathic conditions of this sort are rare in the 
 present regions. Of the intra-abdominal causes, 
 retroperitoneal processes such as glandular masses, 
 aneurysm of the abdominal aorta, and renal diseases 
 at once suggest themselves. The renal causes in- 
 clude tumors pressing on the nerve trunks passing 
 over the posterior surface of the organ, inflamma- 
 tory and suppurative processes, or perinephritic 
 cicatrization following infarct, etc. 
 
 Another etiological factor is formed by hernias 
 which may induce neuralgia through pressure along 
 the hernial canal. 
 
110 PAIN 
 
 Lower Extremities. 
 
 Eeflex neuralgias due to disease of the internal 
 organs like the kidney, appendix, and female geni- 
 tals not rarely occur in the thigh. These forms are 
 less common, however, than those due to disorders 
 of metabolism like gout or adiposity and based on 
 the neuropathic constitution. Such neuralgias, like 
 various forms of rheumatic pain, are prone to be 
 at their worst in the early morning, and may be 
 aggravated by walking so that the erroneous diag- 
 nosis of intermittent claudication due to vascular 
 disease may suggest itself. 
 
 1. Anteriorly and Internally {Crural Nerve). — 
 Pain of the same linear distribution as that of neu- 
 ralgia may sometimes be caused by phlebitic proc- 
 esses in the internal saphenous vein. It may also 
 be the result of femoral hernia and may stand in 
 relation to diseases of the kidney such as nephro- 
 lithiasis, and of the appendix or the female genitals. 
 
 One patient complained that following a miscarriage she fre- 
 quently suffered from pain extending down the front of the thigh 
 to the knee, more in the right side than on the left. As a girl 
 similar pain had appeared a few days before each menstruation. In 
 addition there were migraine and brick-dust sediment in the urine. 
 Here the genital system formed the starting point of the neuralgic 
 condition which was predisposed to by the neuropathic constitution. 
 
 The possibility of renal origin must b© consid- 
 ered when there is at the same time tenderness of 
 the flank on the same side. 
 
 A patient had pain in the left side extending downward along 
 the front of the left thigh. After similar sensations had been felt 
 
THE NERVOUS SYSTEM 111 
 
 for a short time on the right side a white, friable concretion was 
 
 Beyond this, reference may be made to the gen- 
 eral nnderlying causes of neuralgic pain {v. classi- 
 fication on page 99). 
 
 2. Externally. — The neuralgias occurring in the 
 district of the external cutaneous nerve, and there- 
 fore involving the external and posterior surface 
 of the thigh from the iliac crest to the knee, are not 
 usually founded on causative factors specific for the 
 locality. The etiological possibilities coincide with 
 those of neuralgia in general, and therefore include 
 trauma, gout, syphilis, tabes, pernicious anaemia, etc. 
 As the nerve traverses a fibrous canal in the fascia 
 lata of the thigh, it is not astonishing that tension of 
 this structure, such as is caused on standing or 
 walking, easily produces exacerbations of the pain, 
 whereas rest brings relief. 
 
 3. Internally. — Neuralgias involving the region 
 of the adductors of the thigh always suggest the 
 presence of a possibly incarcerated obturator hernia, 
 especially if the thigh cannot be approached to the 
 midline. 
 
 4. Posteriorly. {The sciatic plexus.) — The pain 
 that is principally concerned under this heading is 
 linear in distribution and often extends down the 
 entire posterior side of the lower extremity. Even 
 the laity usually interpret this correctly as a "nerve 
 pain." If there is in addition tenderness over the 
 course of the nerve and pain on stretching it by 
 forcible flexion at the hip with extended knee, there 
 
112 PAIN 
 
 is little room for doubt. Diseases of the hip joitit 
 differ in that flexion of the hip is painful even when 
 the knee is kept flexed. It is the duty of the 
 physician not to rest content with the diagnosis of 
 sciatica, which may already have been made by the 
 patient, but to investigate the particular source of 
 the trouble, and here as in neuralgias in general I 
 think that I may formulate the rule: If nothing is 
 found, search further. The scheme of causes given 
 above may serve to aid in the general task of orien- 
 tation. Examination of the rectum and vagina 
 should never be omitted in order that any possible 
 pelvic lesions, such as new growths of the intestine 
 or pelvic bones or tuberculous disease of the pelvis, 
 may be detected, and the patient's general condition 
 (emaciation, etc.) should be carefully considered. 
 
 The degree of fulness of the rectum should also 
 be taken into account; there is no doubt that a 
 connection exists between fecal stagnation and pain 
 in the sciatic plexus, though it is difficult to ex- 
 press an opinion in regard to the details of the 
 relationship. Usually the condition is merely a pre- 
 disposing and not a causative factor. Before decid- 
 ing to accept the assumption of a purely mechanical 
 direct action of fecal masses on the nerve plexus, it 
 is advisable to think of the association that may 
 exist between headache or trigeminal neuralgia and 
 constipation, and of the fact that fecal accumula- 
 tions probably also serve to increase pain through 
 the interference with venous return (vasa ner- 
 vorum) . The possible existence of external or inter- 
 
THE NERVOUS SYSTEM 113 
 
 nal varicosities (involving the nerve sheath) with" 
 phlebitic or thrombotic processes must always be 
 thought of. In respect to the venous circulation the 
 conditions are much more unfavorable in the lower 
 extremities than in the upper. Bilateral pain always 
 suggests median lesions involving the vertebral 
 column or spinal cord, or diffuse dyscrasic disorders 
 like diabetes. Pain of maximum intensity that is 
 refractory to all treatment sometimes is encountered 
 in tumors of the cauda equina. A careful examina- 
 tion of the nervous system, with special attention 
 to the tendon reflexes of the lower extremities, 
 bladder disturbances, atrophies, etc., should never 
 be omitted. 
 
 NEURALGIAS INVOLVING THE SYMPATHETIC 
 SYSTEM AND THE VAGUS. 
 
 A priori the assumption suggests itself that the 
 neuralgic manifestations just described for the 
 cerebrospinal system may also, in the presence of 
 the corresponding etiological factors, occur in the 
 separate portions of the sympathetic system and tlie 
 viscera supplied by it. This view is fully confirmed 
 by the clinical observations. The task of correctly 
 interpreting visceral neuralgias of this sort is, of 
 course, much more difficult. In this case one is deal- 
 ing not with the anatomically distinct, simply con- 
 structed, and directly accessible nerve tracts of the 
 cerebrospinal nervous system, but with plexuses and 
 groups of ganglia for the most part inaccessible to 
 physical examination. The problem is further com- 
 8 
 
11* PAIN 
 
 plicated by the fact tliat the separate networks have 
 as end stations organs like the stomach, intestine, 
 ureter, genitals, etc., in which painful lesions may 
 originate primarily. Theoretically three possibili- 
 ties may be considered and in practice these are 
 shown to be well founded. 
 
 (a) Simple Neuralgia. — The pain-producing 
 process is a neuralgic condition in one of the im- 
 portant tracts of the vegetative nervous system, and 
 the corresponding organ is anatomically intact. 
 Gastric crises may be regarded as an example of 
 this sort and a counterpart in the province of the 
 cerebrospinal system would be neuralgia of the sec- 
 ond and third branches of the trigeminal nerve 
 without any disease of the teeth. 
 
 (b) Simple Organic Pain. — The pain has exactly 
 the same character in regard to localization, quality, 
 accompanying manifestations, etc., but is the result 
 of an anatomical or functional disorder of the organ 
 itself. As a paradigm reference may be made to 
 the paiu of gastric ulcer or to that of a carious tooth. 
 Eecently an attempt has been made to argue away 
 the existence of stomach pains as such and to regard 
 the cause of every gastric pain as being a sympa- 
 thetic neuralgia. This is entirely inadmissible and 
 in opposition to the facts of clinical observation. 
 One has only to think of the stomach-ache that is 
 promptly checked by a dose of alkali or by the 
 admiaistration of local anaesthetics such as anses- 
 thesin or cocaine. The same thing is true of pyloric 
 stenosis, and the explanation offered by the advo- 
 
THE NERVOUS SYSTEM 115 
 
 cates of the theory just mentioned to the effect that 
 the sympathetic nerves are compressed by the dis- 
 tended stomach is extremely improbable. The exist- 
 ence of true gastralgia, resulting from purely local 
 anatomical and functional disturbances, is as certain 
 as the occurrence of pain in dental caries. 
 
 (c) Mixed Forms. — I believe that a combined 
 form of visceral pain is not at all rare in which both 
 the sensory-conducting tract and the organ in ques- 
 tion play a distinct role in the causation of the pain ; 
 as an example, trigeminal neuralgia and painful 
 dental caries may be mentioned. Such a combined 
 origin of pain in the sympathetic and vagus districts 
 is probably commoner than is ordinarily supposed, 
 particularly in neuropathic individuals. It is con- 
 ceivable that the anatomically or functionally active 
 organic process might arise only secondarily as the 
 result of atrophic disturbance due to a primary 
 neuralgic condition, but the reverse is also probable, 
 as well as coincident causation. When such mixed 
 forms of visceral neuralgia are in question, it is 
 clear that, to continue the example chosen above, 
 the extraction of the decaying tooth may bring relief 
 commensurate with its component of painful sen- 
 sation, but the pain will continue as long as the 
 neuralgic condition of the trigeminus does not im- 
 prove. In the same way, in other cases of mixed 
 form, the same attacks of pain may recur after the 
 removal of gall-stones or the treatment of a pyloric 
 stenosis by gastro-enterostomy. Through exact 
 analysis of the conditions, as well as the study of 
 
116 PAIN 
 
 the psychical make-up of the patient, it is possible 
 from case to case to interpret these mixed forms 
 correctly and to determine approximately the rela- 
 tive proportions of the two components. Sometimes 
 a mighty organic kernel is surrounded by only a thin 
 functional shell, but more often the reverse is true. 
 Cases of the latter sort never belong in the province 
 of the surgeon. The prognostic and therapeutic 
 importance of careful analysis of the possibilities 
 in such cases is self-evident. 
 
 Etiology. — ^As far as the etiological sources of 
 the visceral neuralgias are concerned it may be said 
 that there is a far-going, deep-seated correspondence 
 between the cerebrospinal and sympathetic nervous 
 systems. In this connection reference may be made 
 to the scheme of causes given above as well as to the 
 section on gastralgia. 
 
 How MAT A ViSCEBAL NeUBALGIA BE EeCOGNIZED? 
 
 The diagnosis of a visceral neuralgia is probably 
 one of the most difficult of differential problems and 
 can never be made with absolute certainty, as it is 
 nearly always a diagnosis by exclusion. For ex- 
 ample, what is known concerning the positive symp- 
 toms of a neuralgia of the ooeliac plexus is so inade- 
 quate and so vague that a conscientious clinician 
 would never venture to make this diagnosis directly. 
 The cause of pain induced by deep pressure over the 
 abdomen is difficult to determine. Whoever is 
 anxious to discover tenderness to pressure of the 
 sympathetic fibres or of the solar plexus will usually 
 succeed in doing so ! If the psychical equilibrium is 
 
THE NERVOUS SYSTEM 117 
 
 intact, there is no neuropathic tendency, and etiologi- 
 cal factors of the variety in question are absent, one 
 should be very reluctant to think of a visceral neural- 
 gia. But in this neurasthenic age cases that comply 
 with these requirements are very rare, while on the 
 other hand, even serious nervous disturbances do not 
 exclude the possibility of an organic lesion as the 
 basis of the pain, the more so as they may be second- 
 ary. The important general rule of unity of etiology 
 in disease is open to many exceptions in. this prov- 
 ince, and painful states due to a combination of 
 functional and anatomical components are certainly 
 very numerous. 
 
 ToPOGEAPHY. — The topography of the pain usu- 
 ally has no differential significance. The distri- 
 bution of the pain in a neuralgia of the ureter de- 
 pending on chronic lead poisoning is the same as that 
 caused by the passage of a concretion, and hysteri- 
 cal angina pectoris radiates in the same way as the 
 true organic type. Essential gastralgias, it is true, 
 are rarely asymmetrical in their localization, in con- 
 trast to the pain of ulcer and pyloric stenosis, and 
 this is particularly true of the tenderness to pres- 
 sure. The latter symptom, to be sure, is often absent 
 in cases of essential gastralgia. Gastric crises, 
 however, with their tendency to a left-sided localiza- 
 tion, at least so far as the spontaneous pain is con- 
 cerned, form an exception to the rule. 
 
 Modifying Factobs. — A careful study of these is 
 always of great importance. Whenever reflex in- 
 volvement is evident, as, for example, in cases of 
 gastric pain at the time of menstruation, it is per- 
 
118 PAIN 
 
 missible to think of a simple visceral neuralgia, but 
 it should not be forgotten that the pain of ulcer or 
 biliary and appendicular colic may be induced 
 through the profoundly disturbing process of men- 
 struation. In general, it may be regarded as posi- 
 tive evidence of the existence of a pronounced func- 
 tional component if a sedative regime comprising 
 general hygiene and psychical rest, the diversion of 
 the attention, and administration of quieting drugs 
 like the bromides or valerian, has a notable and per- 
 sistent effect on the intensity and frequency of the 
 pain. On the other hand, it is fair to assume a 
 prominent local component when purely topical 
 treatment like the administration of alkali in gastric 
 pain is promptly effective. Serious consideration 
 must be accorded to mechanical factors and their 
 effect. If a given position of the body always causes 
 prompt increase in the pain, it is natural to think 
 of a localized anatomical lesion of the organ in 
 question (c/. p. 24). The most exhaustive physical 
 and functional examination of the organ that appar- 
 ently is involved and the consideration of its secre- 
 tions or excretions is of course of the greatest 
 importance in reaching a decision. 
 
CHAPTER VI. 
 
 Organs of Motion. 
 
 I. JOINT PAINS OR ARTHRALGIAS. 
 
 TopoGEAPHT. — ^In view of the clearness of the 
 topograpMcal relations and the ease of accurate 
 functional examination, it is ordinarily not difficult 
 to identify an arthralgia as such. Only when the 
 joints concerned are difficult of access, like those of 
 the vertebral column or of the sacro-iliac synchon- 
 drosis, or are abnormal (manubrium-corpus), are 
 difficulties to be expected. Sometimes, however, the 
 topographical considerations themselves may lead 
 astray, as an illustration of which may be cited the 
 pain in the knee that so often precedes coxitis in 
 young persons. On the other hand, it is always our 
 duty not to remain satisfied with the general diag- 
 nosis of arthralgia but to determine which anatomi- 
 cal component of the articulation is the seat of the 
 pain. Accordingly, the articular extremities of the 
 bones, the fibrous capsule, the neighboring tendons 
 and tendon sheaths, and adjoining muscles must all 
 be tested as regards painfulness. The examination 
 must include all structures standing in anatomical 
 relationship to the joint capsule, such, for example, 
 as burssB, nerve trunks, vessels, or fibromas in the 
 subcutaneous tissues. It is also necessary to distin- 
 guish between deep-seated and superficial pain. 
 Functional arthralgias of the sort that sometimes 
 
 119 
 
120 PAIN 
 
 occur in neuropathic individuals are not rarely ac- 
 companied by marked cutaneous hyperaesthesia with- 
 out deep-seated tenderness, so that La functional 
 coxalgia forcible pressure of the head of the femur 
 against the acetabulum is easily borne, although 
 even gentle touching of the skin gives rise to pain. 
 
 In general it may be said that arthralgias do not 
 radiate. The necessary conducting tracts are want- 
 ing, a condition in contrast to the joint pains of 
 neuralgic origin, such as the shoulder pain of angina 
 pectoris. An exception to this rule is formed by 
 coxalgia; in this the pain may radiate down the 
 thigh toward the knee. The same thing is true for 
 the ankle joint in flat foot. In other articular 
 conditions radiation is generally to be expected only 
 in cases of neuritic or spinal complications, such as 
 tabes or syringomyelia, or if the pain is purely 
 functional in nature. 
 
 Intensity. — ^Assuming a normal nervous system, 
 the severity of the pain seems to depend on the 
 degree of acuteness in onset as well as the intensity 
 of the inflammatory process, and therefore many 
 cases of acute polyarthritis, gonorrhoeal joint affec- 
 tions, and gout are highly painful. When the ner- 
 vous system is in a state of hypersensitiveness 
 (hysteria) a disproportion may be observed between 
 the objective conditions and the subjective sensa- 
 tions, but this by itself may not be sufficient to ex- 
 clude the organic nature of the affection. Where, 
 however, the pain-conducting tract is damaged, as in 
 tabes and syringomyelia, one must be prepared to en- 
 
ORGANS OF MOTION 121 
 
 coTinter very slight degrees of pain or even the total 
 absence of tMs symptom in spite of anatomical 
 changes of considerable extent, and this discrepancy 
 may direct the attention into the proper channel. 
 
 Eelations in Regabd to Time. — The relation of 
 joint pains to time can be made use of only with 
 great caution in differential diagnosis. The occur- 
 rence of nocturnal exacerbations is frequently 
 pointed out in cases depending on syphilis in the 
 secondary or tertiary stages. The absence of noc- 
 turnal increase may in general render syphilis less 
 likely, but its presence is far from rare in non- 
 syphilitic conditions also, and may occur often 
 enough in cases of ordinary acute polyarthritis and 
 especially in gouty arthralgias. Only the functional 
 arthralgias of neuropathic nature seem never to be 
 accompanied by nocturnal increase in pain. The 
 occurrence of arthralgias during pregnancy or in the 
 puerperium always suggests gonorrhoea (lighting up 
 of old foci) or sepsis. 
 
 Modifying Factoes. — Among the most important 
 characteristics of a joint pain is its susceptibility 
 to mechanical influences. These may vary in nature, 
 and the two most important are (1) pressure in the 
 neighborhood of the joint (effect on the bone ends, 
 capsule, etc.) ; (2) active and passive motion. 
 
 1. In examining joints, particularly when the 
 larger ones are involved, one should never omit to 
 investigate the possibility of a bone process, such 
 as tuberculosis, syphilis, or osteomyelitis, as the 
 underlying cause of the joint affection, and for this 
 
123 PAIN 
 
 purpose the articular extremities of the bones should 
 be carefully palpated and be pressed against each 
 other. No less care should be used in examining 
 the fibrous capsule and tendon sheath. 
 
 2. The production of pain through active and 
 passive motion is of course one of the chief evidences 
 of an arthralgia. It should be remembered, how- 
 ever, that motion of a joint may also give rise to pain 
 through traction on inflamed muscles, nerve trunks, 
 or vessels {e.g., the shoulder pain in aortalgia) with- 
 out there being any lesion of the articulation itself. 
 If, however, even slow motion of very slight extent 
 causes pain the diagnosis of arthralgia receives 
 greater justification. These are cases in which im- 
 mobilization of the joint is the best analgesic, but in 
 functional arthralgias fixation is very badly borne. 
 This fact may be of differential diagnostic value as 
 well as the noteworthy difference between superficial 
 and deep tenderness. The mechanical factor of 
 trauma may be the inciting agent of both functional 
 and organic arthralgias. 
 
 Theeapbxjtic Influences. — The mechanical fac- 
 tors are supplemented in their action by chemical 
 agents. This is especially the case from the thera- 
 peutic standpoint, but may also be made use of in 
 differential diagnosis. Only in exceptional cases are 
 gonorrhoeal joint affections and the arthralgias of 
 rheumatoid arthritis and gout favorably influenced 
 by the salicylates. Mercury and iodine again 
 are particularly effective in cases of syphilitic 
 arthralgias. 
 
ORGANS OP MOTION 123 
 
 Accompanying Manifestations. — Not rarely the 
 pain may be practically tlie only manifestation of 
 tlie joint affection, and this is not exclusively the 
 case in functional arthralgias, but may occur in 
 organic lesions, ^he harmful agents attacking the 
 joints may also invade the muscular and nervous 
 systems (neuritis), and such complications must be 
 thought of in testing for tenderness on pressure. 
 Possible involvement of the bones, as in syphilitic 
 periostitis, the growth of osteophytes, erosion of the 
 articular surfaces, etc., must be thought of. Where 
 fever is an accompanying symptom the bacteriologi- 
 cal cause of this should be determined if possible and 
 efforts be made to discover the primary focus of in- 
 fection. This may be sought for in the tonsils, acces- 
 sory nasal cavities, the middle ear, the urethra, pros- 
 tate, parametrium, etc. Particular attention should 
 of course also be given to cardiac changes. 
 
 Etiology. — In the foregoing the recognition of 
 an arthralgia as such has been discussed, and from 
 a consideration of the facts elicited in this way much 
 light will often be thrown on the etiology of the 
 process. In analyzing the underlying condition the 
 following classification may be found of service : 
 
 1. Arthralgias of infectious origin: a, acute; b, 
 chronic. 
 
 2. Arthralgias due to disorders of nutrition or 
 metabolism : a, local, e.g., pain about the knee with 
 effusion into the joint in popliteal aneurysm; b, gen- 
 eral, caused by gout, syphilis, etc. 
 
 3. Arthralgias of neurogenous nature. 
 
124 PAIN 
 
 1. The streptococci require special consideration 
 under this head as the inciters of the ordinary acute 
 polyarthritis, or of sepsis. Other organisms of 
 importance are gonococei and the pus-producing 
 cocci in general (staphylococci, diplococci, and men- 
 ingococci), and of less frequent occurrence — ex- 
 cepting the tubercle bacillus — bacilli such as those 
 of typhoid fever, dysentery, leprosy, and influenza. 
 Diseases like scarlatina, variola, parotitis, and 
 syphilis are also to be thought of in this connection. 
 
 2. Under this heading are grouped the arthri- 
 tides of the uratic diathesis and its variants, the 
 arthritis of lead poisoning, and the joint processes 
 sometimes accompanying psoriasis, as well as many 
 cases of chronic polyarthritis, although in these the 
 possibility of an infectious etiology must always be 
 kept in mind. The cases of intermittent hydrops of 
 the knee and the joint conditions of haemophilia may 
 also be included in this class. The position of 
 arthritis deformans is not yet clear. 
 
 3. The arthralgias of neurogenic nature, such as 
 those of tabes and syringomyelia are ordinarily char- 
 acterized by slight intensity which may diminish to 
 almost nothing. They therefore offer a striking con- 
 trast to the arthralgias sometimes occurring in 
 neuropathic individuals and forming an articular 
 manifestation of hysteria. 
 
 II. MUSCULAR PAINS OR MYALGIAS. 
 
 Tenderness on pressure over a muscle and pain 
 which is increased on passive stretching or active 
 contraction, form the most important indications for 
 
ORGANS OF MOTION 125 
 
 the diagnosis of a myalgia. In dealing with the 
 extremities and with the musculature of the head and 
 neck the problem does not ordinarily present great 
 difficulties, providing that there are no painful in- 
 flammatory conditions of the overlying skin and 
 subcutaneous tissues. 
 
 SoTTBCEs 01- Ebboe. — ^It is hardly necessary to 
 point out how puzzling it may he to interpret cor- 
 rectly pain in the region of the diaphragm. Diffi- 
 culties may also be encountered in investigating the 
 musculature of the chest, the back, and abdomen, 
 since functional examination may not give satisfac- 
 tory results or may be hard to carry out, and the 
 pain on pressure may be referable to underlying 
 organs. In this regard it is important, particularly 
 in dealing with tiie abdominal muscles, to ascertain 
 whether, when the muscle is in a state of contraction, 
 it is equally or even more tender. If the sensitive 
 point is situated beneath the muscles a decrease or 
 disappearance of the tenderness may be expected, 
 as the contracted muscle yields but little to the pres- 
 sure. Eeference may also be made at this point to 
 the myalgias frequently occurring in laborers 
 through muscular fatigue or the effects of exposure. 
 These are particularly frequent in the thoracic 
 muscles, and as the pain is increased by respiration 
 owing to the functions of the muscles involved, sus- 
 picion of pleural processes is easily aroused. In 
 these cases it is important if possible to raise the 
 muscle from its underlying structures and test it for 
 tenderness by taking it between two fingers. In gen- 
 
126 PAIN 
 
 eral the tenderness is increased when the muscle is 
 contracted. I should also like to call attention to the 
 tenderness of the abdominal muscles, particularly 
 in the epigastrium, which is not uncommon after 
 severe protracted coughing, as in phthisis. If there 
 happen to be at the same time abdominal symptoms 
 such as gastric disorders, diarrhoea, etc., confusion 
 may easily arise and the pain of gastric ulcer or 
 peritoneal irritation be thought of. The same thing 
 is true in regard to myalgia coming on acutely after 
 the lifting of heavy loads, which may persist for 
 months. In cases in which the diseased muscle be- 
 longs to the deeper layers, e.g., the deep muscles 
 of the neck, diagnostic difiiculties may present them- 
 selves, and there is danger of confounding the con- 
 dition with a bone lesion. 
 
 General Pathology and Etiology. — ^In discuss- 
 ing the general pathology of muscular pain, the fact 
 must be emphasized that the chief site of the sensa- 
 tion is probably to be found less in the parenchyma 
 than in the connective tissue framework. This is 
 most highly developed in the tendons and aponeu- 
 roses, and the pain may extend to these, so that in 
 considering the myalgias these structures must also 
 be taken into account. The pain of cramp, such as 
 that of the calves of the legs, is etiologically among 
 the most easy to understand. In this the purely 
 mechanical factor of pressure is concerned, a form 
 of pain mechanism that is also encountered in organs 
 composed of unstriped muscular fibre, like the intes- 
 tine and uterus. Otherwise inflammatory processes 
 
ORGANS OF MOTION 127 
 
 are the most fundamental causes of myalgias, both 
 those of endogenous nature due to disorders of 
 metabolism and those of exogenous origin depeudiug 
 on toxins in general, and especially those of bacterial 
 nature. The myalgias that are more or less physio- 
 logical in nature and follow over-exertion through the 
 accumulation of fatigue toxins may also be grouped 
 in the class of endogenous origin. It must always be 
 taken into account that the real cause of the myalgia 
 may be found extramuscularly in a primary painful 
 affection of the peripheral nervous system, such as 
 neuritis, provided that sensory intramuscular fibres 
 are involved; an example of this is the tenderness 
 to pressure of the calves of the legs of drunkards. 
 
 Modifying Factoes. — As has already been 
 pointed out tenderness is an important aid in the 
 diagnosis of myalgia. It must be ascertained 
 whether this symptom is locally limited or is diffuse 
 throughout the muscle and tendon. Local lesions 
 such as traumatic or spontaneous haematomas, 
 abscesses, tubercles, gummas, muscular cicatrices, 
 echinococcus cysts, new growths, etc., frequently are 
 characterized by local tenderness. Where the mus- 
 cular inflammation is diffuse, as the result of infec- 
 tion or through causes of a general type, the tender- 
 ness will also be diffuse in nature. Such a condition 
 might be due to infection with the pus-producing 
 coed, acute infectious polyarthritis, typhoid fever, 
 influenza or gonorrhcea. Other processes that may 
 be mentioned are intestinal autointoxication, Unver- 
 richt's dermatomyositis, haemorrhagic myositis, and 
 
128 PAIN 
 
 parasitic diseases, especially trichinosis. In. contra- 
 distinction to the neuralgias spontaneous exacerba- 
 tions of pain are very rare; the symptom is caused 
 through pressure, or active and passive motion. Of 
 other modifying influences climatic conditions such 
 as dampness, draughts, etc., may be mentioned, par- 
 ticularly in connection with myalgias localized in the 
 muscles of the shoulder, neck, and lumbar region. 
 If the process is situated in the muscles of respira- 
 tion the movements of deep breathing, coughing, 
 sneezing, defecation, etc., give rise to pain. The 
 same is true of swallowing if the muscles of deglu- 
 tition are involved. Of therapeutic influences men- 
 tion may be made especially of the effect of salicy- 
 lates and preparations of iodine and mercury. 
 
 EiioLOGY.-^Owing to the great variety of the proc- 
 esses giving rise to myalgias, it is difficult to 
 arrange them in a scheme of classification. The 
 distinction of most service in differentiation is be- 
 tween, on the one hand, the type running its course 
 as a local and afebrile condition, and on the other, 
 the type diffuse in nature and presenting the picture 
 of a severe infectious disease. 
 
 1. MtrscTJLAB Affections Chiefly Local in Natube. 
 
 Traumatic hsematomas and hernias of muscle 
 (the adductor group); hsematomas following pre- 
 ceding vascular damage (typhoid fever, sepsis, 
 phosphorus poisoning, arsenic poisoning, jaundice, 
 etc.); rheumatic affections due to cold, for ex- 
 ample, in the shoulder or lumbar aponeurosis ; mus- 
 
ORGANS OF MOTION 129 
 
 cular cicatrices following fibrous myositis through 
 local venous thrombosis, for example, deep-seated 
 varicosities in the muscles of the calves; atheroma 
 of the muscular arteries (intermittent claudication) ; 
 muscular abscesses and infarcts, gummas, tubercles, 
 echinococcus cysts, new growths. 
 
 2. MxJscxjLAB Affections Chiefly Diffuse in 
 
 Nature. 
 
 1. In general infectious processes through pus 
 organisms, acute articular rheumatism, typhoid 
 fever, influenza, syphilis, etc., Unverricht's der- 
 matomyositis, haemorrhagic polymyositis, acute 
 delirium. 
 
 2. In constitutional disorders, such as the rheu- 
 matic diathesis and ossifying myositis. The latter 
 is unlikely after the twentieth year. 
 
 3. In parasitic diseases, particularly trichinosis. 
 
 4. Periarteritis nodosa. This is most often seen 
 between the twentieth and thirtieth years. 
 
 Differential Diagnosis. — As has already been 
 pointed out the diagnosis of myalgia in general is 
 founded on the symptoms of tenderness to pressure 
 and of increase in pain on active and passive motion. 
 Alterations in the volume and consistency of the 
 structures concerned have a corroborative value, but 
 are not a conditio sine qua non for the diagnosis. 
 If the symptoms mentioned are noted as well as the 
 absence of spontaneous exacerbations the danger of 
 confusion with neuralgia is ordinarily not very 
 great. It is well to keep in mind the pains that are 
 
 9 
 
130 PAIN 
 
 often associated with tlie milder states of weakness ; 
 for example, in the shoulder girdle in cases of aortic 
 disease, processes in the liver and spleen, or ia apical 
 tuberculosis. The connection of lesions of the kid- 
 ney, such as calculus and new growths, as well as of 
 the prostate or parametrium (metastasis of carci- 
 noma), with pain in the thigh, also deserves con- 
 sideration. Involvement of the neck muscles may 
 simulate meningeal rigidity or spondylitis, though 
 the contrast between the intensity of the apparent 
 stiffness of the neck and the absence of other menin- 
 geal symptoms, and especially the tenderness of the 
 muscles, will guard against error. Similar consid- 
 erations will serve to exclude tetanus when the 
 muscles of mastication come in question. In differ- 
 entiating between pleural paia and rheumatoid affec- 
 tions of the thoracic muscles the chiefly, and often 
 exclusively, axillary localization of the former seems 
 to me to be of significance. In order to guard 
 against mistakes it is always advisable to pay par- 
 ticular attention to the presence of tenderness of 
 nerve trunks and of joints, and it should be remem- 
 bered that the simultaneous occurrence of disease in 
 these structures is not impossible. 
 
 Accompanying Manifestations. — ^In addition, the 
 temperature and the general condition should receive 
 careful scrutiny. Serious illness with typhoid-like 
 symptoms suggests the not rarely fatal cases of 
 Unverricht's dermatomyositis whose etiology is still 
 uncertain, hEemorrhagic polymyositis, or in the pres- 
 ence of the appropriate initial intestinal symptoms, 
 
ORGANS OF MOTION 181 
 
 trichinosis. In the latter case, the combination of 
 multiple myalgia with eosinophilia is of particular 
 importance. The presence of cutaneous oedema is 
 also significant. It is brawny and firm, with non- 
 involvement of the joints in Unverricht's dermato- 
 myositis, and involves the eyelids in trichinosis. If 
 the swelling is limited to one lower" extremity, local 
 thrombotic conditions come in question, such as those 
 occurring in the cachexia of malignant disease or as 
 post-infectious complications. 
 
 III. BONE PAINS OR OSTALGIAS. 
 The danger of misinterpreting pain caused by the 
 irritation of sensory fibres in the bone-marrow and 
 periosteum and of ascribing to it a different nature 
 (rheumatic or neural^c) is shown by experience to 
 be no slight one. This is in part explained by its 
 comparative rarity, and in addition there is no dis- 
 tinct localization in the affected part, particularly in 
 diffuse skeletal disease, such as osteomalacia, new 
 growths of the bone-marrow, etc. Furthermore, as 
 far as the factor of motion is concerned, the symp- 
 toms correspond to those of many commoner and 
 therefore better known painful conditions. For ex- 
 ample, if the bone exhibits periosteal changes at the 
 point of insertion of muscular masses, contractions 
 in these will naturally be painful and there will be 
 danger of confusion with muscle or joint pain. 
 Spontaneous exacerbations, which may be nocturnal 
 in character and occur, for example, in osteomalacia, 
 new growths of the bone-marrow, and post-typhoid 
 
13a PAIN 
 
 osteomyelitis, may simulate neuralgic or spiaal 
 processes, and tMs tlie more so if alteration in gait, 
 iacreased reflexes, etc., are present, as in osteo- 
 malacia. If one further reflects that infectious and 
 dyscrasic factors, as well as malignaiit processes, 
 play a particularly important role ia the etiology of 
 ostalgias, it is to be expected a priori, that compli- 
 cating muscle, joint, and nerve pains may appear 
 both primarily and secondarily. From this it is easy 
 to imderstand that errors in diagnosis may readUy 
 occur. 
 
 Etiology. — It is advisable to begin by passing in 
 review the various general and specific disease 
 processes associated with bone pain. 
 
 1. Infectious processes, such as typhoid fever, in- 
 fluenza, sepsis, etc. The lesions of the bone-marrow 
 in these conditions may be manifold in nature and 
 run through all the stages from simple hyperaemia 
 to fibrous exudation, necrosis, and the formation of 
 specific granulation tissue such as a gumma or a 
 tubercle. The scale of subjective pain sensations 
 corresponds to this range of anatomical changes, 
 running the gamut from slight pain evoked only 
 through strong pressure to the most severe spon- 
 taneous paroxysms. Usually the primary lesions 
 run their course in the bone-marrow itself and the 
 periosteal involvement is secondary, although the 
 possibility of an initial affection of the latter cannot 
 be excluded. 
 
 The infectious process may be principally or 
 entirely localized in the bone-marrow and give rise 
 
ORGANS OF MOTION 133 
 
 to local, exceedingly intense pain (acute osteomye- 
 litis), or the lesions may be very slight and be dis- 
 covered only when special search is made for them. 
 For example, in the course of typhoid fever and far 
 into the convalescence it is wise not only to watch 
 for spontaneous ostalgia (often manifesting noc- 
 turnal exacerbations), but also to look for tender- 
 ness in the portions of the skeleton frequently in- 
 volved in osteomyelitis of this type. These are par- 
 ticularly the tibia, ribs, femur, and clavicle, and 
 especial attention should be given to the epiphyseal 
 regions. The bone processes due to syphilis and 
 tuberculosis and the ostalgias associated with them 
 fall within the province of the surgeon, and are 
 therefore only mentioned. Tenderness pointing to 
 irritation of the bone-marrow, particularly in the 
 sternum, is not infrequently encountered in infec- 
 tious processes like malaria and pnexunonia if it is 
 looked for, and the ostitic symptoms sometimes ob- 
 served in biliary cirrhosis may also be placed in this 
 class. Some of the cases at least, of Marie's hyper- 
 trophic osteoarthropathy, associated with clubbed 
 fingers, may be included in the same group, in so far 
 as they occur in empyema of the pleural cavities. 
 The status of the disease of mother-of-pearl workers 
 is still uncertain. 
 
 2. New growths, involving especially the bones 
 of the trunk and of the proximal portions of the 
 extremities. This localization is characteristic for 
 the more or less diffuse lesions of the bony frame- 
 work, such as multiple myeloma, lymphadenia ossium, 
 
134 PAIN 
 
 chloroma, etc., which therefore exhibit somewhat the 
 course of an internal disease. The correct interpre- 
 tation of the not uncommon pain in these conditions 
 is an essential. for the early recognition of the true 
 state of affairs. This is no less true for the cases 
 of metastatic new growths which are often associated 
 with neoplasms of the breast, prostate, thyroid, and 
 adrenal body. Given a history of the removal of a 
 carcinoma of the breast even some years previously, 
 the occurrence of indefinite pain always suggests the 
 possibility of ostalgia. Paradoxical as it may sound, 
 it is precisely the indeterminate nature of a pain 
 that suggests the possibility of its origiuating in the 
 bone. 
 
 3. Blood diseases. It is very tempting to explain 
 the tenderness in the lower part of the sternum that 
 is so often observed in the grave blood diseases like 
 pernicious antemia, myelogenous leukaemia, and 
 pseudo-leukaemia as being associated with hyperse- 
 mic and inflammatory changes in the bone-marrow. 
 Sometimes this symptom is one of the earliest sub- 
 jective disturbances. On leaning agaiust the edge 
 of the table in writing, on resting against the win- 
 dow sill, or in bending over the washtub, the patients 
 experience pain in the portion of the sternum pressed 
 upon, and on examination pronounced tenderness is 
 discovered, particularly in the lower half of the bone. 
 An interesting observation is that the sternal pains 
 are controlled by arsenic, aud as I have convinced 
 myself in numerous cases, are least troublesome dur- 
 ing the acme of the drug's action. In the myeloge- 
 
ORGANS OF MOTION 135 
 
 nous forms of leukaemia they may run parallel to the 
 rise and fall in the number of leucocytes. These 
 pains never occur spontaneously, but are always 
 produced only by pressure over the lower half of the 
 sternum. In exceptional cases there is also tender- 
 ness in other portions of the skeleton, like the 
 humerus, ilium, tibia, or ribs. In such instances, in 
 which the bone pain is widely distributed, the pos- 
 sibility of bone metastases must be considered. The 
 presence or absence of sternal tenderness often gives 
 a useful hint. For example, if the spleen is much 
 enlarged but the sternum is wholly insensitive to 
 pressure, the existence of myelogenous leukaemia is 
 very improbable. On the other hand, if liver and 
 spleen are swollen, but there is also sternal tender- 
 ness, the diagnosis of cirrhosis must be made only 
 with great caution. It is more likely that there is 
 some blood disease like leukaemia or pernicious 
 anaemia. 
 
 4, Dyscrasias. Bone diseases of dyscrasic and 
 trophic nature. For the sake of completeness ref- 
 erence may be made to the extremely rare condition 
 of ostitis deformans (Paget) and of leontiasis ossea 
 (Virchow). The pains occurring about the head in 
 cases of the latter are probably neuralgic in origin 
 rather than ostalgias, and are due to pressure on 
 the nerves through the proliferation of bone. 
 
 A maid-servant, aged twenty-six years, was taken in July, 1905, 
 with pain along the spine, extending from the first thoracic vertebra 
 to the sacrum. The pain was persistent and increased on move- 
 ment; the spine was tender to pressure. By the middle of October 
 the symptoms had greatly increased in severity, so that the patient 
 
136 PAIN 
 
 could not stoop over, and in washing was obliged to steady herself 
 with one hand. The spine was very tender, the body weight had 
 increased ten kilogrammes! A little later the ankles became 
 swollen, and remained so for two months. She also suflfered from 
 ocular pain, oedema of the upper eyelids, transitory diplopia, and 
 tonic spasm of the muscles of mastication. In the summer of 1906 
 she noticed that her hands and feet had become very large, as 
 well as the nose and the lower jaw. In May, 1907, she presented 
 the typical picture of acromegaly, and at this time she complained 
 of shooting pain in the tibiae, which was worst at night. 
 
 This case illustrates the connection that may 
 exist between affections of the hypophysis and bone 
 pain. 
 
 Osteomalacia. — ^In this disease ostalgia appears 
 in its purest and most concentrated form. It must 
 always be our aim to make the correct diagnosis at a 
 time before palpable changes in the skeleton have 
 developed, but this is rendered possible only by 
 familiarity with the initial pain symptoms. The 
 lumbar region and the lower etxremities are usually 
 indicated by the patients as the chief seats of dis- 
 comfort, at least in the puerperal forms. Whenever 
 pains having this localization appear in the course of 
 a pregnancy, the possibility of a beginning osteo- 
 malacia should be thought of. In contradistiaction 
 to the pain due to neuralgic disorders or spinal 
 affections, like myelitis, the pains of osteomalacia 
 usually subside completely during rest, and their 
 onset is intimately connected with mechanical fac- 
 tors. Active and passive movement, coughing, 
 laughing, sneezing, yawning, etc., either become im- 
 possible or cause pain, even in far distant parts such 
 as the lower extremities. Active motion, such as 
 
ORGANS OF MOTION 137 
 
 walking, stooping, and rising after being seated for 
 some time, usually causes the patients great discom- 
 fort. On getting out of bed tbey carefully lift out 
 eacb leg in turn, holding by the thigh. Deep respira- 
 tion often gives rise to pain in the ribs, and descend- 
 ing stairs is sometimes still more uncomfortable than 
 the ascent owing to the jarring of the body that it 
 occasions. While moving about is exceedingly 
 arduous, remaining in the same position for any 
 length of time, either sitting or lying, results in an 
 increase of the pain, so that the patients are obliged 
 to change their position constantly, and sleep is 
 therefore very broken. The movement of abduction 
 at the hip joint is particularly prone to cause 
 paroxysms of pain, as well as rapid dorsal flexion 
 at the ankle joint. In the latter case a pain is not 
 rarely caused which runs the entire length of the 
 lower extremity, radiating to the pelvis and some- 
 times accompanied by dorsal clonus. Lateral com- 
 pression of the thorax, or of the pelvis at the level 
 of the trochanters or the iliac crests, promptly causes 
 pain. Wearing a corset and tight lacing sometimes 
 appear to relieve the subjective symptoms, evidently 
 through the support given to the spinal column. 
 
 It is clear that the mechanical factors influencing 
 the pain of osteomalacia are not deficient in charac- 
 teristic qualities. If in spite of this, confusion with 
 other affections, particularly those of rheumatic 
 nature, is not rare, this may partly be explained by 
 the fact that to some extent they respond in the same 
 
138 PAIN 
 
 way to therapeutic measures. My experience leads 
 me to speak of the prompt relief to pain afforded hy 
 the diaphoresis caused by hot-air baths, as well as 
 of the improvement often spontaneously occurring 
 during the hot summer months. Complications such 
 as myalgias of the adductors and calves, joint pains 
 of arthritic nature, and neuralgias like sciatica also 
 sometimes occur and may contribute to render the 
 picture of typical osteomalacia indistinct as regards 
 its pain phenomena. As suggested above, accom- 
 panying symptoms like ankle clonus, together with 
 the apparent weakness of the lower extremities, may 
 even give rise to confusion with spinal affections. 
 The intimate relationship between the pain of osteo- 
 malacia and mechanical factors like motion, as 
 opposed to the more spontaneous onset of the 
 paroxysms of spinal pain, should be sufficient for the 
 purposes of differentiation. The absence of bladder 
 disturbances is also an important diagnostic poiat. 
 The differentiation from spondylitis in the dorso- 
 lumbar region with secondary neuralgia of the pel- 
 vis — iu which I have found that there may also be 
 tenderness of the pelvic bones owing to involvement 
 of the periosteal nerves — is ordinarily not difficult. 
 It is sufficient to think of this possibility in order to 
 avoid error by a careful examination of the spinal 
 column. Where typical bony changes already exist 
 an extended analysis of the pain phenomena may of 
 course be dispensed with. In its onset, however, the 
 disease belongs to the subjective ostalgias discussed 
 above. 
 
ORGANS OF MOTION 139 
 
 Functional Ostalgias. — It may be assumed 
 a priori in view of the analogous observations in the 
 province of joint and muscle pains that ostalgias 
 may sometimes appear as manifestations of a gen- 
 eral neurosis, like hysteria. In fact, there are obser- 
 vations on record showing the possibility of the 
 simulation of osteomalacia by that great artist in 
 imitation, hysteria. In such cases error is to be 
 avoided by a careful study of all the attendant symp- 
 toms, but it must be borne in mind that the existence 
 of hysteria does not exclude osteomalacia and that 
 the latter disease in a hysterical subject will present 
 confusing symptoms due to this tendency. 
 
 Eeflex Ostalgias. — ^Reflex sensitiveness to pres- 
 sure and percussion over the spinal column may 
 occur in abdominal processes without any anatomical 
 lesion of the bone itself. This is particularly the 
 case in gastric ulcer and cholelithiasis, in which the 
 hyperalgetic spot is often over the twelfth dorsal 
 vertebra at the level of the lower pulmonary border, 
 or in the interscapular space. 
 
 I remember a case of gall-stones in which this localized tender- 
 ness was so pronounced that a very experienced surgeon made the 
 diagnosis of spondylitis. At the autopsy the spinal column was 
 found entirely intact. 
 
 The local tenderness to pressure and percussion 
 sometimes exhibited by areas of the skull overlying 
 cortical cerebral tumors may be due to slight degrees 
 of periostitic irritation (internal erosion). 
 
CHAPTER VII. 
 
 Digestive System. 
 GASTRALGIAS. 
 
 In this section those paroxysms of paia are to be 
 described which are colicky in nature, are localized 
 in the epigastrium, are frequently accompanied by 
 objective gastric symptoms, such as vomiting, eruc- 
 tations, etc., and which in the absence of anatomical 
 disease of the stomach are usually interpreted, and 
 misinterpreted, as "nervous gastralgia." 
 
 Genebal. Pathogenesis. — In view of the negative 
 nature of the condition, it is not astonishing that 
 even the existence of gastraJgia as a painful sensa- 
 tion arising in the stomach itself is sometimes denied, 
 and the sensation in question is assumed to arise 
 entirely outside of the organ in the vagus and sym- 
 pathetic nerve tracts. According to this view gas- 
 tralgia would be sharply differentiated from the 
 pains occurring in other muscular hollow viscera, 
 such as the gall-bladder, intestine, ureter, uterus, 
 etc., and would be brought into association with the 
 neuralgias. For the same reason that it would be 
 improper in the case of a tumor of the Gasserian 
 ganglion, accompanied by pain in the teeth, to speak 
 summarily of toothache, the term gastralgia should 
 be avoided and be supplanted by the expression 
 sympathetic or vagus neuralgia, with the addition 
 of the underlying cause. In analogy to the condi- 
 
 140 
 
DIGESTIVE SYSTEM 141 
 
 tions existing in neuralgias of the cerebrospinal 
 nervous system the occurrence of tenderness along 
 the nerve tracts in question, the vagus, the sympa- 
 thetic nerves, and the solar plexus might be ex- 
 pected. It is clear, however, that owing to the topo- 
 graphical relations tenderness to pressure in the 
 neck or over the anterior surface of the spinal 
 column, in the abdomen, etc., is far from comparable 
 in diagnostic value to the demonstration of distinct 
 tenderness over the sciatic nerve, for example, and 
 it is especially necessary under these circumstances 
 not to allow the wish to become father to the 
 observation. 
 
 Of course the occurrence of gastralgia is per- 
 fectly possible as a purely neuralgic disturbance in 
 the course of the sensory tracts without the exist- 
 ence of any causative motor or secretory disorders 
 in the organ itself. This is especially the case when 
 the attacks of pain persist even when the stomach 
 is empty and are not influenced by alkalies, local 
 anaesthetics, or the ingestion of food. The gastric 
 crises of tabes may serve as a paradigm of this 
 group, and the similar conditions appearing in 
 syringomyelia, multiple sclerosis, cerebrospinal 
 syphilis, vagus lesions, etc., may also be pointed 
 out. 
 
 Vagus Gastbalgia. — ^For example, in a case of 
 gastric crises under my observation, the patient was 
 able to cut short mild attacks by inserting the finger 
 deeply into the left external auditory meatus (vagus 
 
142 PAIN 
 
 fibres), but tbe act was accompanied by violent 
 coTigbing. Starting with this observation of the 
 patient's, to the effect that it was possible to inhibit 
 the painful process — evidently situated in the left 
 vagus — by a sort of counter-stimulation such as is 
 applicable to the act of sneezing, I prescribed with 
 good effect the application to the left auditory 
 meatus of a pledget of cotton moistened with a mix- 
 ture consisting of three drops of oil of mustard, one 
 gram of menthol and ten grams of liquid petrolatum. 
 I would suggest repeating this experiment in other 
 cases of suspected vagus gastralgia. 
 
 There is no doubt that gastralgias of this sort 
 may actually have an extragastric origin, and, as in 
 the case just described, involve the left vagus tract. 
 (It was not possible to influence the pain through 
 the right ear.) Cases of this nature are comparable 
 to those of trigeminal neuralgia in which the seat 
 of the trouble is the Gasserian ganglion. Opposed 
 to this small group is the large number of gastral- 
 gias in which, as is shown by the influence of modi- 
 fying factors, the chief part is played by sensory, 
 motor, or secretory processes in the stomach itself. 
 Here the state of irritability of the nerve tracts is 
 no longer the prime factor as it is in the gastric 
 crises of tabes. It only furnishes the predisposition, 
 in consequence of which various agencies acting 
 within the stomach are enabled to produce the pain- 
 ful sensations. These may be either motor disturb- 
 ances, i.e., spasm of the pylorus either above or in 
 conjunction with over-distention of the adjoining 
 
DIGESTIVE SYSTEM 143 
 
 portions of the stomach, or disorders of secretion 
 and irritability of the mucous membrane. The cor- 
 rectness of these assumptions is shown by a con- 
 sideration of the ways in which modifying agencies 
 act, as wUI be discussed further on. 
 
 Accordingly, I believe that from the clinical 
 stand-point the essential gastralgias without ana- 
 tomical lesions, may simply be grouped in accord- 
 ance with their susceptibility to modification through 
 the stomach itself. Of the agencies acting in this 
 way, diet is of course the most important. We may 
 then distinguish: (1) Central gastralgias, that are 
 only slightly influenced by way of the stomach, espe- 
 cially the diet. As the type of this group the gastric 
 crises of tabes may be mentioned. (2) " Peripheral ' ' 
 gastralgias, which are markedly influenced by the 
 diet and similar factors. It is tempting to make the 
 grouping still more precise, and speak of forms 
 "with" or "without" dietary modification. This 
 would be simplification at the expense of the truth, 
 however. For even the " central " gastralgias of 
 tabetics may be influenced in this way, and for ex- 
 ample, it is necessary as the attack subsides to use 
 great caution in the administration of food not to 
 evoke fresh seizures. Intelligent patients who ob- 
 serve themselves closely are able to bear witness to 
 this. At best there are many transitions between 
 groups 1 and 2, and the classification serves only to 
 emphasize the two extremes. 
 
 Etiology. — The causes of gastralgia are numer- 
 ous, and the following classification suggests itself. 
 
144! PAIN 
 
 I. Ibbitable Weakness of the Neevotjs System. 
 This factor is in most cases the fundamental 
 cause of the essential gastralgias. Without the in- 
 creased susceptibility to pain that it involves, no 
 doubt many of the special factors, for example those 
 of alimentary nature, would be inadequate to cause 
 actual painful phenomena. In these cases the appli- 
 cation of the therapeutic lever is particularly effec- 
 tive, and improvement may often be secured even 
 in the persistence of the specific cause of the pain. 
 The most varied influences and processes may com- 
 bine to produce the condition of irritable weakness 
 of the nervous system, mental overexertion, psychi- 
 cal emotions, sexual aberrations, anaemias, the arthri- 
 tic diathesis, chronic infections such as tuberculosis 
 with possible secondary sympathetic and adrenal 
 lesions, syphilis, chronic intoxications such as nico- 
 tinism, plumbism, alcoholism, arsenic poisoning, etc. 
 These conditions contribute their part in giving rise 
 to essential gastralgias ; they are factors that occur 
 also in the causation of neuralgias in the cerebro- 
 spinal nervous system. Frequently they simply pre- 
 pare the soil for the subsequent action of more 
 specific causes. 
 
 II. DiBECT Causes. 
 
 A. Acting Cbntbally. — This heading comprises 
 especially diseases of the central nervous system, 
 such as tabes, syringomyelia, multiple sclerosis, cere- 
 brospinal syphilis, etc. It is difficult to decide to 
 what extent disturbances of metabolism such as the 
 arthritic diathesis, diabetes, and the chronic infec- 
 
DIGESTIVE SYSTEM 145 
 
 tions and intoxications mentioned in the preceding 
 paragraph, have a central or a peripheral effect. 
 In this class may also be included the gastraJgias, 
 often accompanied by vomiting, sometimes occurring 
 in cases of vascular lesions such as atheroma of the 
 abdominal aorta, of the coronary arteries, the cceliac 
 axis, etc., and concerniag whose exact mechanism 
 we are still ignorant. 
 
 B. Acting Pebipheeax,ly. — Here the point of at- 
 tack lies in the sensory nervous apparatus of the 
 stomach itself. Organic lesions of the gastric 
 mucosa, such as ulcerative or inflammatory proc- 
 esses, may serve to induce gastralgias, especially if 
 there is an already existing predisposition. The 
 actual mechanism of pain production frequently de- 
 pends on a pyloric spasm of reflex nature; that is, 
 on a pathological increase in motor activity which 
 of course may reach its maximum when there is a 
 permanent tendency to abnormal peristalsis, as in 
 pyloric stenosis. Among the chemical factors — 
 whose existence in a given case is indicated by the 
 prompt temporary effect of the administration of 
 alkalies — are to be counted the inorganic and organic 
 acids, contact of which with the gastric mucous mem- 
 brane may induce gastralgias of the most severe 
 type. In view of what was said above under section 
 I., it may be expected that in hypersBsthesia small 
 amounts of acid will be effective, while the variety 
 of the acid is also not without importance. 
 
 Acidity. — The complaints usually ascribed to 
 hyperacidity and capable of being modified by the 
 administration of alkali might therefore more cor- 
 
 10 
 
146 PAIN 
 
 rectly be spoken of as due simply to acidity, since 
 frequently they result not from an excess of acid but 
 tbrougb an increased susceptibility to acids. Here 
 again those gastralgias might be mentioned that 
 sometimes occur with an anatomically intact stomach 
 after the ingestion of strongly acid foods or those 
 forming acid on decomposition (animal fats, milk) 
 or strong spices, coffee, etc. Mechanical factors, 
 such as insufficient mastication, overeating, and foods 
 tending to gas formation, also come in question. 
 Various idiosyncrasies also may come into play, such 
 as an intolerance of egg albumen, ingestion of which 
 induces the severest pain in some individuals. 
 
 HuNGEE Pain. — Just as quantitative and qualita- 
 tive abnormalities in the ingestion of food, including 
 poisoning, may lead to gastralgiform attacks, pro- 
 tracted fasting may have a similar effect. This 
 appears rather paradoxical, since apparently noth- 
 ing becomes a cause. In reality it is probably the 
 physiological increase in peristalsis (growling of the 
 empty stomach) that accompanies the sensation of 
 hunger, and sometimes perhaps also the gastric juice 
 secreted under these conditions that causes the pain, 
 and this is particularly likely to occur if the predis- 
 position already spoken of in section I. exists 
 or the stomach has become a locus minoris resis- 
 tenticB through ulcerative processes (particularly 
 ulcer, rarely carcinoma). I have observed this 
 hunger pain also in cases of achylia and such in- 
 stances prove that the presence of hydrochloric acid 
 is not an indispensable element in its production. 
 
DIGESTIVE SYSTEM 147 
 
 III. Eeflbx Causes. 
 
 The gastralgias comprised under this heading in- 
 clude those sometimes occurring in diseases of the 
 appendix, disorders of the female genital apparatus, 
 sometimes even in nasal affections, hernias of the 
 omentum in the linea alha, movable kidney, etc. In 
 such cases it is always necessary to determine 
 whether factors from groups I. and II. are not also 
 concerned, and accordingly one-sided special treat- 
 ment must be avoided. I consider it very probable 
 that the epigastric pains often accompanied by gas- 
 tric symptoms such as vomiting, eructations, the 
 feeling of peristaltic unrest, etc., which sometimes 
 occur in cases of more or less latent gall-bladder 
 disease as well as in pancreatic conditions and dis- 
 eases of the aorta and coronary arteries, are, as a 
 matter of fact, to be regarded as reflex gastralgias. 
 
 DiFFEBENTiAL DIAGNOSIS. — Colicky paius in the 
 epigastrium associated with gastric symptoms of 
 course always suggest gastralgia, but a satisfactory 
 diagnosis can be made only through the proper inter- 
 pretation of the causative factors. For this purpose 
 it is necessary to pass in review the possibilities sug- 
 gested under headings I., II., and III., unless defi- 
 nite peculiarities of the pain give the necessary clue. 
 
 TopoGEAPHY AND TiMB. — Attention may be called 
 to the purely left-sided character of the pain that is 
 sometimes observed. Biliary colic is never re- 
 stricted to the left half of the epigastrium — ^leaving 
 out of account the possibility of transposition of the 
 viscera. As a rule, left-sided pain is observed 
 
148 PAIN 
 
 oftener in ulcer, carcinoma, and other organic dis- 
 eases of the stomach than in primary gastralgia, 
 though there are exceptions to this. 
 
 In a case of achylia gastrica accompanied by pain in a neuro- 
 pathic tuberculous patient there was tenderness of the epigastrium 
 on the left side. More careful examination revealed that the whole 
 left side of the body was hypersesthetic ! 
 
 It is therefore possible to have even a primary 
 gastralgia accompanied by left-sided tenderness ia 
 this roundabout way. Primary gastralgias ordi- 
 narily do not radiate into the upper extremities, 
 particularly not — as opposed to cholelithiasis — iato 
 the right shoulder and arm. Eadiation into the left 
 upper extremity is also very rare as compared to 
 the epigastric form of angina pectoris. For a con- 
 sideration of the tendency to radiation exhibited ia 
 the colic of pyloric stenosis reference may be made 
 to the section in question. It is also advisable to 
 try to ascertain the depth of the pain from the sur- 
 face in order to avoid erroneously interpreting inter- 
 costal neuralgias in the epigastrium as gastralgias. 
 For this reason it is always wise to test the cuta- 
 neous sensibility of the epigastrium. This is also 
 advisable in order not to overlook possible gastric 
 crises, in which girdle-like zones of sensory disturb- 
 ance are very common. Onset of the pain immedi- 
 ately after eating is more frequent in essential gas- 
 tralgia than in ulcer. Eecurrence of the pain at 
 definite intervals, sometimes of weeks, is of interest 
 and suggests a disorder of functional nature. 
 
 A young lady from Belgrade suffered from attacks of vomiting 
 and severe gastric pain appearing every other day in the forenoon. 
 
DIGESTIVE SYSTEM 149 
 
 I saw the patient in her fifth attack. Examination of the blood 
 showed the presence of the parasites of tertian malaria. 
 
 Witli regularly intermittent attacks of gastric 
 pain the possibility of malaria should never be lost 
 sight of. The regular daily recurrence of the 
 attacks, particularly if a relationship to the taking 
 of food can be demonstrated, suggests the possibility 
 of the conditions discussed in group II. B, such, as 
 ulcer, pyloric stenosis, etc. On the other hand, great 
 irregularity in the appearance of the pain points 
 more to the central diseases spoken of under group 
 II. A, and perhaps the reflex factors of group III. 
 
 Modifying Factobs. — ^In order to avoid errors in 
 drawing conclusions from the causative factors, it 
 is always necessary to remember that these are 
 occasionally multiple in nature. 
 
 Not without reason was the group included under 
 the heading of irritable weakness placed first in the 
 list of etiological factors, for gastralgias of the most 
 varied origin may be founded on this basis. Tbis 
 indeed is true of attacks of pain in general, and the 
 occurrence of a gastralgia under the influence of 
 emotional excitement, such as anger or grief, is far 
 from justifying the exclusion of an organic cause. 
 Among the mechanical factors I should attach a 
 not imimportant role to the matter of bodily posi- 
 tion. If the gastralgia is merely the result of func- 
 tional or organic disease of the nervous system the 
 effect of position will in most instances be hardly 
 perceptible. The reverse may be the case to a very 
 pronounced degree, however, if organic lesions of 
 
160 PAIN 
 
 the stomacli (II. B) or reflex stimtili from abnor- 
 mally movable organs (III.) are concerned. Un- 
 fortunately there are exceptions to this rule which 
 somewhat restrict its applicability, though not in- 
 validating it. 
 
 An officer suffered for some years from frequently repeated 
 attacks of " cramps in the stomach." Color good, somewhat florid. 
 Formerly he smoked more than 100 cigarettes daily, but later reduced 
 the number to 30. The pain comes on after eating and lasts for 
 an hour or two. When riding a good deal or taking exercise, as in 
 hunting, he feels perfectly well and can eat anything. Excitement 
 frequently causes right-sided headache. During the gastric attacks 
 there is a sensation of heat at the back of the head and belching 
 of gas, but no heartburn. 
 
 In this typical case of essential gastralgia due to 
 excessive smoking the patient affirmed that lying on 
 the right side increased his discomfort and that he 
 had the feeling of the gastric contents passing over 
 to that side. If gastralgic seizures occur in connec- 
 tion with rapid motion, stair-climbing, etc., masked 
 forms of angina pectoris must always be thought of. 
 Exercise such as riding or mountain climbing acts 
 favorably in some cases of essential gastralgia, espe- 
 cially those associated with the uric acid diathesis, 
 and this may aid in the differentiation from ulcer. 
 Pronounced tenderness, particularly on percussion 
 of the epigastrium or on pressure, renders the exist- 
 ence of an organic condition likely, especially if 
 asymmetrical, but exceptions in this regard may be 
 encountered both on the organic and on the func- 
 tional side. Massage or firm pressure sometimes 
 relieves the pain in functional gastralgia. 
 
DIGESTIVE SYSTEM 161 
 
 Particular attention must of course be given to 
 the effect of diet. The mechanical, chemical, and 
 thermic factors concerned in the ingestion of food 
 tending to gas formation, strongly acid, spiced, or 
 fatty foods, cold fluids, etc., are of importance, espe- 
 cially in dealing with the organic processes spoken 
 of under group II. B. It would be wrong to assume, 
 however, that the diet is a negligible factor in the 
 functional gastralgias. In those suffering from this 
 predisposition there is a state of gastric weakness 
 in consequence of which the tolerance of the stomach 
 is much impaired. Two points must be emphasized 
 in this connection. In the first place the tolerance 
 for food is often restricted irregularly, for example 
 coffee is sometimes very badly borne. This symp- 
 tom must never be overlooked, it is almost the stigma 
 of the gastric neuropath. Secondly, the degree of 
 tolerance is subject to wide and rapid variations. 
 In every case it should be investigated, not only 
 through the patient's statements, but also experi- 
 mentally. One often sees gastric neuropaths who 
 have long been kept on a strict ulcer diet, and in 
 whom a liberal taxing of the tolerance is not only 
 diagnostically useful but also an effective mode of 
 treatment. 
 
 The effect of acids and the opposite test with 
 alkalies is also of importance. Small doses of 
 sodium bicarbonate are often beneficial in cases of 
 essential gastralgia even if, as I have often seen, 
 hydrochloric acid is absent. The explanation seems 
 to lie in the stimulus to the over-distended stomach 
 causing it to expel the accumulated gas. In a simi- 
 
152 PAIN 
 
 lar way a swallow of cold water or a few drops of 
 brandy sometimes have an anodyne effect. 
 
 An ansemic, nervous lady, who had previously suffered from 
 chlorosis, had for some time suffered from sudden attacks of epigas- 
 tric pain, occurring especially after excitement. She had the feeling 
 as if a stick were being pushed through the mouth into the stomach. 
 The attacks lasted for twenty minutes to two hours and the 
 patient would then fall asleep. There was also a painful point at 
 the top of the head, which was very sensitive to the contact of the 
 comb. The first attack came after taking cold beer. The dietetic 
 tolerance was not restricted. The administration of sodium bicar- 
 bonate relieved the pain, as did also belching of gas. 
 
 In the same way it seems to me that the action 
 of local anaesthetics, such as cocaine and anses- 
 thesin, is of importance from the diagnostic stand- 
 point. If the administration of such agents causes 
 rapid decrease in the discomfort the presence of local 
 pain-producing factors, such as ulcer, carcinoma, 
 hemorrhagic erosion, or hypersesthesia of the 
 gastric mucosa, may be regarded as demonstrated, 
 and in making the otherwise difficult decision be- 
 tween gastric and duodenal ulcer the prompt produc- 
 tion of relief in this way points in favor of the 
 former lesion. The purely nervous origin of some 
 forms of gastric pain explains the prompt effect 
 sometimes seen on the administration of antineu- 
 ralgics such as antipyriu. This point is of diagnos- 
 tic value, though it is only the promptness of the 
 action that is significant, for organic visceral pain, 
 like that of cholelithiasis is also susceptible to the 
 effect of these drugs. 
 
 A possible interdependence between the onset of 
 gastric pain and constipation of long duration should 
 
DIGESTIVE SYSTEM 153 
 
 not be overlooked. In hydrochloric acid hyper- 
 aesthesia or hyperacidity, as well as in ulcer and 
 pyloric stenosis, there is no doubt in regard to a 
 connection of this sort, and it probably depends on 
 interference with the emptying of the stomach and 
 secondary stagnation and fermentation of its con- 
 tents. The effect of menstruation and pregnancy 
 should also be considered. 
 
 Accompanying Manifestations. — Although in 
 cases of gastralgia the best advice that can be given 
 is to make a complete physical examination involv- 
 ing all the organ systems, ia addition to the analyt- 
 ical study of the paroxysms in the manner just 
 indicated and keeping in mind the possibilities sug- 
 gested in the introductory classification, it may be 
 helpful to emphasize several points that aid in rapid 
 orientation, although not of great importance per se. 
 Chief among these is the examination of the stools 
 for occult blood. If found repeatedly this may es- 
 tablish the diagnosis of ulcer or carcinoma. The 
 coincidence of pain in the stomach, vesical disturb- 
 ance, a girdle of sensory disorders at the level of 
 the epigastrium, and pain in the lower extremities 
 suggests tabes. The syndrome gastralgia and 
 distended bladder always awakens suspicion of gas- 
 tric crises. High blood-pressure, accompanied by 
 arteriosclerotic pallor of the face and dyspnoea, even 
 though slight, suggests an arterial starting point 
 such as angina pectoris. Gastralgia with sarcinse 
 in the vomitus or in the feces points to ulcerative 
 stenosis of the pylorus. The same thing is true of 
 visible gastric peristalsis or marked gastric meteor- 
 
154. PAIN 
 
 ism (not to be confounded with distention of the 
 epigastrium through an enlarged liver in choleli- 
 thiasis). Examination for a palpable or painful 
 gall-bladder, for the presence of a hernia in the 
 linea alba, or for tenderness of the appendix and 
 parametrium, should never be omitted. Diarrhoea 
 is associated oftenest with achylia and gastric crises. 
 Herpes labialis suggests the possibility of infectious 
 processes, in the gall-bladder or appendix for ex- 
 ample. Associated headache makes an essential gas- 
 tralgia more likely than ulcer. It may precede, 
 accompany, or follow the gastric pain. Cases are 
 often seen in which the patients state that they 
 suffered for a long period from headaches, which 
 then ceased and were replaced by attacks of pain in 
 the stomach. One sometimes gains the impression 
 that there is actually a sort of vicarious relationship 
 between the two. Important symptoms in essential 
 gastralgia are globus, sometimes followed by hoarse- 
 ness, and clavus hystericus, and these should always 
 be enquired for. 
 
 GASTRIC ULCER. 
 
 Topographical Considerations. — ^It might be 
 assumed a priori that in ulcerative processes of the 
 gastric mucosa the pain, whether spontaneous or 
 produced artificially through pressure or percussion, 
 would have a more or less asymmetrical left-sided 
 localization corresponding to the position of the 
 organ. As a matter of fact, this is true in a large 
 number of cases, at least so far as ulcers in the 
 neighborhood of the cardia or the central part of the 
 
DIGESTIVE SYSTEM 155 
 
 stomach: are concerned, and may be made use of in 
 differential diagnosis. Exclusively or principally 
 left-sided spontaneous pain or tenderness to pres- 
 sure, either in the epigastrium or in the anterior or 
 posterior lower thoracic region, renders painful 
 processes of the right side of the abdomen and par- 
 ticularly gall-bladder affections improbable, and 
 therefore limits tbe diagnostic possibilities from the 
 very begiiming. 
 
 The painful area to be outlined by pressure or 
 percussion is not rarely situated on the left side 
 anteriorly, just below the costal arch, somewhat to 
 the median side of the mammary line. It is also 
 sometimes possible to discover another point of ten- 
 derness on the left side posteriorly, close to the verte- 
 bral column, at about tba level of the twelfth dorsal 
 or first lumbar vertebra. Concussion of the left 
 lower portion of the thorax witb the fist at about 
 the level of the lower pulmonary border is also often 
 exquisitely painful as compared with the right side. 
 Even when the pain is median in onset it frequently 
 radiates in the direction of the left costal border 
 and to the left scapula. This is particularly likely 
 in cases with, perigastritic adhesions to the dia- 
 phragm, the transmission probably taking place 
 through the phrenic nerve into the shoulder. There 
 may then also be a pressure point over the outer and 
 middle third of the upper border of the trapezius 
 muscle. While the left-sided position of the pain is 
 not pathognomonic of gastric ulcer its diagnostic 
 significance is the result of the position of the organ 
 in the abdominal cavity and cannot be neglected. 
 
166 PAIN 
 
 Sometimes, in exceptional cases, the pain may in- 
 volve the left side of the thorax. 
 
 I remember one patient with undoubted uleer who felt pain 
 below the left nipple on raising a, weight, and another who on 
 coughing had pain on the left side in the neighborhood of the third 
 rib in front and in the corresponding region posteriorly. 
 
 The great frequency with which the smaller median 
 and right-sided prepyloric and pyloric portion of 
 the organ is the seat of ulcerative lesions causes the 
 pain to occupy a similar position in a great propor- 
 tion of the cases. Not only is the spontaneous pain 
 experienced in the middle portions of the epigas- 
 trium, but on testing the sensibility by percussion 
 the maximum point of tenderness is frequently found 
 on a line connecting the xiphoid process with the 
 umbilicus. I must caution, however, against draw- 
 ing conclusions in regard to the site of the ulcer from 
 this position of the area that is painful on percus- 
 sion. It is easy to convince oneself, for example, 
 that in cases of hepatic congestion in which the 
 hypersensitiveness of the organ to mechanical insult 
 is no doubt the same throughout, percussion is 
 always most painful in the midline of the epigas- 
 trium, while on the right and left sides it may cause 
 little or no discomfort. This may be explained as 
 follows : On either side of the midline the recti blunt 
 the force of the blow through their contraction, but 
 in the center, where, especially in cases of ulcer, 
 diastasis of the recti may exist together with enter- 
 optosis, this defense musculaire is wanting and 
 the impact is received unaltered by the stomach. 
 
DIGESTIVE SYSTEM 157 
 
 This is apt to be overdistended witli gas and the in- 
 creased tension may result in pain production quite 
 independently of the actual position of the ulcer. In 
 most cases the lesion appears to be near the pylorus 
 on the lesser curvature. The tenderness to percus- 
 sion frequently begins about four finger breadths 
 below the xiphoid process and extends to the neigh- 
 borhood of the umbilicus. If it begins immediately 
 below the xiphoid and corresponds to an area of dul- 
 ness, the possibility of hyperalgesia of the liver, per- 
 haps through congestion, or following an attack of 
 gall-stones, must be seriously considered. It must 
 also be remembered that hepatic congestion and ulcer 
 may occur coincidently and that the development 
 of an ulcer may be favored by the vascular and cir- 
 culatory disturbances. Therefore in cases of myo- 
 cardial degeneration, mitral stenosis, etc., with pain- 
 ful congestion of the liver and accompanied by symp- 
 toms suggesting gastric ulcer, the relations of the 
 tender area to the liver edge should be carefully 
 studied. If it is situated below this the possibility 
 of ulcer must always be thought of. An unusual 
 location of the pain is over the lower portion of the 
 sternum. 
 
 A tinsmith, aged forty-two years, began two years ago to have 
 pain in the abdomen and the feeling " as if he had a heavy stone 
 there." There was loss of appetite and even at that time black, 
 glistening stools. Three months later a burning sensation over the 
 lower part of the sternum, extending laterally along the ribs. The 
 pain began at nine in the morning, two hours after breakfast, and 
 lasted till noon. It ceased after taking soup, and then appeared 
 again in the afternoon from three to six o'clock. In walking he 
 had to take care to avoid a misstep. Lying on the left side gave 
 relief. Only the lower part of the sternum was tender on percussion. 
 
158 PAIN 
 
 Just as spontaneous pain and tenderness to per- 
 cussion or pressure may occur in the midline ante- 
 riorly, symmetrical backache or hyperalgesia of one 
 or more thoracic or lumbar vertebrae (usually the 
 twelfth dorsal or first lumbar) may sometimes be 
 encountered. 
 
 A professional hunter, aged twenty-six years, in March, 1900, 
 vomited black clotted blood and had bloody diarrhoeal stools, accom- 
 panied by vertigo and ringing ears. The following day he fainted 
 and was brought to the hospital with only 20 per cent, of haemoglobin. 
 The epigastrium was not at all sensitive to pressure, but there was 
 great tenderness over the fourth dorsal vertebra. 
 
 Ulceration of the pylorus itself not rarely causes 
 exquisite tenderness on the right side, which 
 may be either just to the right and above the um- 
 bilicus or nearer to the costal border and therefore 
 in unpleasant proximity to the gall-bladder. The 
 radiation of the pain of pyloric ulcer is less inti- 
 mately associated with the ulcer as such than with 
 the pyloric stenosis, and will therefore be discussed 
 with the subject of colic due to this condition. At 
 present only the retrosternal radiation sometimes 
 observed in ulcers of the lesser curvature will be 
 mentioned. Ordinarily only the lower part of the 
 sternum is involved, but sometimes the sensation 
 extends upward toward the neck, and when it is 
 accompanied by the sense of oppression and is de- 
 pendent on motion (traction), confusion with angina 
 pectoris may result. 
 
 The pain of ulcer is nocturnal in a considerable 
 proportion of cases, the paroxysms frequently occur- 
 ring during the midnight hours (from 11 to 1 o'clock) 
 
DIGESTIVE SYSTEM 159 
 
 and lasting into the early morning. The relation 
 between the ingestion of .food and the onset of pain 
 varies greatly from case to case, and I should never 
 venture from this to draw conclusions in regard to 
 the localization of the ulcerative process. Often the 
 pain begins immediately after eating, but sometimes 
 it does not occur until hours after the last meal. In 
 pyloric ulcer, particularly if there is also stenosis, 
 there is more regularity in this regard and the pain 
 customarily begins two or three hours after the 
 midday meal, as will be explained at greater length 
 in discussing the subject of pyloric colic. 
 
 The Natube and Pathogenesis of the Pain. — 
 The nature of the pain is very variable. Sometimes 
 the feeling of a "sore spot" is complained of; fre- 
 quently there is simply a diffuse sense of pressure 
 in the epigastrium, a sensation of heaviness "as if 
 there were a stone in the stomach. ' ' Sometimes it is 
 described as being cutting, piercing, burning, or 
 gnawing, or it may be spasmodic or throbbing in 
 character. The intensity of the pain, and especially 
 also the tenderness, may vary in a short time between 
 wide limits so that while at one moment even deep 
 pressure may not be painful, a few hours later even 
 the contact of the shirt may seem unbearable. It is 
 evident that the ulcerative process itself undergoes 
 no change within so short a lapse of time, but gastric 
 distention may develop, and I think that this 
 accounts for the rapid fluctuations so often encoun- 
 tered. The more the ulcerated gastric wall is 
 stretched by gas formation the greater wUl be the 
 
160 PAIN 
 
 tenderness to pressure and percussion. Before be- 
 ginning to discuss the actual causation of the pain, 
 it may be well to say a few words in regard to its 
 pathology. It is evident that the conditions are 
 rather more complex than in ulcerations of the 
 buccal cavity, for example, for here we have an 
 organ whose wall may sometimes be abnormally 
 distended through the accumulation of gas, and 
 which, on the other hand, is subject to spasmodic 
 contraction. Furthermore, one must take into ac- 
 count its peritoneal covering, which may become 
 inflamed over the ulcerated area (perigastritis), and 
 also the production of acid gastric juice which may 
 serve as a source of irritation. Every one of these 
 factors, and of course to a much greater degree 
 their combination, may occasion pain. 
 
 At this point I should like tO' touch briefly upon 
 the question as to why the deep ulcerations of the 
 gastric mucous membrane caused by carcinoma 
 rarely give rise to painful seizures similar to those 
 of the benign simple ulcer. The acidity of the car- 
 cinomatous stomach is also often high owing to the 
 formation of organic acids, such as lactic, acetic, and 
 butyric. In the explanation of this apparent para- 
 dox two factors play a large part. (1) The carcino- 
 matous stomach is much less prone to spastic con- 
 traction than is the stomach with simple ulcer. The 
 latter in spite of the frequently existing moderate 
 degree of motor insufficiency is still undoubtedly 
 in a state of motor hyperexcitability (irritable weak- 
 ness), and every spasmodic contraction of the ulcer- 
 
DIGESTIVE SYSTEM 161 
 
 ated gastric wall may serve to cause pain. (2) In 
 ulcer the stomach is more liable to meteorism, espe- 
 cially if there coexists pyloric stenosis, either func- 
 tional through spasm, or organic through cica- 
 tricial contraction. The resulting tension of the wall 
 of the organ is a very active source of pain. At any 
 rate the two- mechanical factors of contraction and 
 overdistention play an exceedingly important part 
 in the pathogenesis of the pain of ulcer. 
 
 Not rarely psychical factors, such as excitement 
 or anger, are adduced by the patients as initiating the 
 attacks of pain. If one takes into consideration 
 the interdependence between the emotional state and 
 the motor and secretory functions of the stomach, 
 and on the other hand, the fact that the intensity 
 of stimulus necessary to evoke pain in an emotionally 
 excited person is reduced, the demonstration of such 
 a relationship will probably never be regarded as 
 by itself sufficient reason for assuming the existence 
 of a functional disorder. It is especially necessary 
 to be on one's guard since gastric ulcer is not rarely 
 associated with the neuropathic constitution and a 
 tendency to enteroptosis. 
 
 The mechanical factors in the process of pain 
 production are of the greatest differential value in 
 dealing with the pain of ulcer as opposed to that of 
 other gastralgias, such as those occurring in organic 
 or functional nervous disorders like tabes or neuras- 
 thenia, or those due to secretory anomalies or to 
 intoxications (lead, nicotine). It is clear from what 
 has been said above that the way in which mechanical 
 
 11 
 
16a PAIN 
 
 factors act will not be uniform and that the position 
 of the ulcer and any existing adhesions will be of 
 importance. A peculiarity frequently observed in 
 cases of ulcer is that during the paroxysms, and 
 sometimes also at other periods, the position of the 
 patient while in the horizontal posture, whether on 
 the face, back, or side has an undoubted effect on the 
 intensity of the pain. It may at once be pointed 
 out that similar observations may be made in painful 
 affections of other organs, such as the liver, kidney, 
 appendix, etc. I do not therefore agree with the 
 generally accepted explanation that in certain posi- 
 tions the eroded surface is exposed to the impact, so 
 to speak, of the gastric contents, while in others this 
 is not the case. Assuming that the material in the 
 stomach is pultaceous and therefore not easily mov- 
 able, as must often be the case, this explanation 
 seems somewhat forced. At the most, it could be 
 claimed only that the weight of the overlying 
 layer, which, however, cannot vary very greatly, 
 may have a pain-increasing effect, though this 
 seems to me rather improbable. I should regard it 
 as much more natural that, just as in the case of 
 other painful abdominal organs, displacement, trac- 
 tion, or kinking at the pylorus takes place and in- 
 creases the pain. When the stomach is full it is par- 
 ticularly liable to displacement of this sort as a 
 whole and in part, and this can hardly be without 
 effect in the presence of the inflammatory adhesions 
 usually existing. Such displacement in different 
 positions of the body is the more likely to occur in 
 
DIGESTIVE SYSTEM 163 
 
 ulcer since not rarely the condition is associated 
 with enteroptosis and lax abdominal walls. This 
 imperfect fixation of the abdominal organs as a 
 whole is further contributed to by the considerable 
 reduction in intra-abdominal padding due to the 
 absorption of fat commonly seen in cases of ulcer. 
 Therefore I should consider the effect of the painful 
 position as due less to a displacement of the gastric 
 contents than to that of the stomach itself {cf. page 
 24). The patients themselves often complain, for 
 example, that when lying on the left side "a weight 
 seems to pass to the left." The pain accompanying 
 the lateral position is sometimes experienced on the 
 same side, but may also be contralateral, so that 
 when lying on the right side it is felt to the left of 
 the epigastrium, and often conveys the impression 
 of traction to the right. The painful position may 
 be noted only during the spontaneous paroxysms and 
 frequently appears to depend on overfilling of the 
 organ, which, of course, would predispose to dis- 
 placement. It does not seem to me justifiable to 
 draw conclusions, as is often done, in regard to the 
 localization of the ulcer from the relations between 
 the position of the body and increase or decrease in 
 pain, since the connection evidently does not depend 
 on simple displacement of the gastric contents due to 
 gravity alone. A fairly constant though not invari- 
 able rule is that painful lesions of the pylorus, par- 
 ticularly if accompanied by stenosis, make the right 
 lateral position uncomfortable during the spontane- 
 ous attacks of pain, but more will be said on this 
 subject in discussing the pain of pyloric stenosis. 
 
164 PAIN 
 
 So far only the horizontal position has been con- 
 sidered. In walking, the body is frequently held in- 
 clined forward, at least at the time of the paroxysm. 
 Belief is sometimes afforded in the sitting or crouch- 
 ing position, but in other cases these attitudes in- 
 crease the patient's discomfort. Pain in the back, 
 either bilateral or only on the left side, is sometimes 
 complained of. Movement, as in walking, may bring 
 on pain and therefore rest in bed is often the most 
 important factor in the treatment of ulcer. A mis- 
 step, or exertion while stooping, calling into play 
 the abdominal muscles, as in lifting heavy loads, is a 
 frequent cause of pain, and may bring on a hemor- 
 rhage. I recall an instance in which a patient after 
 lifting a heavy load experienced for the first time a 
 burning sensation below the left breast, which was 
 followed by the development of typical ulcer symp- 
 toms. Violent straining at stool may act in the same 
 way. 
 
 The respiratory movements may also cause pain, 
 usually on the left side of the epigastrium just below 
 the costal border, particularly if perigastritic com- 
 plications are present. In these cases the sensation 
 may radiate from the epigastrium to the left along 
 the axillary portions of the thorax into the shoulder. 
 Such a relationship of the pain to respiratory 
 movements is a significant factor in the differential 
 diagnosis between ulcer and essential gastralgia. 
 It is hardly necessary to indicate that efforts such 
 as those of coughing and sneezing may also be pain- 
 ful. Under these conditions the sensation may be 
 
DIGESTIVE SYSTEM 165 
 
 located in the thorax. Straining at stool sometimes 
 causes pain in the pyloric region, and in one case 
 of mine about the sternal end of the third rib. The 
 dependence of the pain of ulcer on mechanical 
 stimuli, such as pressure and percussion, is among 
 its most useful diagnostic peculiarities, but the im- 
 pression appears to obtain that, as in the case of an 
 ulcer in the mouth, the sensitive area corresponds 
 to the anatomical lesion and depends on this alone. 
 Pain on pressure and on percussion are, however, 
 undoubtedly dependent on the degree of tension of 
 the stomach wall. If the organ is greatly dilated, 
 as may occur without true cicatricial pyloric stenosis 
 through pyloric spasm and secondary stagnation, 
 pressure and percussion will be particularly painful. 
 This will be the case over a considerable area, and 
 even when the trauma does not correspond to the 
 situation of the diseased spot. This view is further 
 borne out by the enormous fluctuations in sensitive- 
 ness often occurring within a few hours and running 
 parallel to the degree of distention of the organ. 
 The possibility of determiniag the position and size 
 of the ulcer by outlining the painful area by percus- 
 sion seems to me to exist only when the stomach is 
 not distended. The percussion must be very gentle, 
 as if forcible it acts as a strong vibration, such as 
 that caused by coughing, for example. Tenderness to 
 percussion over the epigastrium should be looked for 
 in the following situations: (1) From the xiphoid 
 process to the umbilicus. (2) In the apex of the 
 angle on each side between the outer border of the 
 
166 PAIN 
 
 rectus and the costal arcli. (3) At a point about 
 2 cm. to the right of and above the umbilicus. (4) 
 The lower part of the sternum. In the back hyper- 
 algetic areas are- not rarely found in the neighbor- 
 hood of the spinal column, particularly between the 
 shoulder blades in the neighborhood of the twelfth 
 dorsal vertebra. The left flank may also be sensitive 
 to percussion with the clenched fist, less rarely the 
 right, in contradistinction to cholelithiasis. In rare 
 cases the epigastrium, and still more rarely the dor- 
 sal regions just indicated are so hyperalgetic that 
 simple contact and slight pressure (the weight of the 
 bed-clothes, for example) are sufficient to cause pain. 
 Overdistention of the stomach through diagnostic 
 inflation (caution is necessary) may give rise to 
 acute spontaneous pain and tenderness to pressure. 
 So far we have discussed factors concerning 
 whose purely mechanical nature there can be no 
 doubt. The effect of diet presents a much more 
 difficult problem. Here one is dealing with a com- 
 plex of mechanical, chemical, and thermic factors, 
 and this may explain the great variability in the 
 effects of dietary regulation, although certain under- 
 lying principles always stand out clearly from the 
 chaos of inconsistencies. The mere fact that the 
 pain is subject to alimentary modification at all 
 seems to me of greater diagnostic importance than 
 the exact manner and nature of the effect produced. 
 The pain-inducing factor may be regarded as purely 
 mechanical when it is the result of the use of foods 
 causing gas formation. Here, as has already been 
 
DIGESTIVE SYSTEM 167 
 
 pipinted out several times, it is tlie gastric meteorism 
 —which is predisposed to by the atony of the ulcer- 
 ated stomach and its tendency to pyloric spasm — 
 that produces the paroxysms of pain through tension 
 of the walls of the organ. This explains the prompt 
 relief that often follows vomiting or the evacuation 
 of gas, and the beneficial effect of the local applica- 
 tion of an ice bag. Some foods {e.g., pork) may 
 have a purely mechanically irritating effect through 
 their indigestibility and act as foreign bodies. Acid 
 foods and strong spices, including salt and pepper, 
 are nearly always badly borne. Of beverages, hot 
 tea with milk, and milk to which an alkali like lime 
 water or vichy water has been added, seem to agree 
 the best. Coffee, beer, wine, and cold water often 
 induce paroxysms qf pain. Sometimes coffee, 
 whiskey, or carminatives may bring relief to the 
 pain, possibly through hastening the emptying of 
 the stomach which is often overdistended with gas. 
 
 One patient of mine found that hot water with a little 
 brandy was most efifective in relieving his pain. 
 
 Meat sometimes also has a favorable effect which 
 is ordinarily explained as due to the neutralization of 
 the excess of hydrochloric acid. For my part, as the 
 result of numerous observations, I consider that 
 hydrochloric hyperacidity is very far from frequent 
 in ulcer and have furthermore been able to convince 
 myself that in undoubted cases of the lesion even 
 large doses of dilute hydrochloric acid have not in- 
 creased the pain and have sometimes even seemed to 
 have a favorable effect, possibly through an anti- 
 fermentative action. I should always advise testing 
 
168 PAIN 
 
 the effect of acid and alkalies experimentally in 
 cases of gastric ulcer. If the administration of alka- 
 lies relieves the pain the proof of hyperchlorhydria 
 has not been furnished, for there may exist what 
 I think is rather frequent, namely, a hypersesthesia 
 to hydrochloric acid accompanied by even subnormal 
 HCl values. In addition, the discharge of gas and 
 consequent reduction of gastric meteorism sometimes 
 produced must be taken into consideration. That 
 the ingestion of meat and milk frequently does not 
 act exclusively through the neutralization of hydro- 
 chloric acid is shown by the fact that not rarely a 
 piece of bread will have the same effect. 
 
 Increased peristalsis is likely to attend the sen- 
 sation of hunger caused by prolonged abstinence 
 from food. This is evidenced under physiological 
 conditions by the "growling of the stomach," and 
 the ingestion of food of any sort appears to have a 
 quieting effect on the spasmodically increased motor 
 activity. Hunger not infrequently causes pain to 
 appear in ulcer. Similarly, the effect of tobacco in 
 causing pain, not only in essential gastralgias but 
 also in ulcer, may be due to the increased peristalsis. 
 
 It is not possible to formulate distinct rules in 
 regard to the effect of thermic stimuli on the pain 
 of ulcer. In most cases moderate warmth, both in- 
 ternally through beverages such as warm milk or 
 tea, as also externally by means of fomentations or 
 hot water bottles, appears to act favorably on the 
 pain, but cold (a swallow of cold water, or an ice bag 
 to the epigastrium) not infrequently relieves in 
 
DIGESTIVE SYSTEM 169 
 
 cases ia which heat increases the discomfort of the 
 patient. 
 
 Among the interrelationships between the pain of 
 ulcer and the condition of other organs or their func- 
 tions j constipation, which is so frequently seen ia this 
 disease, appears to me to be of importance particu- 
 larly from the therapeutic standpoint. Constipation 
 is undoubtedly a pain-producing factor, for when 
 it has persisted for any length of time the intensity 
 and frequency of the attacks nearly always increase, 
 only to subside again after evacuation of the iates- 
 tine. Occasional enemas of oil or glycerine and pos- 
 sibly the regular administration of mild laxatives, 
 such as cascara sagrada, are therefore urgently indi- 
 cated. It appears most likely that the blocking of 
 the fecal masses reacts upon the stomach and causes 
 stagnation in this organ, thus iacreasing the ten- 
 dency to meteorism. The effect of the latter upon 
 the pain of ulcer has already been discussed at 
 length. It is hardly necessary to point out that a 
 condition of "irritable weakness" of the nervous 
 system is unfavorable, particularly if accompanied 
 by auEemia, and therapeutic measures must be 
 directed along these lines. No less undesirable is 
 the effect of enteroptosis, which is not infrequently 
 encountered in neuropathic individuals. If gas- 
 troptosis exists, the resulting kinking at the pylorus 
 leads to stagnation and abnormal fermentation 
 of the gastric content, while at the same time pain- 
 ful traction on the organ is also likely to be caused. 
 Accordingly, in such cases an abdominal binder 
 should be applied. When pregnancy has a beneficial 
 
170 PAIN 
 
 effect on ulcer and its pain, as was the ease in some 
 instances that I recall, it is possible that among other 
 factors the relief to the condition of enteroptosis 
 produced by the elevation of the abdominal viscera 
 through the enlarging uterus is of importance. 
 
 Accompanying Symptoms. — Among the symp- 
 toms associated with exacerbations of pain the most 
 characteristic are those standing in close relation- 
 ship to the mechanism of pain production. For ex- 
 ample, the distention of the stomach is often evident 
 from the presence of a rounded swelling, or at least 
 an air-cushion-like resistance, in the left (as con- 
 trasted with cholelithiasis) side of the abdomen. 
 Pressure over this sometimes occasions pyrosis 
 through regurgitation upward, sometimes there is 
 distinct, easily produced succussion.* Frequently 
 there is audible and palpable gurgling owing to the 
 increased peristalsis, or there may be acid eructation 
 or belching of gas smelling like putrid eggs (SHg) 
 and vomiting followed by the immediate cessation 
 of the pain (as opposed to cholelithiasis). Chills 
 occur only rarely and then in neuropathic persons 
 with abnormal vasomotor excitability; the superfi- 
 cial abdominal reflex is sometimes increased on the 
 left side, headache and attacks of vertigo are often 
 seen, as well as the feeling of great heat and sweat- 
 ing, especially during a haemorrhage. Microscopi- 
 cally the examination of the vomitus or of the feces 
 
 *In cases of gastric ulcer it is desirable, in order to avoid local 
 injury in testing for splashing in the stomach, to shake the whole 
 abdomen by grasping the two sides of the pelvis with both ha,nds. 
 
DIGESTIVE SYSTEM 171 
 
 may reveal the presence of sarcinas, wMcli is a find- 
 ing of importance. As noted above, I do not regard 
 hyperchlorhydria as a frequent concomitant of 
 ulcer.* 
 
 DiFFEBENTiAL DIAGNOSIS. — In distinguishing the 
 paroxysms of gastric ulcer from those of the gastral- 
 gias of "nervous" nature, such as may he caused 
 by organic lesions of the nervous system, tabes, 
 multiple sclerosis, syphilis, etc., and which are 
 often dependent on a neuropathic basis, as in hys- 
 teria, exophthalmic goiter or nicotinism, the inter- 
 mittent character of the pain in the latter may be 
 emphasized. In these conditions, in addition to the 
 sporadic nature of the attacks and the lack of sus- 
 ceptibility to influence by mechanical factors, such 
 as position, motion, or pressure, there is also the 
 absence of permanent or consistent modification 
 through diet. In difficult cases it is advisable to 
 make careful dietetic observations in order to deter- 
 mine the degree of tolerance for articles of food 
 badly borne in ulcer. The lack of response to 
 dietary changes will also prevent confusion in cases 
 of epigastric intercostal neuralgia. As opposed to 
 the more occasional attacks of gall-bladder colic, the 
 pain of ulcer is characterized by greater persistence 
 and the action of local anaesthetics is of importance 
 [cf. pyloric stenosis colic). The existence of a 
 hernia of the linea alba, which may exhibit the same 
 epigastric tenderness as ulcer, is easily recognized 
 
 * Local conditions, the diet for example, may be of significance in 
 this connection, and my experience relates to patients as seen in 
 Vienna. 
 
17a PAIN 
 
 by palpation while the patient coughs. Still, even 
 after the discovery of a hernia the possibility of the 
 simultaneous occurrence of both conditions must 
 be kept in mind. The epigastric tenderness some- 
 times seen in chronic bronchitis as a muscular phe- 
 nomenon involving the insertions of the recti and 
 comparable to the pain in the calves after fatiguing 
 marches, is likely to lead to error only if the exam- 
 ination is superficial and gastric symptoms happen 
 to coexist, as in tuberculosis. 
 
 Hepatic congestion witii tenderness seems to offer 
 a possibility of mistakes in diagnosis. In cases of 
 ulcer, associated with cardiac insufficiency and 
 hepatic congestion — in which the gastric lesion may 
 be predisposed to by the circulatory disorders — the 
 epigastric pain is likely to be ascribed summarily to 
 the hepatic condition, and the stomach symptoms 
 are explained in the same way. It may be that not 
 THitil perforative peritonitis intervenes, as in a case 
 I have seen, is the true state of affairs recognised. 
 It is important to demonstrate that there is also a 
 spot painful to percussion helow the edge of the liver 
 and that the pain does not subside under digitalis as 
 is the case in the hepatic condition. Of course, care- 
 ful study of the attendant circumstances is also 
 necessary. Angina pectoris, especially in its graver 
 'forms induced through lesions of the aorta and coro- 
 nary arteries, may simulate the symptoms of ulcer 
 if the pain is localized in the epigastrium and evi- 
 dence of gastric disturbance like vomiting is present. 
 This is the more likely to be the case if the epigas- 
 
DIGESTIVE SYSTEM 173 
 
 triuin is tender to pressure, as the result of inflam- 
 matory atheroma of the abdominal aorta. In deal- 
 ing with persons over forty, of stocky build and pale 
 complexion, with a tendency to dyspnoea, thick arter- 
 ies, and high blood pressure, one should always be 
 slow to make the diagnosis of ulcer, particularly if 
 it is found that rapid motion, stair climbing, etc., 
 give rise to the epigastric pain. The characteristic 
 anguished facies of the patients during the attack 
 also gives a hiat as to the true state of affairs. If 
 the dietary has no particular effect on the pain, as 
 is usually the case, the distinction is not difficult to 
 draw. The conditions are more difficult when the 
 ingestion of food also induces attacks in coronary 
 or aortic angina. In such cases the nature of the 
 food is frequently without significance ; for example, 
 in one case the attacks occurred no matter whether 
 the patient took nulk or pork and sauerkraut; it was 
 the iagestion of food as such irrespective of its qual- 
 ity that caused the pain. Those cases should also 
 be borne in mind in which gastric ulcer affords the 
 reflex starting point of hysterical angina pectoris, 
 particularly if aortic lesions are present, such as 
 aortic insufficiency. Neuroses are most apt to occur 
 in anatomically damaged organs. 
 
 In all cases of suspected ulcer the region of the 
 appendix should be examined for tenderness. Just 
 as appendicular colic not rarely begins in the epigas- 
 trium, chronic appendicitis may be associated with 
 epigastric symptoms simulating ulcer. The possible 
 combination of both conditions must also be consid- 
 
174 PAIN 
 
 ered. In cases of achylia gastrica, such, as occur in- 
 dependently or as part of the picture of a pernicious 
 anaemia, ulcer-like symptoms, sometimes even asso- 
 ciated with the apparent symptoms of hyperacidity, 
 may occur. The demonstration of tie absence of 
 hydrochloric acid will give the necessary clue. The 
 same thing is true of gastric carcinoma, which some- 
 times begins with typical ulcer symptoms. In 
 chronic gastritis tenderness over the pylorus may 
 be present, though this is usually slight. There may 
 also be similar dietary symptoms, though seizures of 
 severe pain are almost never observed. The possi- 
 bility of ulceration in other portions of the gastro- 
 intestinal canal must also be taken into account. 
 These exhibit similar and therefore confusing die- 
 tary symptoms. I believe that it is impossible to 
 distinguish with any degree of certainty between the 
 pain of gastric and of duodenal ulcer. The appli- 
 cation of the ansesthesin test has already been de- 
 scribed (c/. page 42). If the pain of intestinal 
 ulceration, for example, of tuberculous nature, is 
 accompanied by symptoms such as vomiting, gastric 
 splashing, etc., and is localized in the epigastrium, it 
 is very difficult to make the distinction, particularly 
 in view of the similar behavior of the two affections 
 in regard to the ingestion of food. The case- is ren- 
 dered still more complex if, as in an instance ob- 
 served by me, intestinal symptoms such as diarrhoea 
 and increased peristalsis are absent. Under these 
 conditions the appearance of pain in the lower abdo- 
 men, as well as of tenderness in the ileocaecal region, 
 
DIGESTIVE SYSTEM 175 
 
 seems to me of great importance. At any rate, great 
 caution is necessary in making the diagnosis in 
 patients having pulmonary tuberculosis. 
 
 THE COLIC OF PYLORIC STENOSIS. 
 
 Just as stenosis of the intestine may give rise to 
 attacks of colic more or less independently of the 
 nature of the obstruction, paroxysms of similar eti- 
 ology are occasioned when the pylorus is narrowed. 
 As is the case in the intestinal canal, internal ste- 
 noses induced by lesions of the mucosa produce the 
 most intense attacks of pain. Fresh pyloric ulcera- 
 tions are not necessary for this ; it is rather chronic 
 cicatricial inflammatory changes or malignant new 
 growths that are at fault. In short, the causes of the 
 obstruction may vary, but the pain phenomena in- 
 duced are the same. It therefore seems to me justi- 
 fiable to classify separately the paroxysms of this 
 type and to give them the new designation of pyloric 
 colic. In the pathogenesis of this it appears to me 
 that — as in the stenotic colics in general — the factor 
 of overdistention is of greater importance than that 
 of muscular spasm. The quality of the pain itself 
 and particularly the accompanying symptoms in ad- 
 vanced cases, such as visible peristalsis, leave no 
 doubt in regard to the underlying causes. At the 
 acme of the paroxysm the patients nearly always 
 complain of pain that is etxquisitely colicky and grip- 
 ing in character and is associated with the sensation 
 "as if there were something alive in the stomach 
 region," "as if the stomach were contracting vio- 
 
176 PAIN 
 
 lently and there were an obstruction to tlie exit of 
 its contents." The spasmodic attempts of the gas- 
 tric muscles to force the contents of the organ 
 through the stenosed pylorus manifest themselves 
 in this way and sometimes even the direction of peri- 
 stalsis from left to right is manifest to the sufferer. 
 The distention that is ordinarily also present gives 
 rise to an extremely disagreeable or even painful 
 feeling of fulness. 
 
 Objective Symptoms. — Although the subjective 
 sensations of the patient depending on the underly- 
 ing conditions of spasm and overdistention give a 
 sufficiently clear picture of the actual condition, the 
 other objective symptoms bauish all doubt, at least 
 in well-marked cases. The cardinal phenomenon is 
 the fact that the contours of the stomach are ren- 
 dered visible and palpable. At the same time gur- 
 gling and rumbling sounds may be heard. This so- 
 called rigidity of the stomach is often observed by 
 the patient himself as a "hardening" of the epigas- 
 trium, which is likely to be most marked on the left 
 side. It corresponds in time fairly closely with the 
 paroxysm of pain. The distended stomach does as a 
 matter of fact become harder to the touch and is 
 palpable as a mass resembling an inflated air-cushion 
 in consistency. This is a symptom that deserves 
 consideration in all cases of gastric pain in which 
 pyloric stenosis is suspected. If the abdominal 
 muscles are well developed and the stomach is not 
 greatly dilated the abnormal increase in peristalsis 
 may not be visible, but can be detected on palpation 
 
DIGESTIVE SYSTEM ITTf 
 
 as a rapid change in the degree of tension of the 
 organ. In testing for this it is advisable to palpate 
 with the outspread fingers pressing vertically against 
 the abdominal wall, especially over the left half of 
 the epigastrium and below the left costal border. 
 In some cases, particularly if there is no gastric dis- 
 tention, an increase in the pyloric resistance may be 
 felt at the onset of the paiin. The sausage-like trans- 
 verse mass so formed disappears again as the pain 
 subsides. If the stomach is more dilated and ap- 
 proaches the vertical in position peristalsis is often 
 most marked in the neighborhood of the umbUicus 
 and little eminences appear at either side of this. 
 More rarely the protuberance is in the neighborhood 
 of the gall-bladder. A similar observation is some- 
 times made by patients with gall-stones and is due 
 to a specie of erection of the gall-bladder. The 
 auscultatory manifestations have the same origin as 
 the visible and palpable phenomena and correspond 
 to the loud borborygmi accompanying intestinal 
 stenosis. They are caused by the gurgling of gas 
 through the narrowed pylorus and are ordinarily 
 followed by decrease of the tension of the gastric 
 wall and subsidence of the paroxysm of pain. The 
 evacuation of gas upward through the cardia has the 
 same effect. The violent peristalsis battling against 
 the pyloric obstruction also often produces eructa- 
 tions of sour material accompanied by retrosternal 
 pyrosis which may extend up into the throat. 
 Finally, there may be vomiting of an abundance of 
 material that is not bile stained, the act being usually 
 
 12 
 
178 PAIN 
 
 followed by cessation or considerable diminution in 
 the pain, as opposed to the vomiting of biliary colic. 
 Although in the typical cases with marked dilatation 
 the large quantity of the vomitus, which comes up in 
 great gulps, and the facts that the material brought 
 up is almost never bile stained, frequently contauis 
 old food particles and sarcinas, and is often hyper- 
 acid, usually make the recognition of the underlying 
 conditions easy, there are other instances in which, 
 in spite of years of stenosis, there is never vomiting, 
 no sarcinse are to be found in the gastric contents, 
 and there may also be no food residue in the fasting 
 stomach. In these cases there is probably a compen- 
 satory change without extreme stenosis, and instead 
 of dilatation there is rather a concentric hypertrophy 
 of the muscular layers. The absence of vomiting 
 may also be caused by perigastric adhesions, and in 
 such cases the careful study of the attacks of colic 
 may be of great diagnostic importance. Of other 
 symptoms frequently observed there may be men- 
 tioned the belching of gas having the odor of putrid 
 eggs (SH2) ; the microscopical pendant to this is the 
 discovery of sarcinse. Another typical manifesta- 
 tion is the presence of gastric splashing, which may 
 be elicited at any time, and is often noticed by the 
 patient in walking. It is only rarely (in neuropathic 
 patients with an excitable vasomotor system) that a 
 short chill accompanies the attack of colic. Eleva- 
 tions of temperature do not go with the seizures of 
 pyloric stenosis, as opposed to biliary colic. Con- 
 stipation is a regular concomitant in almost every 
 
DIGESTIVE SYSTEM 179 
 
 case of well-marked pyloric stenosis and is aggra- 
 vated at the time of the attack. The urine is often 
 dark in color and reduced in quantity owing to the 
 loss of fluid through vomiting. 
 
 Time of Onset. — The time at which attacks of 
 pyloric colic occur is fairly regular. In most cases 
 the pain begins two to three hours after the midday 
 meal; more rarely after the lapse of one to four 
 hours. At this time the expulsion of the gastric con- 
 tents through the narrowed pylorus, or an attempt 
 at this, takes place. Gastric rigidity sets in and 
 gurgling sounds are audible, while gas is belched up 
 and there are eructations of sour fluid. In short, 
 in typical cases there appear the various manifes- 
 tations of increased but ineffectual peristalsis. 
 Large quantities of indigestible food cause delay in 
 the onset of the pain, but increase its severity. The 
 attacks often last from two to three hours, and are 
 ordinarily terminated by the onset of copious vomit- 
 ing. These afternoon attacks depending on the in- 
 gestion of the midday meal are in many cases fol- 
 lowed by nocturnal seizures that are regular in 
 recurrence but do not exhibit a distinct connection 
 with the evening meal and have a greater resem- 
 blance to the irregular paroxysms of biliary colic. 
 In some cases this nocturnal type even predomiaates. 
 As in colic of other sorts the attacks are most likely 
 to occur at about midnight, lasting several hours 
 until vomiting relieves the pain. 
 
 Topography. — In regard to the situation of the 
 pain I should like to consider especially the ten- 
 
180 PAIN 
 
 dency to radiation, which is also prominent, as is 
 ■well known, in gall-bladder colic. This appears 
 to depend in part on the degree of tension of the 
 stomach wall. On the evacuation of gas by belching, 
 there is often abrupt cessation of the radiating pain ; 
 for example, that passing into the back. Several 
 types may be recognized from the topographical 
 standpoint, but they all have a stenosis of the pylorus 
 (cicatricial) as underlying cause. 
 
 1. Type of Pseudo-gall-stone Colic. — The pain of 
 the attack begins in the epigastrium or in the pyloric 
 and gall-bladder region, and radiates into the right 
 lumbar region and right shoulder. It accordingly 
 simulates that of biliary colic, and error is to be 
 avoided only by a careful analysis of the attendant 
 circumstances, time of onset, etc. The difficulties 
 may be still further increased in those fortunately 
 rare cases in which pyloric ulceration — through in- 
 fection, secondary duodenal catarrh, or adhesions — 
 leads to lesions in the gall-bladder or gall passages, 
 and therefore causes jaundice. 
 
 2. Type of Gall-stone Colic with Left-sided Pain. 
 The pain begins on the left side of the epigastrium 
 and radiates into the left lumbar region, left shoul- 
 der, and possibly left breast. Owing to the left- 
 sided position of the distended organ this type 
 appears to be commoner than the preceding. 
 
 3. Type of Pseudo-girdle Pains. — The pain be- 
 gins exactly in the middle line of the epigastrium 
 and extends in girdle form with equal intensity to 
 each side to the back. It may also radiate retro- 
 stemally and into both shoulder blades. 
 
DIGESTIVE SYSTEM 181 
 
 4. Type of Diagonal Radiation. — The pain be- 
 gins, for example, in the right half of the epigastrium 
 in the immediate neighborhood of the gall-bladder, 
 but radiates backward, especially into the left shbul- 
 der. Such left-sided radiation is of value in differ- 
 entiating the condition from the ordinarily right- 
 sided bUiary colic. 
 
 MoDirYiNG Factoes. — In this connection mechani- 
 cal factors are of great importance, particularly in 
 regard to the position of maximum pain (c/. page 
 24). Lying on the right side is very likely to bring 
 on the pain or to increase it if already present. Dur- 
 ing the intervals between attacks this position is 
 often well borne, however. I have already indicated 
 my doubts in regard to the assumption that the ex- 
 planation is to be fouftd in a simple settling or dis- 
 placement of the stomach contents on to the surface 
 of the ulcer or the cicatricial tissues. This view is 
 also opposed by the observation that in some cases 
 of ulcerative cicatricial pyloric stenosis the right 
 lateral position is well borne, but the left is accom- 
 panied by nausea, belching, etc., so that the patients 
 turn on the right side during the attack. Sometimes 
 ia the course of the disease a change in the position 
 of maximum pain is observed so that for a time it 
 may be the right and later the left side. It is of 
 especial interest to note that in such cases imme- 
 diately after a gastro-enterostomy has been done 
 there is no longer any painful position. The follow- 
 ing case illustrates this in a typical way : 
 
18a PAIN 
 
 A farmer's wife, aged thirty years, came under observation on 
 October 21, 1901. Her present symptoms have developed gradually 
 during the past four years. To begin with, there were cramp-like pains 
 in the stomach, at first only in the daytime and sometimes not 
 appearing for several days. A month after the iirst of these seizures 
 she began to vomit, often bringing up a pint of acid, watery fluid. 
 After vomiting the pain ceased, only to recur on taking food. Later 
 the pain began to be more on the left side of the epigastrium and 
 to radiate backward into the left flank and to the angle of the 
 scapula. During the attacks there was swelling below the left costal 
 margin, and loud gurgling followed by some diminution in the pain. 
 The seizures frequently came on between eleven and twelve at 
 night and were accompanied by a feeling of fulness and distention. 
 Taking a meal at noon would be followed by pain at about three 
 in the afternoon. There was intolerance of vegetables, starchy 
 desserts, beer, and wine. At first she could lie on either side, but 
 in the course of a year she became unable to lie on the right side 
 during the attacks. She had the feeling as if eveiything were 
 " dropping over " to that side. For some months she had been in 
 the habit of lying on her face during the attack with one hand 
 pressed against the epigastrium and the other making counter- 
 pressure over the back. She frequently massaged the epigastrium 
 with the closed fist. Evacuation of the bowels seemed to lessen 
 the pain. The physical examination showed among other things 
 that the stomach was tense, like an air cushion, with active peri- 
 staltic movements. The vomitus contained hydrochloric acid and 
 many sarcinse. She was operated on in Gussenbauer's clinic on 
 November 5, 1901. The pylorus was found drawn close to the 
 cardia by a. wedge-shaped scar along the lesser curvature which 
 was also adherent to the pancreas. A gastro-enterostomy was done, 
 and two weeks later the patient could eat everything, had no symp- 
 toms whatever, and could lie on either side. 
 
 It has been pointed out above that it is therefore 
 much more rational to consider that the effect of 
 position depends on kinking, traction, inflammatory 
 adhesions, etc. The part played by the overdisten- 
 tion of the stomach in bringing on the attack is 
 demonstrated by the fact that the belching of gas 
 and vomiting relieve or cut short the paroxysm. 
 
DIGESTIVE SYSTEM 183 
 
 Many patients instinctively massage tlie distended 
 epigastrium or they fnrnisli a support to the anterior 
 stomach wall by pressure with the fist, and in this 
 way favor the evacuation of gas. 
 
 It is often possible to demonstrate the presence 
 of pyloric tenderness by percussion and deep palpa- 
 tion. Frequently it is more or less limited to a 
 point in the linea alba between the navel and the 
 xiphoid process. Sometimes there is tenderness of 
 the spinal column to percussion between the shoulder 
 blades. The influence of diet manifests itself in the 
 same way as spoken of under the heading of ulcer. 
 It is hardly necessary to emphasize the fact that 
 owing to the narrowing of the pylorus the ingestion 
 of foods tending to produce distention or fermenta- 
 tion is very likely to cause gastric meteorism, and 
 that these are particularly to be avoided. The fol- 
 lowing articles are nearly always very badly borne : 
 Potatoes, turnips, uncooked fruit, cabbage, smoked 
 meat, and fatty foods in general, as well as pastries 
 prepared with yeast, and alcoholic beverages, espe- 
 cially sour wines. Foods that agree well are thick 
 rice soup, spinach, potato puree, tea with milk, milk 
 dishes, chopped ham, etc. The drinking of large 
 quantities of fluid is always of untoward effect. 
 Irritating substances like whiskey or black coffee 
 sometimes give symptomatic relief. Evidently they 
 encourage the discharge of the gastric contents and 
 so relieve the tension of the over-filled stomach. 
 
 In speaking of thermic stimuli I wish only to 
 point out that in those cases of pyloric colic accom- 
 panied by considerable distention of the stomach. 
 
184 PAIN 
 
 the application of cold, possibly through its tonic 
 effect in encouraging contraction, seems to be more 
 beneficial than the various warm applications ordi- 
 narily used in attacks of colic. In some such cases I 
 have seen heat not only unproductive of relief but 
 the patients have even complained of increase in 
 their sufferings. Internally, lukewarm drinks are 
 to be recommended. 
 
 What was said concerning the effect of the func- 
 tions of other organs on the pain of ulcer is also ap- 
 plicable here. The indication for careful regulation 
 of the intestinal functions is the more important 
 since the tendency to gastric meteorism is evidently 
 more pronounced than in cases of ulcer not accom- 
 panied by stenosis. There is no doubt in regard to 
 the effect of constipation in increasing pain. Psy- 
 chical factors, such as overwork or excitement, fre- 
 quently cause the attacks to recur at shorter 
 intervals. Disregard of this fact might make con- 
 fusion with functional conditions likely. 
 
 DiFPERENTiAx, DIAGNOSIS. — The possibility of mis- 
 taking pyloric colic for biliary colic is particularly 
 great in those cases in which the characteristic evi- 
 dences of pyloric stenosis, such as gastric rigidity, 
 very copious vomiting, etc., are absent, or in which 
 jaundice appears as a result of secondary duodenal 
 catarrh. Sometimes, though fortunately rarely, the 
 two conditions occur in combination. Some of the 
 more important differential signs may be summar- 
 ized in the following table : 
 
DIGESTIVE SYSTEM 
 
 185 
 
 Ptlobic Couo. 
 
 Active borborygmi in the epi- 
 gastTium. 
 
 Distention, most marked below 
 the left costal border. 
 
 Acid eructations with heart 
 burn; copious vomiting of 
 strongly acid material that 
 is not bile stained but con- 
 tains sarcinse and possibly 
 particles of old food. 
 
 Eructations smelling of SH2. 
 
 Copious vomiting or eructations 
 of gas are followed by a 
 marked diminution in pain. 
 
 Usually no chill. 
 
 The fasting stomach contains old 
 
 food. 
 Attacks are very numerous, 
 
 often occurring daily for 
 
 weeks and months. 
 The pain tends to radiate to the 
 
 left. 
 The attacks regularly begin two 
 
 to three hours after the 
 
 midday (or largest) meal. 
 Foods causing gas formation 
 
 tend to increase the pain. 
 Attacks of colic are sometimes 
 
 brought on by lying on the 
 
 right side. 
 
 Local anaesthetics sometimes re- 
 lieve the pain. 
 
 BlLIABT COUC. 
 
 Swelling of the gall-bladder and 
 of the liver. 
 
 Vomiting of bitter material that 
 is bile stained and is not 
 very great in amount. 
 
 Vomiting has no noteworthy 
 eflfect on the pain or it may 
 even increase it. 
 
 Often a chill followed by eleva- 
 tion of temperature. 
 
 Attacks are sporadic, frequently 
 with intervals of several 
 months. 
 
 Tends to radiate to the right. 
 
 Irregularity in time of onset, or 
 a longer interval after eat- 
 ing (about 5 hours). 
 
 The nature of the food is of 
 comparatively slight effect. 
 
 The left lateral position is often 
 badly borne and is accom- 
 panied by a feeling of pain- 
 ful traction on the right. 
 
 Urine in some cases contains 
 bilirubin or urobilinogen. 
 
 Numerous as the differential signs are, it may in 
 some cases be exceedingly diflScult to distinguish, be- 
 tween these widely separated pathological condi- 
 tions. On the one hand, there are cases of very slight 
 
186 PAIN 
 
 pyloric stenosis in whicli there is good compensation 
 and the objective cardinal symptoms are absent or 
 few, but in which, possibly in consequence of gen- 
 eral irritability of the nervous system, the attacks 
 of pain may be extremely severe; while on the other 
 hand cholelithiasis may be accompanied by symp- 
 toms such as gastralgia, or pain due to adhesions 
 between gall-bladder and duodenum, which arouse 
 the suspicion of a pyloric stenosis due to ulceration. 
 Finally, of course, the two conditions may coexist. 
 
 Tuberculous Intestinal Ulceration. — Ulcerative 
 processes in the small intestine causing stenosis 
 may give rise to error, particularly if the intestinal 
 symptoms are not well marked. So in one case 
 observed by the author which came to operation, the 
 stools were normal, gastric symptoms, comprising 
 dilatation with persistent splashing, vomiting, etc., 
 were prominent, the effect of diet was as in pyloric 
 stenosis, but the condition was one of very slight 
 chronic intestinal stenosis due to tuberculous ulcera- 
 tion. In this connection attention should be directed 
 to pain in the lower abdomen, which generally does 
 not occur in pyloric colic. On the other hand, I 
 attach little diagnostic value to visible intestinal 
 peristalsis of slight degree, particularly if the ab- 
 dominal wall is relaxed and thin. I have frequently 
 seen this at the acme of gastric peristalsis in un- 
 doubted cases of pyloric stenosis, and regard it as 
 being due to a sort of sympathetic activity. Further 
 differential points may be found in the chapter on 
 gastric ulcer. 
 
DIGESTIVE SYSTEM 187 
 
 GASTRIC CANCER. 
 
 In view of the various anatomical lesions accom- 
 panyiag the development of gastric carcinoma, such 
 as pyloric stenosis, ulceration, perigastritis, meta- 
 stases in the liver, retroperitoneal glands, etc., as 
 well as direct extension to neighboring structures, 
 it might well be expected that the course of the dis- 
 ease would be accompanied by pain. As a matter 
 of fact this is true in a certain number of cases, and 
 the character of the pain as well as its modifying 
 factors often indicate the manner of its causation. 
 
 Pain as an Eaely Symptom. — ^While pain not 
 rarely begins very early, often at a time at which 
 anorexia has not yet set ia and the general condition 
 is good, this is to be explained by the fact that in 
 most such instances the growth has commenced very 
 near the pylorus and is causing obstruction at that 
 point. This stricture of the pyloric region, which 
 at first is probably purely spasmodic, manifests itself 
 in a series of subjective sensations which, according 
 to the degree of stenosis and other circumstances, 
 such as the motility and total acidity, closely re- 
 semble those described in the section on pyloric colic. 
 At any rate, these subjective sensations precede the 
 objective evidences of pyloric stenosis, such as gas- 
 tric rigidity, by a considerable period of time, and 
 this very fact gives them a distinct importance. 
 This spontaneous pain due to the early onset of 
 pyloric stenosis may be contrasted with other arti- 
 ficially evoked pains that indicate ulceration and are 
 the result of the anatomical process (new growth 
 
188 PAIN 
 
 formation and ulceration) per se. We must there- 
 fore discuss : 
 
 I. Pain due to tlie local process, which, usually 
 leads to pyloric stricture. 
 
 II. Pain caused by the local invasion of other 
 organs, or distant metastases. 
 
 III. Pain resulting from inflammatory complica- 
 tions, such as perigastritis and local or diffuse 
 carcinomatous peritonitis. 
 
 I. A priori it might be expected that the phe- 
 nomena comprised under this heading would be iden- 
 tical with those described in the section on pyloric 
 stenosis which was devoted to the benign cicatricial 
 stenosis. One would suppose that the malignancy 
 of the ulcerative process would not alter the char- 
 acter of the pain. In fact, there are cases of gastric 
 carcinoma which during their entire course are ac- 
 companied by just such painful phenomena, pecu- 
 liarities of radiation, etc., as were described in the 
 chapter referred to. In general, however, the inten- 
 sity of the spontaneous attacks is less and the 
 progress of the stenosis and increased activity of 
 peristalsis are often accompanied by a marked de- 
 crease in the pain, so that it may be said that be- 
 nign pyloric stenosis is much more painful than the 
 malignant form. The rather paradoxical-appearing 
 fact that the malignant stenosis is exceeded in pain 
 by the benign process is readily explained on more 
 careful consideration. The mere decrease in appe- 
 tite accompanying carcinoma causes dietary errors 
 — ^which are so often responsible for attacks of colic 
 
DIGESTIVE SYSTEM 189 
 
 in benign stenosis — to be much, rarer. In addition 
 the musculature of the carcinomatous stomach early 
 becomes atonic, whereas in ulcer it is more likely 
 to be hypertonic, or at least in a condition of irritable 
 weakness, which renders it easily excitable and prone 
 to spasm. At the very beginning of the affection 
 the pain in carcinoma may present great similarity 
 to that of ulcer. While the appetite is still good, the 
 dietary is not appropriately restricted, and therefore 
 the early stages of a carcinoma are sometimes accom- 
 panied by very intense pain. One of the most fre- 
 quent initial symptoms of cancer of the stomach is 
 a sensation of pressure in the epigastrium, usually 
 occurring about half an hour after eating. Some- 
 times this is simply a disagreeable, uncomfortable 
 feeling, but in others it already has the quality of 
 pain. The patients often speak of "a heaviness in 
 the stomach." This sensation of fulness, tension, or 
 pressure in the epigastrium, sometimes accompanied 
 by "burning," appears to correspond to the first 
 degree of commencing narrowing of the pylorus, and 
 may be the result of a functional spasmodic stenosis, 
 for at this time other objective symptoms of perma- 
 nent organic stricture are usually absent. Some- 
 times it is possible at the moment of appearance of 
 this sensation, which frequently lasts for only a 
 short time, to detect a momentary air-cushion resist- 
 ance in the epigastrium due to a wave of contraction 
 of the organ. If the stenosis increases, stronger 
 contractions striving to overcome the obstruction 
 appear, and these are manifested to the patient as 
 
190 PAIN 
 
 pains of a knife-like boring and twisting character. 
 Sometimies the sensation is described "as if a ball 
 were rolling around." These are true colic pains 
 and the spasmodic contraction in the epigastrium 
 may become exceedingly violent; in such cases it is 
 usually followed by vomiting. 
 
 Accompanying Symptoms. — These variously 
 graduated sensations, ranging from a simple feeling 
 of pressure to colicky pain, may be accompanied 
 by other manifestations also differing in intensity. 
 The slight initial grades of stagnation and the sub- 
 jective sensation of simple pressure, which often is 
 not really painful, may be accompanied by eruc- 
 tation of small quantities of acid fluid, frequently 
 accompanied by heartburn, or there may be belch- 
 ing of odorless gas; while in benign stenoses the 
 gas has the odor of putrid eggs (SH2). Copious 
 vomiting, or indeed vomiting at all, does not usually 
 occur during this initial stage of epigastric pressure 
 after eating. It has already been pointed out that 
 not infrequently advanced malignant stenoses ex- 
 hibit a contrast between the intensity of the stenosis 
 and the slightness of the pain, and an explanation 
 for this has been offered. If a benign stenosis be- 
 comes malignant an apparent improvement may re- 
 sult, as the attacks of pain sometimes become less or 
 cease entirely. It may also be mentioned that in 
 malignant stenosis bile-stained, yellow-colored vomi- 
 tus is more frequent than in cases of benign stricture, 
 owing to the absence of marked pyloric spasm in the 
 former condition. 
 
DIGESTIVE SYSTEM 191 
 
 The vomiting of a coffee-ground character, which 
 occasionally" accompanies the benign stenoses, has 
 been mentioned abova In the stage of simple epi- 
 gastric pressure, anorexia is not usually present. 
 On the other hand, there is a certain amount of intol- 
 erance for meat and solid food, especially cooked 
 food, and, even earlier, intolerance for vegetables 
 and for beer. Sluggishness of the bowels deserves to 
 be mentioned as a symptom which is occasionally 
 very early in its occurrence and is rarely absent in 
 the later stages. 
 
 Chemical and microscopical examinations of the 
 stomach contents are rarely decisive during this 
 initial stage of subjective symptoms. It is always 
 well to note the presence of slight bulging of the 
 epigastrium, especially in its left half, which repre- 
 sents a rudimentary peristalsis and is present espe- 
 cially after the taking of food. This symptom, of 
 course, as well as the rigidity of the epigastrium 
 which comes a little later, depends more or less upon 
 the development and natural stiffness of the abdom- 
 inal muscles. 
 
 Occasionally the colicky pains occur two or three 
 hours after meals. In other cases they show a de- 
 cidedly nocturnal type (eleven o'clock at night, last- 
 ing until about two a.m.). Frequently, however, 
 they follow directly upon the taking of food. The 
 feeling of heaviness, especially, occurs either imme- 
 diately upon, or within a half hour after, the taking 
 of food. Only in very rare cases are these pains 
 postponed for a longer interval than six to seven 
 hours after a large meal. 
 
192 PAIN 
 
 In regard to the abdominal regions involved, a 
 great similarity with the previous conditions may be 
 observed. In many cases, for instance, there is a 
 definite relation between the posture of the patient 
 and the pain. When the patient lies on the right 
 side, there is commonly an increase of pain, abdom- 
 inal bulging, and nausea. Here, as in the case of the 
 pain accompanying pyloric stenosis, the suffering is 
 immediately ameliorated by the belching of gas and 
 by vomiting. In every respect where the mechanical 
 agencies are involved the analogy of this condition 
 with pyloric stenosis is so close that the subject can 
 be dismissed by referring to the chapter on pyloric 
 stenosis. 
 
 There is a marked similarity also in regard to the 
 influence of diet upon the pain. The sensations of 
 pressure and of hunger which so frequently occur 
 ia neuroses of the stomach, in which the pain is 
 alleviated by the taking of food, occur but rarely in 
 this condition. It is an almost invariable rule that 
 food increases or begins the pain, and in this respect 
 the quality of the food plays a very important role, 
 the most troublesome articles of food being boiled 
 beef, heavy vegetables, rye bread, and fluids of all 
 kinds, especially beer and acid wines. 
 
 We have still to consider th'e localization of the 
 pain, and in this connection we must differentiate 
 between 
 
 (a) Spontaneous pain, and 
 
 (b) Artificially induced pain produced by pres- 
 sure and percussion. 
 
DIGESTIVE SYSTEM 193 
 
 (a) Spontaneous Pain. — The pain is usually pro- 
 jected forward into th.e epigastrium. More rarely 
 it is situated retrosternally under the lower half of 
 the sternum. In the epigastrium there may be vari- 
 ations in the position of the pain just as in gastric 
 ulcer. In some cases the left side of the epigastrium 
 becomes the most painful area; in other cases the 
 mid-line is the seat of greatest pain; and, again, 
 in other cases, the suffering is chiefly localized over 
 the pyloric region. The subjective pain may remain 
 localized here, or, just as in benign stenoses, it may 
 radiate especially into the loins and back, toward 
 the hypochondriac regions, and occasionally even 
 into the shoulder blades. The pain which occa- 
 sionally is noticed as radiating up behind the ster- 
 num into the throat is usually accompanied by re- 
 gurgitations of the acid stomach contents, and may 
 easily be controlled by small doses of alkalies. 
 This must not be confounded with the sensation of 
 a foreign body rising upward, or the globus hys- 
 tericus, occurring in hysteria. Those patas in the 
 back which are produced by a pyloric stenosis and 
 secondary dilatation of the stomach as such, and not 
 by metastases, are in direct proportion to the epi- 
 gastric pains, are increased and decreased with 
 these, and are simply backward radiations of these 
 pains. Their appearance seems to be favored by 
 constipation and they disappear with thorough 
 emptying of the bowels. Such pains may occasion- 
 ally be produced when the stomach is artificially 
 inflated, a fact which may be regarded as important 
 in clearing up the mechanism of such sensations. 
 
 13 
 
194 PAIN 
 
 (b) Artificially Induced Pain.— Not infrequently 
 it is possible to map out by palpation, and occasion- 
 ally even by percussion, a definite bypersesthetic 
 zone in tbe epigastrium, wHcb frequently corre- 
 sponds to tbe position of tbe tumor. In tbose cases 
 wbere a tumor is impalpable on account of its small 
 size or of great muscular development of tbe epi- 
 gastrium, tbe localization of sucb a bypersestbetic 
 area may, if cautiously interpreted, give mucb diag- 
 nostic aid. If sucb a zone be placed asymmetrically 
 on tbe left or rigbt side below tbe costal border, it 
 will be more wortby of notice tban if placed mesially. 
 
 As in gastric ulcer, tbe vertebral column in its 
 interscapular and dorsolumbar regions, as well as 
 in tbe left lumbar region, is frequently painful to 
 percussion. 
 
 II. Following tbe classification proposed above, 
 we are now about to deal witb tbose painful sensa- 
 tions wbicb depend upon local extension of tbe proc- 
 ess as well as upon metastases into otber regions. 
 Tbese are, of course, of mucb less importance, since 
 we are no longer dealing witb early symptoms ; on 
 tbe otber band, tbey will find furtber mention wben 
 we reacb tbe discussion of organic pains of otber 
 regions (bepatalgia, etc.). 
 
 Tbese pains, in contradistinction to tbose dealt 
 witb above, are differentiated in general by tbeir per- 
 sistence and by tbeir independence from digestive 
 influences, so tbat even wben localized in tbe epigas- 
 trium (metastases into tbe liver, pancreas, and 
 glands), tbey are easily separated from tbe pains 
 previously described. 
 
DIGESTIVE SYSTEM 195 
 
 III. Inflammatory complications are often the 
 basis for the pain occurring with gastric carcinoma ; 
 this may be more or less local, as in fibrinous or 
 purulent perigastritis, or diffuse, as in carcino- 
 matous peritonitis. 
 
 The new growth itself does not seem to be par- 
 ticularly sensitive to pressure. In cases where a 
 more severe sensitiveness to pressure exists, we are 
 usually dealing with a superimposed inflammatory 
 process in the ulcerated tumor mass. A localized 
 peritonitis may occasionally be evidenced by a 
 noticeable leather-like creaking brought out by pal- 
 pation. The motion of the tumor mass in such cases 
 produces pain by rubbing against the inflamed por- 
 tions of the peritoneum. This may be brought about 
 by coughing, bending forward, pressure during defe- 
 cation, deep breathing, etc. 
 
 Eapid changes of position also (from the dorsal 
 position to the right or left) may in the same way, 
 by producing sudden motion of the tumor, give rise 
 to local pain. Whenever the perigastric process 
 extends, giving rise to subphrenic abscesses or to 
 pleurisy, which seems to occur usually on the left 
 side, pain will occur, on this side in the lower inter- 
 costal spaces, in addition to the epigastric pain. 
 
 But in cases where the peritoneum, as a whole, 
 is involved in the carcinomatous process inflamma- 
 tory changes usually take place and give rise subjec- 
 tively to general abdominal tenderness, and to a 
 painful sensation of general distention. 
 
196 PAIN 
 
 The pain wHch depends upon peritoneal involve- 
 ment may frequently be influenced by local treatment 
 (sapo kalinus, tincture of iodine, alcoholic com- 
 presses, etc.) ; on the other hand, lavage, which fre- 
 quently relieves pains due to stagnation in the 
 stomach and overdistention of its walls, increases 
 the pain when we are dealing with a perigastric con- 
 dition, in that it is contrary to the first principle 
 of treatment in inflammatory processes, i.e., immo- 
 bilization. 
 
 It is only after a careful consideration of all the 
 elements involved, and a careful physical examina- 
 tion, that we can reach the conclusion that certain 
 pains are due to the development of a gastric carci- 
 noma. Of the most practical importance are the 
 epigastric sensations which have been described un- 
 der I., and which appear at a time when other symp- 
 toms, such as anorexia, progressive emaciation, 
 achlorhydria, etc., are still absent, and the patient 
 is as yet unaware of any severe illness. 
 
 In this connection all those conditions which have 
 been mentioned under gastric ulcer and pyloric 
 stenosis must again be considered in making the 
 differential diagnosis. The greatest difficulty will 
 be encountered in the exclusion of gastric ulcer, both 
 in its development and in its recurrence. Suspicions 
 of carcinoma will be strengthened when the general 
 symptoms of gastric ulcer and anorexia persist, in 
 spite of rest in bed and regulation of the diet. The 
 greater the effect of mechanical factors in influenc- 
 
DIGESTIVE SYSTEM 197 
 
 ing the pain, the less the likelihood of the condition 
 being a gastric neurosis. Difficulty may occasionally 
 be experienced in separating carcinoma of the 
 stomach from the dyspepsia which accompanies 
 cases of chronic tuberculosis. This may occur with 
 but slight involvement of the lungs and may give rise 
 to such extreme anorexia and progressive emacia- 
 tion that the suspicion of early carcinoma is aroused. 
 These cases, however, are rarely accompanied by 
 the attacks of spontaneous epigastric pain seen in 
 carcinoma. Even in tuberculosis it is not rare to 
 find epigastric tenderness, and this is easily ex- 
 plained by oversensitiveness at the insertion of the 
 recti, produced by severe paroxysms of coughing. 
 
 TUBERCULOUS INTESTINAL ULCERATION AND 
 INTESTINAL STENOSIS.* 
 
 Ulcerations of the gut give rise to more or less 
 characteristic phenomena of pain, though they do 
 this less regularly than do ulcerations of the 
 stomach. Tuberculous ulcerations are the most fre- 
 quent, and they may be taken as an example of 
 intense intestinal ulcerative and obstructive condi- 
 tions throughout. Tuberculous ulcerations, how- 
 ever, give rise to attacks of pain more characteristic 
 than those arising from other intestinal ulcers (for 
 instance, those of typhoid and dysentery). This is 
 because they have a greater tendency to produce ste- 
 nosis, and during their existence the pain is less defi- 
 
 • Cf. page 63. 
 
198 PAIN 
 
 nitely under dietetic control than is generally the 
 case in typhoid and dysentery. 
 
 Similarly to gastric ulcers, the tuberculous ulcera- 
 tions of the gut may remain entirely latent. This, 
 however, is not frequently the case. The production 
 of stenosis is here, as in conditions of the stomach, 
 one of the chief causes of pain; added to this, of 
 course, are the conditions of enteritis, abnormal fer- 
 mentation, and the peritoneal lesions produced by 
 perienteritis. The following observation may serve 
 as an example of the colic produced by tuberculous 
 stenosis of the gut, and also illustrates how acutely 
 the first symptoms may set in, in spite of the chro- 
 nicity of the process. 
 
 A maid-servant, eighteen years of age, was taken on November 4, 
 1906, with anorexia and during the following eight days there 
 were no movements from the bowels, which previously had been 
 regular. Severe colic followed within ten minutes on taking bread, 
 meat, or cold fluids. The pain began in the epigastrium and 
 radiated to the ileocsecal region. There was no vomiting. The 
 stools were hard and of lead pencil type, or else of mucous fluid, 
 containing lactic acid bacilli in great numbers. Later the attacks 
 began in the ileocsecal region and radiated upward to the epigas- 
 trium. From November 10 to 18, the pain was almost continuous 
 night and day with only five-minute intermissions; the bowels were 
 kept open by means of cathartics. During the seizures she felt as 
 if the intestines were tearing open, and she would run about the 
 room. Cordials gave some relief to the pain, but changes of posi- 
 tion had no effect. The pressure of the waistbands was painful. 
 There was seen to be active periumbilical peristalsis, there was no 
 noteworthy distention in the flanks, but there was loud intestinal 
 gurgling. Movable dulness could be demonstrated in the flanks. 
 There was much indican in the urine, which also gave strong acetone 
 and diacetic acid reactions. The stools now were mucous, with 
 pus, red blood-cell shadows, and many lactic-acid bacilli. On Novem- 
 
DIGESTIVB SYSTEM 199 
 
 ber 19 there was slightly fecal vomiting with many lactic acid 
 bacilli. At the operation in Hochenegg's clinic it was found that 
 about 3 cm. above the ileocecal valve the ileu was the seat of 
 a cicatricial stricture for a, distance of 5 cm. and was sharply 
 angulated. Above the stenosis the gut was much distended and 
 hypertrophied. 
 
 The pain accompanyiag stenoses is closely analo- 
 gous to the colic resulting from pyloric stenosis. 
 Even the localization of the pain is occasionally very 
 similar, so that the patient when consulting the 
 physician describes it as epigastric. Spontaneous 
 pains frequently begin in the epigastrium. Eadia- 
 tion, in these cases, towards the ileocsecal region is 
 of considerable importance, since such radiation is 
 very uncommon in gastric conditions. This may be 
 due to the anatomical position of the lesion, since 
 the ileocaecal region is involved with special 
 frequency. 
 
 Pain is noticed in the umbilical region rather 
 more frequently than in the epigastric ; here it may 
 occur to the right or left of the mid-line, and may 
 extend to both sides, encircling the body. The most 
 common seat of the pain, however, is the hypogastric 
 region, and here it occurs especially in the right side. 
 The pain is usually projected forward; it rarely 
 is localized in the back; but when it is, the posterior 
 pain is always accompanied by the anterior pain, 
 and is directly dependent upon the taking of food. 
 
 The objective pains produced by pressure or per- 
 cussion generally correspond, in localization, with 
 the subjective ones; therefore the ileocaecal region 
 
200 PAIN 
 
 is almost always sensitive. This is likewise true 
 of the hypogastrium, especially when there is dis- 
 tention. There is frequently a well-localized pain- 
 ful zone in the neighborhood of the umbilicus which, 
 especially if situated above the umbilicus, gives rise 
 to a suspicion of gastric ulcer. In such cases it is 
 important to determine whether or not this area of 
 pain is situated above or below the major curvature 
 of the stomach. 
 
 The time of occurrence of the pain is, in many 
 cases, in direct relation to the taking of food. This 
 is especially noticeable in connection with the large 
 meal in the middle of the day, which is followed, 
 with more or less regularity, within one half to one 
 hour, by attacks of pain which may last for several 
 hours. While the length of this interval between 
 the meal and the onset of pain varies greatly in dif- 
 ferent individuals, there is great constancy in the 
 duration of the interval in the same individual, in 
 that attacks occur in one case with great regularity 
 in from three to four hours, in other cases in from six 
 to seven hours after meals. Whenever a very short 
 time elapses between the meals and the appearance of 
 the pain, we are undoubtedly dealing with a stimula- 
 tion of intestinal peristalsis produced by the food 
 still remaining in the stomach; and it is this peri- 
 stalsis which produces the pains in the ulcerated 
 area. It is important to note that patients with this 
 form of intestinal ulceration may experience entire 
 freedom from pain during intervals often lasting 
 for months. As the disease progresses, these free in- 
 
DIGESTIVE SYSTEM 201 
 
 tervals become shorter and shorter, until the attacks 
 are of daily occurrence ; this is due, of course, to the 
 constantly increasing stenosis. 
 
 Mechanical Considerations, — Since the condition 
 is most frequently localized in the ileocaecal region, 
 the paiu is usually most severe in this region. Thus 
 the patients, when lying on the left side, complain of 
 feeling as though something were being drawn from 
 the ileocaecal region into the left side, while when 
 lying on the right side the pain is directly localized 
 ia this region. In general, the position on the left 
 side is less painful than that on the right. This is 
 undoubtedly due to the traction brought about by 
 the weight of the diseased gut and of the involved 
 glands, a traction which is the more painful because 
 peritoneal inflammations and adhesions are com- 
 paratively frequent. 
 
 The condition may be confused, with cases of 
 acute and chronic appendicitis where the same pecu- 
 liarities as to the relation of pain and position are 
 present. This error is more easily made because 
 in both of these conditions the patient will be re- 
 lieved by flexion of the right leg at the hip through 
 relaxation of the abdominal muscles during the 
 attacks. 
 
 The pain which is elicited in circumscribed areas, 
 especially the hypogastric and umbilical regions, by 
 jarring of the body, as in coughing, walking down- 
 stairs, rapid turning and deep inspiration, is easily 
 explained by the correspondingly localized inflam- 
 matory processes in the peritoneiun. 
 
PAIN 
 
 A number of other minor symptoms unquestion- 
 ably depend upon the fact that the intestinal pain 
 is frequently accompanied by local or general dis- 
 tention. Thus the patients, during their attacks, 
 rub the hypogastrium, place their hands upon their 
 hips and turn the trunk upon the pelvis in an in- 
 stinctive attempt to cause a general distribution of 
 the local distention. The same fact explains the 
 relief produced by enemata, by vomiting, or by the 
 discharge of gas per os or per anum, all of which 
 bring about a relief of the distended intestinal wall. 
 
 The influence of the diet upon the pain is depen- 
 dent upon this very question of distention; and the 
 same conditions which we considered in speaking of 
 gastric idcer and of pyloric stenosis must be taken 
 into account here. In the first place, those articles 
 of diet which give rise to fermentation will cause 
 pain. Chief among these are cabbage, turnips, len- 
 tils, potatoes, pastries prepared with yeast, rye 
 bread, beer, not infrequently mUk, and furthermore 
 all those ailicles of diet which are apt to constipate. 
 
 Great pain can be produced by those articles of 
 diet which produce active peristalsis when present 
 in the stomach; this probably explains the attacks 
 of pain which regularly occur a few minutes after 
 the ingestion of cold beverages (water, nailk), strong 
 coffee, and certain drugs, as thiocol; on the other 
 hand, these very articles which stimulate peristalsis 
 may aid in relieving local distention and thus have 
 the opposite effect. Direct chemical irritation of 
 the ulcerated areas probably occurs very rarely; 
 
DIGESTIVE SYSTEM gOS 
 
 but if it does occur this may explain the production 
 of pain by very acid food such as salad. More fre- 
 quently mechanical injury may be caused by the 
 ingestion of solid food, especially raw fruit ; so that 
 in general a flidd or semi-solid diet is to be preferred. 
 
 It is self-evident that the quantity of food intro- 
 duced may, by its filling of the intestine, become a 
 serious consideration in the production of pain. 
 
 Just as the introduction of cold substances may 
 produce pain by their active stimulation of peri- 
 stalsis, so also thermic influences brought to bear 
 from without may play a similar role. 
 
 Chilling of the feet seems to have special in- 
 fluence in initiating attacks of pain. Thus attacks 
 may be brought on by walking upon a cold floor with 
 bare feet. This is, in general, a peculiarity of pains 
 due to intestinal peristalsis and may have a certain 
 amount of differential value. Applications of cold 
 compresses to the abdomen, in that they relieve dis- 
 tention, usually have a favorable influence; while 
 the application of heat often increases the pain. 
 
 The secondary symptoms are especially impor- 
 tant because they so frequently give rise to errors 
 in diagnosis. 
 
 The importance of this fact is well illustrated by 
 those cases of tuberculous ulceration which are 
 accompanied by gastric symptoms, vomiting and 
 belching. The vomiting is often in large quantities, 
 and in the vomitus there are frequently particles 
 of food which have been ingested several days be- 
 fore. In these cases we are unquestionably 'dealing 
 
204. PAIN 
 
 with, stagnation in the stomach, secondary to the ob- 
 struction in the gut. The very facts that the vomit- 
 ing is copious, that the microscopical examination 
 points to stagnation, and that the clinical signs 
 obtained on palpation indicate modeiate dilatation, 
 may give rise to the erroneous diagnosis of pyloric 
 stenosis. This error may be more easily made since 
 th.e pain in these cases is often localized in the epi- 
 gastrium, and occasionally there may be an entire 
 absence of symptoms referable to the intestines, 
 such as diarrhoea, or even irregularity of the bowels. 
 
 In doubtful cases it is particularly important to 
 remember that, in contrast with pyloric stenosis, 
 the vomitus frequently contains bile, and the pains 
 are radiated either into the hypogastrium, or, more 
 frequently, into the ileocsecal region . The discovery 
 of sarcinsB in the vomitus is pretty positive indica- 
 tion of the gastric nature of the condition. On the 
 other hand, the presence of large numbers of lactic 
 acid bacilli in the faeces or vomitus, is not to be taken 
 as direct evidence of a malignant pyloric stenosis. 
 These organisms may also be found in tuberculous 
 stenosis of the small intestine, and if discovered in 
 the stools may be of assistance in making this diag- 
 nosis. 
 
 DiarrhcEa, especially the very foul variety which 
 occasionally accompanies tuberculous ulcerations, is 
 almost unknown in cases of pyloric stenosis. These 
 are almost invariably accompanied by constipation. 
 For this reason, too, the succussion noticed occasion- 
 ally in cases of tuberculous ulceration is extremely 
 rare in pyloric stenosis. 
 
DIGESTIVE SYSTEM 205 
 
 It is sometimes extremely difficult to distinguisli 
 the condition under consideration from acute or 
 chronic appendicular inflammations. This is true 
 particularly because the point of maximum tender- 
 ness may often be located in the right ileoeaecal re- 
 gion, and paraBsthetic sensations may occur on the 
 inner surface of the right thigh. Flexion of the 
 right leg at the hip during the attacks and slight 
 distention of the right ileocascal region aid in confus- 
 ing the picture. Occasionally bladder symptoms are 
 present, due to pressure of the full bladder upon the 
 inflamed parts. 
 
 Grreat help can be derived in such a confusion of 
 evidence from a positive diazo reaction ; ia contrast 
 to appendicitis, too, ulcerations of the gut even dur- 
 ing the colicky attacl^s may be entirely free from 
 temperature. Added to this we may have a previous 
 history of long-continued symptoms of slight intes- 
 tinal obstruction and the general evidences which 
 point to tuberculous trouble, night-sweats, pul- 
 monary symptoms, etc. 
 
 In those cases in which the stenosis is slight, vis- 
 ible peristalsis is often limited, and is noticeable par- 
 ticularly in the ileoeaecal region and in the immediate 
 neighborhood of the umbilicus. The peristalsis is 
 often accompanied by crackling sounds produced by 
 the passage of gas through the stenosis, which is fol- 
 lowed by relief from pain as the pressure upon the 
 overdistended gut is diminished. While occasion- 
 ally slight chilly feeliags, or in severe cases even col- 
 lapse, may occur in this condition, a true shaking 
 chill is extremely rare. 
 
206 PAIN 
 
 It would be impossible to review all the condi- 
 tions which, make a differential diagnosis in this con- 
 dition difficult. It is, however, advisable to be sus- 
 picious of tuberculous ulceration of the gut in all 
 those cases of abdominal pains of colicky nature in 
 which there are any other factors in the history or 
 in the physical examination which point to a tubercu- 
 lous tendency in the patieat. 
 
 DISEASES OF THE APPENDIX. 
 
 It is not wise to speak in a vague way of "appen- 
 dicular colic." The acute or chronic inflammatory 
 conditions of the appendix originate from a variety 
 of causes, and it is necessary to understand clearly 
 the pathological basis of the pains which occur in 
 each of these conditions in order to draw diagnostic 
 conclusions from them. It is generally assumed that 
 the colicky pains in appendicular conditions are 
 primarily due to the intra-appendicular pressure of 
 inflammatory exudates, which cause contractions of 
 the musculature, and a condition not unlike neural- 
 gia. This is an assumption which has much in its 
 favor and cannot be dismissed lightly. This explan- 
 ation of the pains, however, is entirely insufficient 
 for the more chronic conditions where the appendix 
 is well imbedded in the surrounding inflammatory 
 'thickenings. Here, of course, distention of its 
 lumen and contraction of its muscular walls are 
 quite out of the question. I should like to suggest 
 that it is quite possible that many of these so-called 
 cases of appendicular colic are nothing more than a 
 
DIGESTIVE SYSTEM 207 
 
 simple intestinal colic reflexly initiated in the appen- 
 dix, and even the stomach may be involved in this 
 way. In these cases intestinal inflammations seem 
 frequently to have preceded, the attack of appendi- 
 citis occurring during an acute exacerbation of 
 these. This assumption would be supported by 
 the frequency with which the parasitic flora of the 
 feces is changed from the normal in cases of appen- 
 dicitis, and would explain the previous diarrhoeas 
 which often are present during the early develop- 
 ment of appendicitis. 
 
 Comparison of the pains in appendicitis with 
 those in tuberculous ulceration of the intestine 
 shows many points of similarity. Distinction be- 
 tween the conditions would be almost impossible, as 
 far as the pains themselves are concerned, were it 
 not that in contrast to the intestinal pains of other 
 diseases, in appendicitis we have added the pains 
 due to peritoneal inflammation, and from this a 
 number of important differential symptoms can be 
 deduced. 
 
 The early pains of appendicitis rarely corre- 
 spond ia localization to the position of the appendix. 
 Usually the pains begin diffusely in the umbilical 
 and hypogastric regions, occasionally in the epigas- 
 trium, and differ in nothing from the pains of ordi- 
 nary intestinal colic following errors of diet, or 
 acute gastro-enteritis. The suspicion of appendi- 
 citis at this stag© is not aroused by the character of 
 the pains but depends upon the secondary symptoms, 
 such as temperature, etc., and the absolute absence 
 of the usual causative agents of intestinal colic. It 
 
208 PAIN 
 
 is only the rare cases which begin with localized 
 pain over the appendix, or even with a distinctly 
 right-sided pain. Occasionally, there may appear 
 radiations of the pain into the right inguinal or 
 Ittmbar regions, and this seems to depend upon a 
 retrocsecal position of the appendix. It is extremely 
 important in these cases to determine whether or 
 not there is radiation into the right thigh. This is 
 not often found, but when present may be regarded 
 as characteristic of true appendicular colic, since 
 it never occurs in the ordinary pains of the intes- 
 tinal peristalsis. Such radiation is not commonly 
 seen in intestinal colic, but it does sometimes accom- 
 pany painful affections in the female pelvis, and may 
 occur in conjunction with distention of the caecum 
 with gas ia neuropathic persons. In contrast to 
 them, however, we have pains which are due to the 
 localized peritonitis or peri-appendicitis, and these 
 are situated more exactly over the position of the 
 appendix. 
 
 On the other hand, it must not be overlooked that the severest 
 appendicular lesions, even perforation, may exist without tenderness 
 in the region of the appendix. Other regions may then be sensitive, 
 however, for example above Poupart's ligament on the left side. 
 
 Extension of such processes and the formation 
 of abscesses will lead to pressure pains in the right 
 inguinal region, as well as to extreme tenderness 
 upon rectal examination (abscess in the pouch of 
 Douglas). These local peritonitic pains are very 
 sharply defined, and are of extreme importance in 
 differential diagnosis. 
 
DIGESTIVE SYSTEM 209 
 
 There are three principal elements which under- 
 lie the causation of pain in such conditions, which 
 will have to be discussed in greater detail. 
 
 1. Pressure. — There is, almost invariably, pain 
 upon pressure in the ileocsecal region corresponding 
 to the location of the disease. This pain is subject 
 to wide variations in intensity. It is usually great- 
 est during the stage of abscess formation, when 
 the abscess wall is subject to great distention. In 
 such cases the slightest pressure, even the weight of 
 the bed-clothes, will be marked by extreme agony. 
 Pain upon pressure may occasionally exist in the 
 right flank as well, especially in cases where abscess 
 formation occurs retrocsecally. When the tender- 
 ness is situated high up under the right costal bor- 
 der, it is probable that the pain is chiefly of peri- 
 toneal origin. It has frequently come to my notice, 
 however, that when the bowels have been freely 
 moved by an enema (for instance, five grams of glyc- 
 erin) the sensitiveness diminishes immediately upon 
 reduction of the distention. This indicates unques- 
 tionably that the pressure of the distended intes- 
 tinal walls upon their inflamed serous coverings 
 may play an important role in the mechanism of 
 these pains; this may also explain those less fre- 
 quent cases in which the sensitiveness to pressure 
 is greater over the left half of the abdomen above 
 Poupart's ligament, than to the right, intestinal 
 distention being more intense on that side. When 
 the appendix itself is pressed upon, radiation of the 
 
 14 
 
210 PAIN 
 
 pain often occurs towards the epigastrium and into 
 tlie left hypogastrium. 
 
 "We have already considered the more or less 
 traumatic pains produced by examination. Spon- 
 taneous movements of the patient produce pain in 
 the same way, especially contraction of the abdom- 
 inal and pelvic muscles. Thus the first pains fre- 
 quently occur in the ileo<jsecal region when the 
 patient stoops, sits down, sits up in bed, lifts a 
 weight or bends the body back upon the hips. 
 Sometimes even the lifting of the head when in the 
 prone position will give rise to pain. More particu- 
 larly, however, pain is caused by contracture of the 
 right ileopsoas (produced by the bending of the right 
 leg upon the hip). This motion gives rise to pain 
 in the ileocaecal region, especially severe when the 
 abdominal muscles are contracted. The pains, 
 therefore, would be greater when the patient is 
 standing, walking, or climbing stairs than when he 
 is lying down, for in these positions the diseased 
 tissues are compressed between the contracting ileo- 
 psoas and the contracting abdominal wall. It is 
 important to remember this when testing pain on 
 flexion of the right leg, for even during the exist- 
 ence of an appendicitis such motion of the right leg 
 when the patient is lying down may be entirely with- 
 out pain, while the same motion may be very painful 
 when the patient is standing or walking. Thus this 
 symptom of hip flexion is entirely dependent upon 
 the position of the body. In some cases it can be 
 elicited only when the patient is lying on his left side. 
 
DIGESTIVE SYSTEM 211 
 
 The first indication of appendicular pain has often 
 occurred during the drawing on of shoes, and here 
 again it is unquestionably a pressure pain, since the 
 patient in carrying out this motion lifts the right 
 leg and produces a contraction of the corresponding 
 pelvic muscles. While this symptom is apparently 
 trivial, it is so frequently the first indication of early 
 appendicular trouble that it may become extremely 
 important in differential diagnosis. 
 
 In some cases of early appendicitis the pain is 
 markedly increased when the patient is lying on the 
 right side, and this again is due to pressure upon the 
 inflamed parts. Because of the pain caused by these 
 muscular contractions, the patient involuntarily re- 
 laxes these muscles and thus many patients with 
 appendicitis bend fofward when walking or bend 
 toward the right side, or, when lying down, draw up 
 the right thigh and arouse by their very position the 
 suspicion of appendicitis. 
 
 2. Jabbing. — For diagnostic purposes the most 
 practical way of producing jarring of the abdomen in 
 the ilocaecal region is by percussion. With its help 
 a very exact demarcation of the area of pain can be 
 made, and it is much to be preferred for this purpose 
 to simple palpation. The pathological basis of pain 
 produced by jarring is probably the same as that of 
 the pressure pains. Percussion in the mid-line is 
 often more painful than on either side of the line be- 
 cause of the absence in this location . of muscular 
 defenses. Other forces which actively cause jarring 
 of the' abdomen are coughing, stepping on the right 
 
212 PAIN 
 
 leg in going downstairs, jumping, etc. In all these 
 cases pains are produced in the appendicular region 
 which are of a sharp, boring nature. This method 
 of pain production is frequently possible before 
 other symptoms have occurred. 
 
 3. Displacement. — ^Under this heading we will 
 consider chiefly those tearing pains which are pro- 
 duced in certain positions of the body by the weight 
 of the diseased organs. It is not surprising that the 
 slightest displacement of its kind should cause pain 
 when we consider that we are dealing with fresh in- 
 flammatory adhesions. This must be our interpre- 
 tation of the pains complained of by patients who 
 are unable to lie upon the left side, and who inform 
 us that, in this position, they feel a painful drawing 
 as though something were falling from the right to 
 the left side. When the peritoneal process has ex- 
 tended into the left side the same variety of pain 
 may be caused by the right-sided position. It is 
 clear that such pains must be primarily influenced 
 by two factors : 
 
 (1) The closeness with which the abdominal 
 organs are held together. For instance, when the 
 abdominal muscles are flabby and weak, and the 
 viscera are in consequence very loosely packed to- 
 gether, even the slightest change of position will 
 give rise to displacement. 
 
 (2) The formation of tumor in the , ileocaaeal 
 region, either in the form of exudate or of enlarged 
 glands. When the patient is lying on the left side 
 the weight of the tumor mass will exert considerable 
 
DIGESTIVE SYSTEM 213 
 
 traction, a traction wliich may, however, be exerted 
 by tbe weight of the intestinal contents themselves. 
 
 The pains described in the foregoing paragraphs 
 are all referable to the localized peritoneal inflam- 
 mation. 
 
 The general intestinal pains which are added 
 to those of more purely appendicular origin are 
 difficult of interpretation. It is not easy to say 
 whether the basis of these lies in the appendix itself, 
 or whether they are to be regarded as an accompany- 
 ing intestinal colic. The localization of these colicky 
 pains aids us but little in determining this. At any 
 rate, it seems wise to restrict the term "appendicular 
 colic" to those cases only in which, with other symp- 
 toms of appendicitis, sudden colicky pains occur 
 spontaneously without reference to previous dietetic 
 errors or other causes. 
 
 More frequently, however, the beginning of the 
 colicky attacks is directly dependent upon intestinal 
 disorders, especially those following errors in diet, 
 and it would be hard to understand how such influ- 
 ences could affect the appendix itself since the pain 
 very often appears within a few minutes of the in- 
 gestion of food. The fact that diarrhoea frequently 
 occurs in these cases points to the likelihood that we 
 are often dealing with an acute or an exacerbated 
 chronic enteritis in the course of which changes in 
 the appendix and its peritoneal surroundings may 
 occur. 
 
 The diarrhoea is of great differential importance 
 since it occurs frequently in early appendicitis, 
 
ai4 PAIN 
 
 whereas constipation is the rule in cases of lead 
 colic, gall-bladder colic, and the pains of pyloric 
 disease and diseases of the ureters. This is likewise 
 true of most of the gastric pains (ulcer and hyper- 
 chlorhydria) which may in other respects have a 
 superficial similarity to appendicitis. In this con- 
 nection the gastric crises of tabes deserve mention 
 since they are often accompanied by diarrhoea. Dis- 
 tention of the csBcum may give rise to pain which 
 can be correctly interpreted only if the entire clin- 
 ical picture is considered. The patients are usually 
 neuropathic and have irritable digestive tracts. 
 They complain of pain in the appendicular region 
 that has existed for years, is not very severe and not 
 associated with rise in temperature, but it appears 
 during periods of constipation and is relieved by 
 emptying the bowels. I have frequently elicited 
 high pitched tympany over the caecum in such cases. 
 Abuse of tobacco seems to be a predisposing factor. 
 The condition appears to be most easily explicable 
 on the assumption of a distention of the caecum, and 
 if the appendix is removed the pain usually per- 
 sists, or soon recurs. Such persons are undoubtedly 
 predisposed to appendicitis and this must be taken 
 into consideration in expressing an opinion as to the 
 prognosis. Abnormal mobility of the caecum does 
 not appear to be of especial importance. In differen- 
 tiating the condition from the ordinary acute inflam- 
 mations of the small and large intestines, our most 
 important aid lies in the localized peritoneal pains 
 which have been spoken of above; of special impor- 
 
DIGESTIVE SYSTEM 215 
 
 tance is the Mp-flexion symptom. Help may be de- 
 rived from the bladder symptoms, which aid us in 
 determining the existence of a local peritonitis. 
 These often consist of pains during micturition; 
 strong pressure is required to expel the urine, and 
 occasionally retention of urine occurs. 
 
 In differentiating the intestinal pains produced 
 by the ingestion of irritating substances or by flatus, 
 we are aided particularly by the temperature. 
 Functional enteralgia, as in mucous colitis, some- 
 times renders the diagnosis difficult. The following 
 history illustrates this : 
 
 In December, 1907, I was consulted by an American banker, 
 aged thirty years. For several years he had had attacks of colic 
 low down in the abdomen, associated with tenderness on both sides 
 and distention. Before the attacks began a, tape-worm had been 
 expelled. Immediately before the attacks faetor ex ore was notice- 
 able, and a fit of anger would be followed in about half an hour 
 by an attack of the pain. There was no fever, but if the seizure 
 was a severe one there would be slight chilliness. An enema given 
 during an attack would bring away large quantities of mucus. 
 The attacks were usually preceded by a copious evacuation, then 
 one or two days of constipation, and then the attack. 
 
 Occasionally errors are made in cases where for- 
 eign bodies, introduced per os or per anum, give rise 
 to a suspicion of appendicitis, the similarity being 
 more marked because of the increased temperature.* 
 It is often extremely difficult to differentiate appen- 
 dicular pains from those produced in inflammatory 
 diseases of the female genitals (parametrium, tubes, 
 and ovaries) ; this is especially true because often 
 
 * Cf. page 66. 
 
216 PAIN 
 
 disease of the adnexa and appendicitis occur to- 
 gether. In such cases only a very exact analysis of 
 the pains will lead to a correct interpretation. 
 
 The pains of peritoneal origin in both of these 
 conditions show great similarity. In a general way 
 however, the symmetrically bilateral location of the 
 pain, and the deeper, pelvic position of the tender- 
 ness will point more directly to parametritis than to 
 appendicitis. The influence of menstruation upon 
 the pains must be carefully considered, without for- 
 getting that it is not rare for adhesions to have 
 formed between the appendix and chronically in- 
 flamed ovaries, and that the existence of a parame- 
 tritis by no means excludes the existence of an 
 appendicitis. 
 
 Furthermore in differentiating between these 
 two conditions we may be guided by the fact that 
 enteric pains are almost never present in diseases 
 of the genitalia, and that the diet is entirely without 
 influence upon the pain. 
 
 Appendicular colic may occasionally be simulated 
 by right-sided ectopic pregnancy. During rupture, 
 pain occurs which radiates into the right thigh and 
 is accompanied by collapse and sensitiveness of the 
 abdomen. The absence of temperature, however, 
 the presence of acute anaemia, and occasionally bleed- 
 ing from the genitals, with a previous history of 
 pregnancy, and the discovery of a periuterine tumor, 
 lead us in the right direction. 
 
 Occasionally we will have to consider in the dif- 
 ferential diagnosis torsion of a right-sided ovarian 
 
DIGESTIVE SYSTEM 217 
 
 cyst, hydrosalpinx, etc. In women, too, in tlie ab- 
 sence of fever and leucocytosis, it is necessary to 
 searcli carefully for signs of hysteria, especially in 
 the abdominal regions {vis., analgesia of the umbili- 
 cal region). It is absolutely necessary, however, to 
 analyze carefully the various factors which influence 
 the pain in these cases, for, unquestionably, a true 
 appendicitis may occur in an hysterical individual. 
 Marked increase in the abdominal reflex * usually 
 enables acute appendicitis to be excluded. When 
 we consider that the appendicular pains are dis- 
 tinctly due to two components, on the one hand 
 a local peritonitis, on the other hand a colic, it is 
 plain that other inflammatory processes occurring 
 in the ileocsecal region may give rise to the same 
 symptom complex, chief among these being tuber- 
 culous, actinomycetic, and malignant processes. 
 Similarly localized tenderness may occasionally 
 occur in diseases of the kidney and gall-bladder, in 
 psoas abscesses, in right-sided pleurisy, and in pneu- 
 monia. This, however, is usually most acute just 
 below the right costal border. Psoas abscess must 
 also be excluded, especially as it may be accompanied 
 by a high leucocyte count. 
 
 LEAD COLIC. 
 
 When sudden attacks of colic occur in an anaemic 
 individual who gives a history of dyspepsia, ano- 
 rexia and constipation, and when these attacks are 
 
 ' Best elicited by picking up and pinching a fold of skin. 
 
218 PAIN 
 
 localized in tlie epigastrium and are accompanied 
 by retraction and rigidity of the abdominal walls, 
 our first thought must be of chronic lead poisoning. 
 On the other hand, it would be hasty to conclude 
 from the coincidence of colicky pains and the signs 
 of chronic plumbism that we are necessarily dealing 
 with a neuralgia of the mesenteric plexus due to lead. 
 Occasionally, other toxic conditions must be consid- 
 ered, to which patients with lead poisoning are par- 
 ticularly predisposed. Chief among these is nico- 
 tine poisoning. In cases of lead colic there is also 
 a condition of general hypersensitiveness, and the 
 patients, like the neuropathies, tend to exaggerate 
 their symptoms. It is not rare, also, to find tubercu- 
 losis in individuals with lead poisoning, and in such 
 cases we may well be dealing with tuberculous ulcer- 
 ations. Again, ulcerative processes in the stomach 
 and duodenum are not infrequent during the course 
 of lead poisoning, and may be especially favored by 
 the condition of the vessels and by a tendency to 
 spastic contraction in the stomach and intestinal 
 canal. On this account chronic plumbism and duo- 
 denal ulceration are sometimes associated. Further- 
 more, I should like to call attention to the fact that 
 in cases of chronic lead poisoning there is sensitive- 
 ness to pressure in the region of the appendix, and 
 for this reason also the question of appendicitis 
 must be considered. It goes without saying, further- 
 more, that chronic lead poisoning does not protect 
 against the colics of gall-stones and renal calculi. 
 It becomes necessary, therefore, in each case, to 
 
DIGESTIVE SYSTEM gl9 
 
 consider carefully tlie individual symptoms and to 
 analyze the pains as they occur. 
 
 In regard to the factors modifying the pains we 
 can assume that, because of the nervous origin of 
 the disease, dietetic influences do not come imder 
 consideration; and, as a matter of fact, this con- 
 clusion is justified by actual fact. The pains in this 
 condition are independent of dietetic influences. 
 This is in contrast to the state of affairs found in 
 the case of most intestinal pains (tuberculous ulcera- 
 tions and stenosis of the gut) and therefore is of the 
 greatest differential importance. It would, how- 
 ever, be silly to expect that the hyperassthetic gut of 
 chronic lead poisoning may not react forcibly to 
 errors of diet, and all those articles of food which 
 cause much flatus may in these cases give rise to true 
 colic. This, of course, would not represent a true 
 case of lead colic, but would simply consist of a 
 colica flatulenta favored by the existing lead poison- 
 ing. It is probable that in a great many cases of 
 so-called lead colic the pains are caused by the pres- 
 ence of stagnated fecal material and abnormal quan- 
 tities of gas, and thus are explained the frequent 
 prompt results gained therapeutically by high ene- 
 mata, and the observation frequently made by 
 patients that the passage of gas immediately relieves 
 the colic; in some cases, too, relief may be experi- 
 enced from vomiting. 
 
 Excessive use of tobacco is unquestionably an 
 important factor in the initiation and increase of 
 the colicky .pains, a consideration which is worthy 
 
2^0 PAIN 
 
 of notice therapeutically. Alcohol in concentrated 
 forms, such as brandy, in many cases causes diminu- 
 tion of the pains. Mechanical agencies, because of 
 the neuropathological basis of the pains, have little 
 influence. 
 
 Changes of position do not influence the pain in 
 these cases as they do in ulcerative processes or in 
 the localized peritoneal inflammations. It is fre- 
 quently claimed that pressure upon the abdomen is 
 not painful in cases of lead colic, but on the contrary 
 often relieves pain. This is true in a great many 
 instances, but cannot be regarded as a rule. Pain 
 on pressure may frequently be due to the fact that 
 there exists a severe neurasthenia which is accom- 
 panied by general hypersesthesia. In those cases 
 where gas collects, locally or diffusely, in the intes- 
 tinal tract during the attacks, it is perfectly natural 
 that there should be a certain amount of tenderness 
 to pressure over the distended intestinal coils. The 
 sensitiveness of the abdomen to pressure, therefore, 
 can give us little help in differentiating this condi- 
 tion from the peritoneal processes. Flexion of the 
 thighs upon the abdomen frequently gives relief; 
 but it is important to notice whether both thighs are 
 flexed or whether the right thigh simply, as would 
 be the case in appendicitis or in the tuberculous 
 ulcerations of the intestine. 
 
 The application of heat usually influences the 
 colic favorably. The application of cold often ini- 
 tiates an attack. Emotional excitement may fre- 
 quently give rise to a severe attack of pain. 
 
DIGESTIVE SYSTEM 2^1 
 
 The pains, which, are chiefly of a sharp, boring or 
 cutting character, and which are almost invariably 
 paroxysmal, are located priacipally about the um- 
 bilicus. Occasionally, however, they occur in the 
 epigastrium. When the attack is at its height it is 
 hard to refer pains to any particular region, and 
 they may cover the abdomen diffusely. The pain is 
 as a rule limited to the abdominal region and 
 only in the rarest cases radiates into the sternum, 
 the chest and the shoulders. On the other hand, 
 pain frequently occurs in the lumbar region, and may 
 radiate into the genitals or bilaterally into the thighs 
 (lead colic of the ureters). This latter form differs 
 from the ureteral colic due to stone in being bilateral. 
 It is important to bear this possibility in mind, for 
 in consequence of the lead nephritis the urine may 
 contain red blood-cells. 
 
 A wood turner, aged forty-six years, came under observation 
 in December, 1909. For years he had used a polish consisting of 
 shellac and white lead, and the air would be filled with dust from 
 the lead pigments employed. Bemains of the polish were found 
 about his nails and there was a lead line on the gums. As long 
 as twenty-two years ago he had had attacks of abdominal cramps 
 with vomiting and constipation. The attacks at first occurred once 
 a month. Two years ago he had a very severe one, and then there 
 was a remission until four days before admission, when there was 
 sudden, severe, cramp-like pain in the epigastrium with vomiting. 
 At the height of the attack there was radiation of the pain into 
 both testicles and down the thighs to the knees. There was vesical 
 tenesmus, but the urine was voided only drop by drop. The abdo- 
 men at first was hard and tender. During the attacks he could 
 not take solids, acids, or cold drinks. The urine contained traces 
 of albumin and of blood pigment and the sediment showed a few 
 granular and epithelial casts. 
 
222 PAIN 
 
 * 
 
 There is no radiation into the ileocaecal region, 
 as is so frequently the case in tuberculous ulcera- 
 tions. This region, however, and occasionally the 
 situation of the sigmoid flexure may be quite sensi- 
 tive to pressure. This can be easily explained by 
 the fact that in these two regions especially there is 
 apt to be stagnation of the faeces which, with slight 
 inflammatory changes, leads naturally to tenderness. 
 
 As far as the time of occurrence of these pains 
 is concerned we are able to gather no facts of differ- 
 ential importance. The very irregularity of the at- 
 tacks, which often show prolonged intervals between 
 separate seizures, should give us some clew. Attacks 
 occur more frequently during the night than during 
 the day ; but this peculiarity is common to all varie- 
 ties of abdominal colic. 
 
 The most important of the secondary symptoms 
 which accompany the colicky attacks are the follow- 
 ing. Nausea and vomiting, often an absolute intol- 
 erance for solid, or fluid food, constipation preceding 
 the attack,, sometimes ; with tenesmus, usually with 
 retraction of the abdominal wa,ll. Visible peristalsis 
 and succussion are rarely present, and are found 
 only in those cases where the constipation is of a 
 very chronic Order and where the abdominal walls 
 are extremely flabby. There , are practically no 
 alarming general symptoms. The diagnosis, of 
 course, will be much strengthened by the discovery 
 of other symptoms of chronic lead poisoning^ such 
 as a lead line, weakness of the muscles silppl'ied by 
 
DIGESTIVE SYSTEM 223 
 
 the radial nerve, and high, blood pressure. The 
 high blood pressure itself is by no means constant 
 in these cases, since it may even be diminished in 
 cases where the anaemia is severe or where tubercu- 
 losis exists as a complication. 
 
 There are other conditions which, resting on a 
 purely neuropathological basis, may also produce 
 gastro-intestinal colic, and from these we must occa- 
 sionally differentiate lead colic. Chief among these, 
 of course, would be the intestinal crises of tabes, 
 and in such cases the nervous system must be care- 
 fully examined in order to make the differentiation. 
 The crises, however, differ from lead colic in their 
 frequent association with diarrhoea. 
 
 Ulcerations of the gut with stenosis may give 
 rise to difficulty in diagnosis. Lead colic is ex- 
 cluded in such cases by the close relation of the pains 
 to the taking of food, their constancy, and their 
 definite variation upon changes of position. The 
 discovery of sarcinae in the vomitus or the faeces 
 during an attack would point quite distinctly to the 
 existence of pyloris stenosis. If, as sometimes 
 happens, lead colic is associated with catarrhal 
 jaundice the differentiation from cholelithiasis may 
 be very difficult. The possibility of confounding the 
 condition with nephrolithiasis has already been 
 mentioned. 
 
 In distinguishing lead colic from appendicitis 
 and peritonitis, our chief strongholds are the afebrile 
 course and the absence of a leucocytosis. These two 
 conditions carry with them also voluntary immo- 
 
224 PAIN 
 
 bilization of the abdomen and the patient usually 
 assumes a supine position, whereas in lead colic the 
 constant restlessness is characteristic, and the 
 patient may walk about or remain in a sitting posi- 
 tion, pressing his hands upon his abdomen. The 
 indifference of the patient to mechanical disturb- 
 ances of the abdomen is quite characteristic and 
 helps very much in differentiating lead colic from 
 other conditions. This aid is lost, however, in those 
 cases mentioned above of neurasthenic patients, who 
 occasionally show abdominal sensitiveness. 
 
 In closing, it is necessary to call attention again 
 to the fact that, even when chronic lead poisoning 
 can be definitely diagnosed, the possibility of a com- 
 plicating gastric ulcer or renal calculus must not 
 be overlooked. 
 
 MALIGNANT NEW GROWTHS OF THE INTESTINE. 
 
 There is nothing absolutely characteristic about 
 the pains occurring in the conditions we are about 
 to discuss. They may be caused by organic changes 
 and mechanical stenosis of the gut, and the disten- 
 tion and increased peristalsis dependent upon these. 
 Or, again, their pathological basis may rest chiefly 
 upon peritoneal involvement. The pains are impor- 
 tant, nevertheless, from a diagnostic point of view, 
 in that they frequently occur during the very early 
 stage of the condition when other physical signs are 
 entirely lacking. 
 
 These pains are frequently regarded as harmless 
 
DIGESTIVE SYSTEM 225 
 
 manifestations of intestinal indigestion sucli as fol- 
 low errors in diet or exposure to cold, and yet if the 
 phenomena of the pains are carefully analyzed we 
 may often find distinct reasons for believing that 
 there is a well-localized cause for the attacks. 
 Whenever this can be accomplished an important 
 diagnostic advance has been made. In dealing with 
 persons beyond middle life, with no past history of 
 digestive disturbances, the significance of attacks of 
 intestinal colic should never be underestimated, and 
 under these conditions the stools should always be 
 carefully investigated for the possible presence of 
 occult blood. 
 
 Corresponding with the localized process from 
 which they arise, there is a tendency in such cases 
 towards a localization 'of the pains. This is par- 
 ticularly true of the neoplasms of the large intestine 
 where frequently, at the very beginning of the at- 
 tacks, the pain is felt in the seat of the lesion, and, in 
 consequence, usually occurs in the caecum or in the 
 three flexures of the large gut. At the height of such 
 an attack the pain is generally diffuse, but centers 
 chiefly in the region of the umbilicus, and is fre- 
 quently accompanied by pain in the lumbar regions. 
 Whenever the obstructing process lies in the neigh- 
 borhood of the splenic flexure there may be distinct 
 radiation into the lower half of the thorax and occa- 
 sionally, though rarely, into the left leg (one case 
 of hysteria). When the neoplasm occurs in the 
 hepatic flexure the condition may strikingly simulate 
 gall-bladder colic. The pains begin in the neighbor- 
 
 15 
 
^m PAIN 
 
 hood of the gall-bladder, radiate backwards into the 
 small of the back, and frequently reach even to the 
 right shoulder blade. Eadiation towards the anus is 
 a phenomenon of extreme importance, for it indicates 
 most frequently a deep-seated carcinoma of the sig- 
 moid flexure. Occasionally it may accompany new 
 growths which are situated higher up in the colon, 
 but whenever it is present it appears to the writer 
 to be a most important sign of stenotic processes 
 in the large intestine. In carcinoma of the sigmoid 
 flexure and rectum a more distinct localization can 
 often be made. When the process is situated in 
 these regions there are frequently dull pains in. the 
 left inguinal region which radiate into the left tes- 
 ticle. Again pains may arise in the left half of the 
 epigastrium and radiate towards the anus ; radiation 
 into the left inguinal region and along the outer 
 aspect of the left thigh occurs and seems to be a 
 particular accompaniment of left-sided tumors. 
 Pains in the back are rarely present, or when occur- 
 ring are simply added to the sum of the other pains. 
 The same may be said of pains in the region of the 
 left sciatic nerve. 
 
 . Not less important than the topographical consid- 
 erations are those symptoms which give us a clew 
 to the factors influencing the pains, and these aid us 
 particularly in differentiating the localized carcino- 
 matous processes from those occurring in acute or 
 chronic enteritis. 
 
 It appears to me of special importance, when- 
 ever intestinal colic occurs in older people^ to deter- 
 
DIGESTIVE SYSTEM 227 
 
 mine whether there is a "position of the greatest 
 pain, ' ' such as that which we have considered in the 
 discussion of the pains accompanying ulcers {v. page 
 161). When we are dealing, for instance, with a car- 
 cinomatous process in the region of the hepatic flex- 
 ure patients will frequently tell us that they cannot 
 lie comfortably upon the left side because in this 
 position they have pains in the right side which give 
 them the impression of a mass dropping from right 
 to left. This is unquestionably in many cases due 
 to traction upon peritoneal adhesions and therefore 
 points strongly towards the eixtension of a local 
 process. The occurrence of such an extremely im- 
 portant diagnostic position of pain is not rufre- 
 quently noticeable at an earlier stage than the occur- 
 rence of any local sensitiveness to palpation. It is 
 always important to examine the abdomen carefully 
 for sensitiveness to local pressure, since in many 
 cases pains may be produced in this way, which then 
 give an important clew. Absence of abdominal ten- 
 derness does not, of course, exclude absolutely the 
 condition under consideration, for sensitiveness to 
 pressure may be absent in those neoplasms which 
 are situated in the pelvis, in the neighborhood of the 
 rectum and in the lower half of the sigmoid flexure. 
 Local sensitiveness corresponding to the seat of the 
 tumor is occasionally felt during strong contraction 
 of the abdominal muscles, such as that produced by 
 lifting a weight or in defecation. Deep diaphrag- 
 matic inspiration may give rise to such pain, espe- 
 cially iu cases where peritoneal inflammations are 
 
PAIN 
 
 present. The same kind of pain may be elicited by 
 careful inflation of tbe rectum. Whenever pains 
 are present in the limibar region these are increased 
 by stooping. 
 
 The peculiarities of the pain in cases of malig- 
 nant tumors which we have so far enumerated, have 
 a diagnostic significance chiefly because they lead 
 us to suspect a localized cause for the attacks of 
 colic, and therefore considerably limit the diagnostic 
 field. For, by reaching such a conclusion, we are 
 able to exclude a great many of the more generalized 
 causes for intestinal colic, such as the conditions 
 caused by flatulence and the ordinary intestinal in- 
 digestion. The differentially significant phenomena 
 in the, case of neoplasms are based upon the early 
 occurrence of a local peritonitis, giving rise to the 
 occurrence of a position of the greatest pain, and to 
 local sensitiveness. No specific or characteristic 
 factors, of course, can be ascribed to those phenom- 
 ena which depend upon flatulence and consequent 
 distention of the gut, or upon the increased peristal- 
 tic contractions of the intestinal muscles. If the 
 symptoms depending upon these conditions are par- 
 ticularly prominent they lead easily to confusion 
 with other conditions. However, these general pains 
 will aid very much in differentiating the conditions 
 we are speaking of from colicky attacks occurring 
 with diseases of other organs. This would be par- 
 ticularly important in cases such as carciaoma of 
 the hepatic flexure where the confusion with gall- 
 bladder colic is very easy, and where such general 
 
DIGESTIVE SYSTEM 22^ 
 
 intestinal symptoms protect us from mistaking one 
 condition for the other. This becomes especially 
 significant when we consider how frequently even 
 the secondary symptoms of these' two conditions 
 (fever and slight jaundice) are common to both. 
 
 "When, in intestinal new growths, the attacks of 
 pain are dependent chiefly upon the general intes- 
 tinal condition, their onset may frequently be directly 
 related to some thermic stimulation, such as the 
 application of cold, walking with bare feet upon a 
 cold floor, sudden throwing off of the bed-clothes or 
 drinkiag cold fluids. The reason for this is a stimu- 
 lation of peristalsis. Again, the attacks of pain may 
 be incited by articles of diet which increase the pro- 
 duction of gas in the intestine, such as certain vege- 
 tables, bread, etc., and' frequently in the history of 
 intestinal carcinoma the first attack of pain is 
 directly referable to such errors of diet. It is well 
 to remember these things in order to protect our- 
 selves against mistaking the early symptoms of a 
 carcinoma for simple intestinal colic, and it is espe- 
 cially desirable when dealing with older individuals 
 to search carefully for the existence of a new growth 
 even when the colicky pains seem to have been 
 directly connected with an error in diet. 
 
 It frequently happens that the positive physical 
 signs are delayed for a long period after these first 
 subjective symptoms have been noticed. In those 
 cases where the above-mentioned subjective symp- 
 toms are absent, but where we have some other 
 reason to suspect the existence of a neoplasm, it is 
 
230 PAIN 
 
 well to attempt by palpation and by changes of posi- 
 tion to produce artificially tbe conditions most favor- 
 able to the production of the pains ; and in this way 
 we may be led to a clearer comprehension of the 
 case. 
 
 An important symptom which is frequently pres- 
 ent in these cases is prolonged constipation. The 
 passage of feces or gas from the intestine is usually 
 followed by an immediate diminution of the pains. 
 The patients themselves frequently, during the at- 
 tacks of colic, massage the abdomen ia the region 
 corresponding to the position of the tumor in order 
 to diminish their pains. Thus the distribution of 
 the distention which is probably the cause of the 
 pain actually leads to great relief. Occasionally, 
 even, the definite localization of the spontaneous 
 massage carried on by the patient will be of diag- 
 nostic aid. 
 
 "While there is generally no distinct relation be- 
 tween the attacks of pain and the taking of food, 
 occasionally there does exist some regularity in their 
 occurrence in relation to the large meal. In some 
 cases attacks occur within two to three hours after 
 the meal, and are probably directly dependent upon 
 the occurrence of powerful peristalsis during this 
 time. This same interpretation may be given to the 
 frequency of nocturnal attacks. Duriag early car- 
 cinoma there are usually intervals of several months 
 between the attacks of pain. As the disease pro- 
 gresses the intervals become shorter and shorter, 
 a fact which may have much diagnostic significance, 
 
DIGESTIVE SYSTEM 231 
 
 since these intervals depend upon the nature of the 
 process. Frequently the pains occur a short time 
 before defecation. This is chiefly the case m those 
 carcinomata which are situated well down under the 
 sigmoid flexure. 
 
 The symptoms which occasionally accompany the 
 pains due to intestinal neoplasms are often of such 
 a nature that their erroneous interpretation might 
 welllead to false localization of the disease in the 
 stomach, the gall-bladder, the kidneys, etc. Thus 
 vomiting is frequently present at the height of the 
 attack, and, with it, appear epigastric pains. The 
 suspicion of gastric disease aroused by these symp- 
 toms can be allayed by remembering that whenever 
 vomiting occurs in iutestinal neoplasms we may pre- 
 suppose a considerable degree of stenosis and may, 
 therefore, expect such vomiting to be accompanied 
 by visible or palpable intestinal peristalsis. When 
 the vomitus is bile-stained, is foul, or contains B. 
 coli, we will, of course, be led to recognize the intes- 
 tinal character of the condition. 
 
 In carciaoma of the splenic flexure pains fre- 
 quently occur immediately after the taking of food, 
 and are caused either by inflammatory adhesions to 
 the stomach, or by direct invasion of that organ. 
 In such cases careful distention of the rectum will 
 usually give rise to immediate pains in the region 
 of the splenic flexure. The pains of carcinomata of 
 the hepatic flexure are frequently confused with 
 gall-bladder colic, especially when the paia is local- 
 ized over the gall-bladder, because of adhesions or 
 
PAIN 
 
 direct metastatic growth. Icterus is often present 
 in these cases, and a sensation of resistance in the 
 neighborhood of the gall-bladder may be felt. In 
 such cases, as we have mentioned before, especial 
 attention must be paid to the influence which the 
 application of cold exerts upon the production of 
 peristalsis and to the presence of visible peristalsis 
 or succussion in the ascending colon. The tendency 
 to diarrhoea, the occasional foul stools containing 
 mucus, and the presence of blood or of an abnormal 
 flora iu the feces, are additional evidences pointing 
 to carcinoma. The local bulging which might occur 
 in the neighborhood of the gall-bladder when the 
 intestine in this vicinity is abnormally distended 
 could very easily be misinterpreted as a large gall- 
 bladder. Chills occur in this form of intestinal 
 carcinoma also, just as they occur in gall-bladder 
 colic. In some cases, especially in carcinomata of 
 the sigmoid flexure or the caecum, difficulty in urina- 
 tion, pain in. the bladder, frequent micturition, aad 
 even radiation into the testicle may be present, aad 
 these may easily lead to false conclusions. In this 
 connection it is simply necessary to remember the 
 danger of error and to avoid it whenever the tumor 
 is impalpable and visible peristalsis is absent by 
 careful examination of the stools and the peculiari- 
 ties of defecation, such as tenesmus and distention 
 of the descending colon. 
 
 In differentiating carcinomatous disease of the 
 intestine from the other more distinctly enteric 
 causes of colic (flatulence, intestinal indigestion, etc.) 
 
DIGESTIVE SYSTEM 233 
 
 we have already called attention to the fact that a 
 careful analysis of the pain alone may give us much 
 basis for a sharp localization of the pathological 
 condition. A distinct recognition of this, if we con- 
 sider the relatively limited number of such localized 
 processes iu the intestinal tract, will make the fur- 
 ther differential diagnosis quite simple, for there 
 are few ulcerative or stenotic conditions with well- 
 localized symptoms which are of practical impor- 
 tance. Thus, in the ileocascal region we have, outside 
 of carcinoma, to deal almost exclusively with 
 tuberculosis; in the sigmoid flexure, almost exclu- 
 sively with dysentery or occasionally membranous 
 enteritis. 
 
 LIVER. 
 
 There are three chief factors which give rise to 
 pain in the region of the liver. These may be dis- 
 cussed in three groups, as follows : 
 
 I. Conditions of Spasm oe Distention in the 
 
 BlLE-PASSAGBS AND GaLL-BLADDEE. 
 
 The pains occurring "in this region are closely 
 analogous to those occurring in the gastro-intestinal 
 tract — a fact which is not surprising when we con- 
 sider the great similarity between the two systems 
 functionally and anatomically. As in the intestinal 
 tract, a simple narrowing in the system of bile ducts 
 is followed by spasm and overdistention in front of 
 the stenosis, which consequently give rise to colicky 
 pains. Thus here, too, colicky pains may be caused 
 without absolute anatomical occlusion of the lumen. 
 
234i PAIN 
 
 WMle such attacks of gall-bladder colic are usually 
 associated with, tlie presence of gall-stones, this is 
 not by any means necessary, and it is illogical to 
 speak invariably of such attacks as gall-stone colic. 
 
 Further analogy to the conditions in the alimen- 
 tary canal is found ia the fact that inflammatory 
 processes without any existing organic stenosis may 
 be accompanied by the same attacks of pain, the con- 
 ditions for such attacks being especially favorable 
 in the appendix to the gall-duct system — the gall- 
 bladder. Here a colicky attack may be initiated by 
 an inflammatory exudation with a rapidly increasing 
 intravesical pressure and overdistention of the walls. 
 In discussing the conditions in the biliary system 
 which can give rise to spasms and overdistention, 
 with their consequent attacks of colic, we shall have 
 to consider: 
 
 (a) Stenosis due to carcinoma at the papilla of 
 Vater or in the head of the pancreas, ascarides in 
 the ductus choledochus, aneurysms of the hepatic 
 artery, intrahepatic carcinoma, cysts and gummata, 
 kinking of the cystic duct in enteroptosis by adhe- 
 sions, etc. 
 
 (b) Inflammation, as in cholangeitis with or 
 without biliary cirrhosis, acute yellow atrophy, 
 cholecystitis with or without the formation of stones, 
 carcinoma, etc. 
 
 It is hardly necessary to mention that occasion- 
 ally attacks of colic may be initiated by a combina- 
 tion of (a) and (b). It is a universal rule that 
 wherever secretions accumulate because of the for- 
 mation of a stenosis the opportunity for infection 
 
DIGESTIVE SYSTEM 235 
 
 and for the development of a ''stagnation-flora" is 
 particularly favorable. 
 
 It would probably be very advisable to drop the 
 expression gall-stone colic entirely, and to substitute 
 for it the words gall-bladder colic or gall-duct colic, 
 terms which imply no premature anatomical diag- 
 nosis. This may seem pedantic, because in the ma- 
 jority of these cases stones are actually present, but 
 this slow method of diagnosis seems to the writer 
 extremely desirable, since by its use we may often 
 avoid overlooking other and rarer causes for these 
 attacks. 
 
 II. Distention of the Liveb Capsule. 
 
 Whenever a free flow of blood out of the hepatic 
 veins is prevented, a .swelling of the liver results 
 which leads to painful distention of the peritoneal 
 coverings. A similar condition is caused by obstruc- 
 tion to the flow of bile. The presence of cysts in the 
 liver tissue, and the growth of neoplasms, may give 
 rise to a similar result. Distention of the capsule 
 of the liver may also be produced by active hyper- 
 aemia. Thus in malaria, pernicious anaemia, par- 
 oxysmal hsBmoglobinuria, leukssmia, diabetes, this 
 occasionally occurs. In the last-named condition, 
 however, the sensitiveness to pressure is usually of 
 very moderate degree. 
 
 III. Inflammatory Pkocesses in the Capsule op 
 THE LivEE (Local and Diffuse Perihepatitis). 
 
 The general diagnosis of a hepatalgia is based 
 chiefly upon the discovery of sensitiveness to pres- 
 
236 PAIN 
 
 sure or percussion, upon the size of the organ as 
 determined by the liver dullness and upon a close 
 analysis of the subjective pains. 
 
 It now becomes our task to analyze more closely 
 the details of the mechanism of these pains. In 
 doing this we shall find that the groups which we 
 have just discussed will often act in combination. 
 
 I. Gall-bladder Colic. 
 
 It is plain, from the very pathological conditions 
 underlying the pains occurring in diseases of this 
 organ, that the general phenomena must frequently 
 be of an extremely complicated nature. Thus, ad- 
 hesions between the gall-bladder on the one hand, and 
 the duodenum or colon on the other, may give rise 
 to entirely independent attacks of pain ; the develop- 
 ment of peritonitis, the occurrence of septic throm- 
 bosis in the lower extremities, with the pains that 
 occur in them simulating radiation from the original 
 seat of trouble, offer extreme difficulties to inter- 
 pretation. It must also be remembered that, at the 
 height of the attacks, neurasthenic patients may 
 experience most unusual radiations of pain into 
 the left arm or into the right leg, so that in judging 
 of the condition it is especially important to pay 
 attention to the pains which have occurred at the 
 very beginning of the attack. 
 
 The usual locations of the earliest pains are in 
 the epigastrium, in its middle portion or just below 
 the right costal margin. Whenever the attack of 
 colic is localized chiefly on the left half of the epi- 
 
DIGESTIVE SYSTEM 237 
 
 gastrium we will be much, more apt to think of a 
 simple gastralgia (excepting, of course, in cases of 
 transposition of the organs). The natural explana- 
 tion of this right-sided position of the pain is found 
 in the topography of the gall-bladder and the liver. 
 
 The pain most usually radiates from the epigas- 
 trium upwards, in rare cases up to the right half 
 of the neck and to. the right acromion process. More 
 often, however, it radiates, in front, up to the right 
 nipple and backwards into the shoulder blade and 
 into the right lumbar region. The radiations which 
 occasionally occur into the right arm and leg, or even 
 into the left arm, are present only at the height of 
 very intense attacks of colic, and only in patients 
 who are of unusually neurotic constitution. The 
 paraBsthesiae which occur occasionally in the arms are 
 probably of a vasomotor nature. Whenever the 
 radiations into the left arm are prominent we must 
 consider the possibility that the attack of gall- 
 bladder colic by increasing the blood pressure has 
 brought on secondarily an attack of true functional 
 or organic angina pectoris. 
 
 Radiations into the genitals with retention of 
 urine and severe pains above the symphysis occur 
 but rarely, but when they do occur usually depend 
 upon the development of the peritonitis which occa- 
 sionally accompanies the gall-bladder inflammation ; 
 pains in the lower extremities, especially those which 
 occur in the nerves of the legs, are frequently due 
 to septic thrombi. Such complications must be very 
 carefully considered in order that we may avoid any 
 
238 PAIN 
 
 confusion with renal calculi. It is only at the very- 
 height of tlie attacks that the pains are diffuse or 
 lack definite localization. 
 
 Wliile the localization of these subjective pains 
 is extremely important, just as much help can be 
 obtained by a careful determination of those areas 
 which are tender to palpation and percussion. 
 
 1. The Gall-bladdee Itself. — This organ is 
 often enlarged and is usually markedly tender to 
 palpation and percussion. There are certain pecu- 
 liarities connected witb this tenderness, the pres- 
 ence of which confirms the diagnosis of gall-bladder 
 tumor and aids in distinguishing it from the lower 
 pole of the kidney. Pressure upon the gall-bladder 
 frequently produces radiation of the pain along the 
 phrenic nerve towards the acromion. Radiations 
 backward towards the left balf of the epigastrium 
 and towards the ensif orm process are quite frequent. 
 This artificially produced radiation is an important 
 adjunct to the spontaneous radiations. 
 
 2. The Mid-line of the Epigastrium from the 
 Ensiform to the Edge of the Liver. — In this region, 
 corresponding to the area of liver dullness, limited 
 below by the edge of the liver, there is in almost all 
 cases of early gall-bladder colic marked tenderness 
 to percussion. In those cases which are accompa- 
 nied byicterus, this tenderness may remain for a long 
 while after tbe end of the attack of colic and may, 
 by its diminution, indicate an improvement in the 
 accompanying pathological changes. This symptom 
 of tenderness to palpation in the mid-line which 
 
DIGESTIVE SYSTEM 239 
 
 occurs in cases- of gall-duct colic is directly referable 
 to increase of intrahepatic pressure, and will receive 
 further attention in the section on hepatic conges- 
 tion, 
 
 3. The Eight Lumbar Ebgion (Limited Above by 
 THE Base op the Lung).— Here we are dealing with 
 a symptom which frequently remains for some time 
 after the attack proper has ended, and has probably 
 the same etiological causes as the symptom just 
 described under 2. In order to determine the pres- 
 ence of this symptom it is best to tap lightly with 
 the ulnar surface of the fist upon both lumbar re- 
 gions in order to compare the tenderness of the two 
 sides. 
 
 In addition to these well-localized areas of pain 
 there are other varieties of pain which undoubtedly 
 are of reflex origin (phrenic nerve, etc.). 
 
 (a) Tenderness in the area of the shoulder 
 girdle. There is great tenderness to pressure in the 
 right brachial plexus ; this symptom is rare. More 
 frequently there is a point of sensitiveness situated 
 along the upper portion of the trapezius muscle, 
 about three fingers' breadth distant from the acro- 
 mion. Pressure at this point causes pain which 
 radiates towards the gall-bladder. Pressure upon 
 the gall-bladder, on the other hand, may cause pain 
 radiating towards this point. There exists thus a 
 mutual radiation from one point to the other. 
 
 The pains we have just discussed are not fre- 
 quent in their occurrence, but when they are present 
 they may be of considerable importance in differen- 
 
240 PAIN 
 
 tiating these conditions from otlier similar attacks 
 of colic, such as those of pyloric stenosis, etc. They 
 are also found, however, in cases of liver abscess, 
 and in general in all cases of subdiaphragmatic 
 inflammations. 
 
 (b) Tenderness to palpation along the vertebral 
 column. There is no localized tenderness over any 
 one particular spinous process. The hypersesthetic 
 zone extends usually over several spinous processes 
 and is commonly subject to great variations, but, ia 
 general, it occurs between the fourth and the twelfth 
 thoracic vertebrae. Occasionally there may be ten- 
 derness to pressure in the ileocaecal region. This, 
 when present, is not easy to interpret. Probably ia 
 most cases it is a direct transmission of the pressure 
 upwards, and thus in reality a true gall-bladder pain. 
 On the other hand, we must remember that in 
 patients with gall-stone disease, and liver disease in 
 general, there are usually intestinal disturbances, 
 chiefly chronic constipation, and it is necessary for 
 us therefore to think of chronic inflammatory con- 
 ditions of the appendix. 
 
 In order clearly to dijBferentiate between gall- 
 bladder colic and attacks of paroxysmal pain from 
 other causes, it is necessary to pay very close atten- 
 tion to the gradual increase and decrease of the 
 attacks and to the cramp-like, sharp character of 
 the pain. In those cases in which stone formation 
 is present this characteristic of a rapid rise to a 
 climax and gradual decrease, is especially marked, 
 and the intensity of the attack seems to reach its 
 
DIGESTIVE SYSTEM 24.1 
 
 maximum at the time when the stone is expelled. 
 This peculiar intensity of the pain is par excellence 
 a characteristic of biliary colic, and is frequently 
 of service in the differential diagnosis. There are 
 cases which have a more chronic and latent char- 
 acter and which in the course of years may have 
 no sharp attacks, but in which there is a constant 
 sensation of soreness in the epigastrium. Such 
 cases of gall-stones without actual colic usually 
 occur together with enteroptosis, and these run their 
 course with constant parsesthetic sensations in the 
 region of the epigastrium. Weakness of the abdom- 
 inal muscles, as well as relaxation of the muscula- 
 ture of the gall-ducts, may be responsible for this. 
 
 The attacks of colic may occasionally be preceded 
 and followed by pains of another nature. These are 
 usually sharp, cutting sensations which are directly 
 dependent upon deep breathing and coughing, and 
 which are due to inflammatory changes about the 
 gall-bladder. In these cases auscultation may re- 
 veal a leather-like creaking over the gall-bladder, 
 and the patient may have the sensation of dis- 
 tention of the gall-bladder or stomach. 
 
 As regards the influence of the taking of food 
 upon the attacks of gall-bladder colic, we may say 
 that a marked contrast exists between this condition 
 and cases of pyloric stenosis. There is no injury 
 done to the affected parts by the food, as is the case 
 in gastric ulcer, and peristalsis of the gall-ducts, if 
 at all excited by the taking of food, is certainly not 
 so deeply influenced as is intestinal or gastric peri- 
 stalsis. "We may thus say that, in these cases, the 
 
 16 
 
242 PAIN 
 
 relation of the taking of food to the beginning of 
 an attack is entirely unimportant, and, as a matter 
 of fact, this is true in all those cases where chole- 
 lithiasis occurs in patients of otherwise normal 
 gastro-intestinal tracts. The taking of food is im- 
 portant in relation to the attacks only in those cases 
 where we are dealing with delicate, anaemic individ- 
 uals, often with some degree of enteroptosis, espe- 
 cially those with gastroptosis and general atony of 
 the stomach. These cases are chiefly limited to the 
 female sex, and in them a differential diagnosis be- 
 tween a gastric condition Eind gall-bladder colic is 
 extremely difficult. 
 
 It is not at all out of the question that in some of 
 these cases following an error in diet, a gastralgia 
 with cramp-like contractions of the stomach is 
 started which may secondarily give rise to an attack 
 of colic in the gall-ducts, the muscular activity of 
 the two systems being functionally so closely allied. 
 The influence of diet upon gall-duct colic is similar 
 in many ways to its influence upon the pains of 
 pyloric stenosis, and it is not at all unlikely 
 that, accompanying some cases of gall-stone, there 
 actually does occur slight obstruction at the pylorus 
 or in the duodenum itself. On the one hand, gas- 
 troptosis, which is so often present, may readily 
 lead to kinking of the duodenum and subsequent 
 stenosis; on the other, it is not infrequent to find 
 adhesions between the pylorus and the gall-bladder 
 which may cause similar obstruction. 
 
 The articles of diet which are especially apt to be 
 responsible for the attacks are all those which lead 
 
DIGESTIVE SYSTEM 249 
 
 to distention, vegetables, carbohydrates, bread, etc. ; 
 also fat, meat, cheese, acid food, beer, etc. Attacks 
 are occasionally inhibited by strong alcohol in the 
 form of brandy. Antineuralgic drugs act well dur- 
 ing the attack in those cases in which there is a 
 general neuropathic substratum and there are no 
 complications due to infection. The quality of the 
 food is often less important than the quantity, in 
 that the attack is initiated simply by the mechanical 
 overfilling of the stomach. 
 
 Just as in the case of the pain accompanying 
 ulceration of the pylorus, in these cases the position 
 of the patient has an important influence upon the 
 course of the attacks. The pain is especially severe 
 when the patient is lying on his left side. In this 
 position he may complain of a drawing sensation 
 which gives the impression of something being 
 tugged from the right hypochondriac region toward 
 the left. This pain, in the left-sided position, is 
 especially severe whenever there is great flabbiness 
 of the abdominal walls, and therefore corresponding 
 mobility of the abdominal organs. Mechanically the 
 explanation is extremely simple, since in this posi- 
 tion the swollen organs are freely suspended from 
 their inflamed peritoneal attachments. It is true 
 that in some cases there is pain also in the right- 
 sided position, and this is easily explained by the 
 fact that greater pressure is exerted upon the liver 
 and gall-bladder ; but when this does occur the pain 
 is not accompanied by nausea and belching, as is 
 
244 PAIN 
 
 almost invariably the case when the right-sided pains 
 occur with ulceration and stenosis of the pylorus. 
 
 Inflammatory changes in the neighborhood of the 
 gall-bladder and in the serous coverings of the liver 
 give rise to other secondary symptoms. Thus the 
 jarring accompanying speech, rapid walking, rmi- 
 ning down hill, coughing and sneezing, gives much 
 discomfort during the attack and for a long time 
 afterwards. Likewise those motions are very pain- 
 ful which are accompanied by pressure upon the 
 abdominal organs in general, such as stooping, put- 
 ting on the shoes, lifting a weight. Bending for- 
 ward occasionally causes pain in the back, and owing 
 to this the patients often instinctively relax their 
 abdominal muscles by walking in a stooping position 
 or shoving a pillow under their backs. In thin per- 
 sons with enteroptosis movement is particularly 
 likely to induce pain, and in these cases rest in bed 
 is certainly indicated. Cold may sometimes incite 
 attacks. 
 
 I have seen patients who believed that cold air striking the 
 epigastrium brought on their pain, and vrho were accustomed to 
 guard against this by wearing a pad of cloth or cotton wadding 
 over the upper abdomen. 
 
 Like the stomach and intestine, the gall-bladder 
 has an important functional dependence upon the 
 central nervous system, and it is thus not surpris- 
 ing that observations have been made which would 
 indicate that attacks of gall-stone colic have been 
 initiated by psychic or emotional impulses. 
 
DIGESTIVE SYSTEM 245 
 
 It is at least worth, considering whether such 
 attacks cannot be reflexly initiated from other 
 organs, the kidneys, the genitals, the stomach, or the 
 intestine, either in the presence of gall-stones or 
 with any other lesion of the bile passages. Abnor- 
 mal irritability of the nervous system may certainly 
 also come into question as a factor favoring the at- 
 tacks. 
 
 In one case of undoubted cholelitliiasis under my observation 
 menstruation was always accompanied by tenderness over the gall- 
 bladder. 
 
 There is a little definite connection between gall- 
 stone colic and conditions of obstruction in the 
 alimentary canal. Thus, prolonged constipation 
 may occasionally staxt an attack, probably by pre- 
 venting the free expulsion of bile, and occasionally 
 an attack of colic may be interrupted by a free evacu- 
 ation of the bowels by enema or otherwise. Such 
 close interrelation is logically to be expected when 
 we consider the intimate functional relationship that 
 exists between the intestine and the bile passages. 
 
 As regards the time of attack, there is unques- 
 tionably a greater frequency during the night or 
 evening, but this is not striking and attacks may 
 occur at any time during the day. Severe abdom- 
 inal cramps coming on shortly after parturition are 
 not infrequently due to cholelithiasis, and this point 
 is a useful one to remember in making a differential 
 diagnosis. 
 
246 PAIN 
 
 In differentiating gall-stone colic from pyloric 
 etenosis, we may be helped by remembering, first, 
 the long, free intervals occurring between attacks 
 of the former condition, in contrast to the almost 
 uninterrupted suffering of the latter. When attacks 
 occur daily for weeks we may usually conclude that 
 we are dealing with stones which are immovably 
 lodged in the cystis duct or with one of those cases 
 of enteroptosis mentioned above. Stones which are 
 situated further down, in the less narrow common 
 duct, usually give rise to comparatively little peri- 
 staltic unrest in the gall-duct system and conse- 
 quently are less productive of pain. 
 
 The most important of the secondary symptoms 
 which are to be considered is vomiting. This symp- 
 tom especially may lead to confusion in pointing 
 towards a gastric condition, such as ulceration at the 
 pylorus; but the character of the vomiting is quite 
 different in the two conditions. In the case of 
 pyloric ulceration or ptenosis the vomiting is usually 
 very copious, does not consist of bile, has a sour 
 taste, and is usually followed by immediate relief 
 from pain ; in gall-stone colic it is usually full of bile, 
 is bitter in its taste, and in most cases increases the 
 pain because the general disturbance of the act, as 
 well as the pressure of the abdominal muscles, causes 
 considerable pain in the sensitive liver and gall- 
 bladder. 
 
 If the physician is present during the attack, 
 examination of the urine will quickly determine 
 
DIGESTIVE SYSTEM Ml 
 
 whether obstruction of the bile exists or not. Such 
 a decision is much more difficult when we have to 
 make up our minds simply by means of the state- 
 ments of the patient. We must not lay too much 
 weight upon the patient's statement that his urine 
 was dark during the attack, for in the attacks of the 
 colic of gastric ulcer we often notice the excretion 
 of a dark concentrated urine. If the patient is able 
 to tell us that the urine has left yellow marks upon 
 the linen or that there has been pruritus, the likeli- 
 hood of the existence of true icterus becomes very 
 strong. In exceptional cases cholelithiasis may be 
 accompanied by haematuria, and is then due to an 
 associated hemorrhagic nephritis. "While it is true 
 that jaundice is occasionally absent in diseases of the 
 liver and, on the other hand, is often present in other 
 diseases, such for example as gastric and appendicu- 
 lar disease, in duodenal ulcer and in carcinoma of the 
 hepatic flexure; nevertheless too much importance 
 cannot be attached to this point, and, when icterus 
 has never been present in patients whose disease has 
 existed for a considerable period, extreme caution 
 must be used before a diagnosis of hepatic disease 
 is made. 
 
 Shaking chills and rise of temperature are fre- 
 quently present during the attacks themselves, but 
 are of much less importance than increased tempera- 
 ture which is present for some length of time after 
 the attacks. The chills and rise of temperature dur- 
 ing the attacks may be present in many other condi- 
 tions in persons who have irritable vasomotor sys- 
 
248 PAIN 
 
 terns. The temperature whicli occurs after attacks, 
 however, is usually an expression of an infection, 
 such as that which is frequently present in gall- 
 bladder colic, and is therefore of much more impor- 
 tance in clearing up the diagnosis. Herpes is rarely 
 present. 
 
 The symptoms which appear on physical exam- 
 ination are chiefly tumor of the gall-bladder and 
 liver, creaking friction sounds over the gall-bladder, 
 crepitant rales over the base of the right lung, and 
 occasionally also over the base of the left lung 
 (splenic enlargement). 
 
 There are a number of conditions which may 
 simulate gall-bladder colic. Chief among these are: 
 
 1. Cicatricial and ulcerative processes of the 
 pylorus (see page 185). 
 
 2. Duodenal Ulcer. — The localization of the at- 
 tacks may be very similar in the two conditions. In 
 a general way the same distinguishing characteris- 
 tics may be drawn between these two conditions 
 as are useful in differentiating gall-bladder colic 
 from pyloric stenosis. In duodenal ulcer there is 
 almost immediate relief after vomiting because of 
 the evacuation of the distended stomach. 
 
 3. Appendicitis. — The danger of false, diagnosis 
 is especially due to the fact that many cases of 
 cholelithiasis show tenderness to pressure in the 
 ileocsecal region ; this is usually caused by an abnor- 
 mal position of the gall-bladder on account of a 
 sinking and rotation of the liver. 
 
 In a great many cases also there may be a chronic 
 inflaromatory process of the appendix directly re- 
 
DIGESTIVE SYSTEM 249 
 
 lated to the dironic constipation accompanying gall- 
 stone disease. A superficial examiner might there- 
 fore easily misinterpret attacks of colic with sensi- 
 tiveness in the ileocaecal region as appendicular colic. 
 On the other hand, cases of true appendicitis may 
 simulate gall-stone colic when the appendicular pain 
 is situated high up, because of an abnormal position 
 of the appendix. Careful analysis of the pains, to- 
 gether with most painstaking examination of the 
 liver for enlargement, tenderness, etc., can alone 
 give us clearness. 
 
 4, Carcinoma of the Colon. — Another condition 
 which it is dijB&cult to differentiate from the pain 
 under consideration is carcinoma of the hepatic 
 flexure of the colon, with adhesions to the gall-blad- 
 der and liver. In these cases there are colicky at- 
 tacks with localization and radiation similar to those 
 of true gall-stone colic. Added to these, slight 
 jaundice is present, due to adhesions to or metas- 
 tatic infiltration of the bUe passages. The difficulty 
 may be further increased by the presence of a 
 rounded sensitive tumor which cannot be separated 
 from the liver. 
 
 While the examination of the feces and other 
 subjective signs will clearly differentiate these con- 
 ditions, the writer would like to call attention, for 
 the purpose of rapid diagnosis, to the great diifer- 
 ence which exists in the reaction of the pains of 
 these two conditions to thermic influences. When- 
 ever the attacks of pain are easily brought on by the 
 application of cold (cold drinks, exposure of the 
 
250 PAIN 
 
 abdomen, etc.), gall-duet colic is extremely unlikely, 
 this characteristic being peculiar chiefly to the 
 paroxysmal pains occurring in the intestines. 
 
 Eises of temperature occur in ulcerating carci- 
 noma of the colon and therefore give us no differ- 
 ential help. However, chills at the time of the attack 
 would point more particularly to gall-stone colic. 
 In addition, it is important to consider the con- 
 stancy of the pain, its dependence upon dietetic 
 influences, its relief by the expulsion of flatus, etc. 
 
 As far as objective symptoms are concerned the 
 most important are those which point to obstruction 
 of the gut. These, of course, may be absent for a 
 long time. Most important among them are bor- 
 borygmi in the region of the tumor and succussion 
 sounds along the ascending colon; it must not be 
 forgotten, however, that even disease of the gall- 
 bladder may secondarily lead to slight obstruction 
 in the region of the hepatic flexure. 
 
 Diarrhoea when present would point towards an 
 intestinal origin of the pains, for gall-duct colic, 
 especially when due to stone, is almost always accom- 
 panied by constipation. 
 
 5. Movable Kidney. — Errors are very easily 
 made, because it is not infrequent that, together with 
 an irregular cholelithiasis, there exists a movable 
 kidney which is assumed to be the cause of the entire 
 trouble. This combination is quite usual, and there- 
 fore errors often occur. A mistake is most easily 
 made when we are dealing with cases of chole- 
 lithiasis which run their course with constant pain 
 
DIGESTIVE SYSTEM 251 
 
 in the epigastrium, without the real colicky attacks 
 and without icterus. The pain in these cases is 
 influenced by jarring and motion, and it is not at 
 all unlikely that when the kidney is movable and at 
 the same time gall-stones are present, the tugging 
 of the loose kidney may reflexly lead to peristaltic 
 unrest in the bile-duct system. 
 
 If the colicky pains occur while the body is in 
 complete rest, for instance, during sleep, of course 
 the assumption of movable kidney is quite out of 
 the question. 
 
 6. Hysteria. — This error can be made only when 
 the existing cholelithiasis is of an atypical kind. 
 Here also one must not forget that the conditions 
 may frequently coincide. Whenever, of course, 
 purely mechanical methods, such as the position of 
 the patient, exert an influence upon the pain, we can 
 hardly assume that the condition is entirely of a 
 functional nature. So, too, it is important to know 
 whether there is a lack of harmony between the gen- 
 eral nervous condition and the severity of the local 
 pain, for with an improvement in the general ner- 
 vous condition, the local pains in the epigastrium 
 are rather more likely to increase than to decrease 
 when gall-stones are present. General rules can- 
 not be made for cases of this kind, and it is of the 
 greatest importance to consider carefully the in- 
 dividuality of the patient in order to make a correct 
 diagnosis. When, together with the existence of 
 gall-stones, severe hysteria is present, even opera- 
 
252 PAIN 
 
 tive interference will not always guarantee' complete 
 cessation of the pains. It seems that in these cases 
 we must consider that we are dealing in part with 
 a visceral neuralgia (solar plexus? cf. page 97), 
 in which the gall-bladder pain has the same relation 
 to the neuralgia that a carious tooth would have to 
 the ordinary trigeminal neuralgia. The extraction 
 of the tooth might bring about a temporary improve- 
 ment, but the neuralgic foundation would remain. 
 
 It is an open question whether or not pure neural- 
 gia of the liver may exist by itself without organic 
 foundation. According to^ some observers such 
 cases may occur with all the attributes of a true gall- 
 stone colic, except fever and inflammatory changes. 
 
 7. Syphilis of the Liver. — Attacks of pain may 
 occur in the train of rapidly developing liver gum- 
 mata, the causes of the pain being sudden tension 
 of the liver capsule and local peritonitis. The con- 
 fusion of this condition with gall-stone colic seems to 
 be all the more likely because these cases are fol- 
 lowed by jaundice and increase of temperature, and 
 palpation of the liver reveals enlargement and ten- 
 derness. However, more careful examination will 
 frequently show unevenness of the liver surface, 
 and, on the other hand, syphilitic processes occur 
 frequently in the left lobe of the liver; thus 
 there may be a peculiar left-sided localization of the 
 pains, a localization which hardly ever occurs in gall- 
 stone colic. In every difficult case the prompt im- 
 provement under iodides may be decisive. Similar 
 
DIGESTIVE SYSTEM 253 
 
 symptoms may occur with primary or secondary car- 
 cinoma of the liver. 
 
 In our introduction we have already called atten- 
 tion to the fact that while gall-bladder colic is usually 
 caused by the existence of gall-stones, there may 
 nevertheless exist cases of true gall-bladder colic 
 without the presence of gall-stones. These cases, 
 as it was pointed out, are chiefly dependent upon 
 inflammatory stenoses along the bile ducts. 
 
 The occasional combination of a gall-stone colic 
 with hsBmatemesis and melaena would lead us to 
 think of aneurysm of the hepatic artery. Likewise 
 we would have to consider ulcerative-stenotic condi- 
 tions at the papilla of Vater. 
 
 In patients who are suffering from marked en- 
 teroptosis mild attacks of such colicky pains would 
 suggest kinking along the cystic duct. When other 
 symptoms point to biliary cirrhosis the possibility 
 of an inflammatory colic of the gall-ducts must be 
 thought of. 
 
 It is a point of practical importance that in pa- 
 tients who have their first attack of gall-stone colic 
 at an advanced age, or in those in whom such attacks 
 are repeated only after prolonged intervals, we may 
 be dealing not with gall-stones but with a developing 
 carcinoma of the gall-bladder, or possibly with both 
 conditions together. An early operation for carci- 
 noma of the gall-bladder is made possible only on the 
 basis of the subjective phenomena, and even then 
 only upon a diagnosis of probability. 
 
254 PAIN 
 
 Gall-bladder Pains without Attacks of Colic. 
 
 In all the preceding conditions we have spoken 
 of attacks of colicky pain which are probably caused 
 by the more or less sudden increase of intravesical 
 pressure or by tonic contractions along the muscu- 
 lature of the bile ducts. 
 
 There are still those cases to be considered in 
 which the same etiological factors may give rise- to 
 more gradual pathological changes, and therefore 
 express themselves in more constant local pains over 
 the gall-bladder rather than in paroxysmal attacks. 
 Here, too, we must consider stenotic processes which 
 lead to an overdistention of the gall-bladder. The 
 chief conditions which must be thought of in this 
 connection are diseases of the pancreas of an inflam- 
 matory or malignant nature, and inflanunatory proc- 
 esses of the gall-bladder itself, either of a local 
 nature (gall-stones, typhoid) or of an ascending 
 nature (duodenal catarrh, cholangeitis, biliary cir- 
 rhosis). Added to these conditions there frequently 
 occur inflammatory changes in the peritoneal cover- 
 ings of the organ, a pericholecystitis ; and this gives 
 us a third factor which, together with the distention 
 and the muscular contractions, adds to the general 
 picture of gall-bladder pains. Such lesions are for 
 many reasons extremely unsatisfactory for physical 
 examination, and the subjective pains, therefore, 
 assume especial diagnostic importance. 
 
 Generally the pains are localized in the gall- 
 bladder region itself; in cases of enteroptosis or 
 corset liver the pains may be close to the ileocascal ' 
 region. 
 
DIGESTIVE SYSTEM 255 
 
 The peculiarities of the paias which can be pro- 
 duced by physical examination have already been 
 spoken of in the section on gall-bladder colic. 
 Sharply localized, stabbing pains in the gall-bladder 
 region may be caused by percussion in the right loin, 
 by coughing, by sneezing, and by the pressure ex- 
 erted in strong contraction of the abdominal muscles 
 such as vomiting, straining at stool, and rising from 
 a horizontal position. Deep respiration causes pain 
 over the gall-bladder, especially in those cases where 
 pericholecystic complications exist. Spontaneous 
 pain is very slight in many cases; and often the 
 fact that there is tenderness of the gall-bladder is 
 brought out only by the methods just described. 
 
 Similar sensations might occasionally be caused 
 by an abnormally movable right kidney. Findings 
 of such a nature, of course, caimot be decisive, 
 since gall-bladder disease is frequently coexistent 
 with movable kidney. It would be much more im- 
 portant to find an enlarged gall-bladder. Increase 
 of the temperature (cholecystitis) and persistence 
 of the pain during the prone position would point 
 towards the gall-bladder as the origin of the pains. 
 
 Pains due to flatulence, which so frequently occur 
 with atony of the gut, as in chronic nicotine poison- 
 ing and neurasthenia, are occasionally localized over 
 the gall-bladder region (hepatic flexure), but can 
 easily be distinguished from gall-bladder disease by 
 the fact that they vary in their localization. Firm 
 pressure is often grateful to the patient. 
 
a56 PAIN 
 
 II. and III. Distention and Inflammation of the 
 Capsule of the Liver. 
 
 Up to the present time we liave spoken only of 
 liver pains which have their seat in the biliary sys- 
 tem, and its appendix, the gall-bladder. Here we 
 had in addition to the factor of distention the cramp- 
 like peristalsis of the muscular elements. In the 
 following paragraphs we will deal with conditions 
 localized in the peritoneal coverings of the liver. 
 In these, pains are caused both by distention, when 
 the liver is enlarged, and by inflammatory processes 
 about the liver (perihepatitis). 
 
 It is more practical and useful not to separate 
 these two varieties of pain, since, although they are 
 distinct etiologically, they very frequently occur 
 together. 
 
 (a) Hcematogenous Congestion of the Liver. — 
 Such cases are usually caused by cardiac lesions, 
 especially by insufficiency of the right heart. Never- 
 theless occasionally extracardial causes must be con- 
 sidered, such as narrowing of the inferior vena cava 
 by aneurysms, thrombi, fibrous changes of the peri- 
 cardium, fluid exudate in the right pleura, right 
 pneumothorax, and narrowing of the hepatic veins 
 through perihepatitis. 
 
 Next to the regularly present enlargement of the 
 organ the most constant symptom of these anomalies 
 of the circulation, at least in their acute and sub- 
 acute stages, is the characteristic pain. There can 
 hardly be any reason for doubting that the mechan- 
 ism of the pains in these cases depends upon the 
 
DIGESTIVE SYSTEM 257 
 
 stretcliiag of the liver capsule. Tlie quality of these 
 pains is almost always that of a feeling of pressure 
 in the epigastrium which varies in degree from, sim- 
 ple discomfort to actual pain, so that the patients 
 speak often of "stomach-ache." Radiations do not 
 occur in this kind of pain. The patient frequently 
 feels as though there were a constant and heavy 
 weight upon the stomach. 
 
 The most characteristic quality by which this 
 species of pain can be recognized is the increase in 
 its severity which occurs whenever more work is 
 laid upon the heart. This, of course, is natural in 
 that it increases the actual cause of the pain. The 
 patient who is suffering from a congested liver com- 
 plains of an increase of the pain when he walks up- 
 stairs, whereas it is very much less marked when he 
 is waUdng downstairs. Struggling against the wiad, 
 running, in short, every physical exertion increase 
 the suffering. 
 
 Percussion of the liver is painful, and it is not 
 surprising that in the face of the diffuse and even 
 stretching of the liver-capsule the pain, on percus- 
 sion, should have an analogously diffuse and even 
 distribution. As a matter of fact, however, the 
 maximum, pain is felt in percussion along the linea 
 alba and extends in this line from the tip of the 
 ensiform down to the liver margin. This close cor- 
 respondence of the zone of greatest pain with the 
 liver dullness in the line of the linea alba is particu- 
 larly important in differentiating this condition from 
 other epigastric pains. For this reason examina- 
 
 17 
 
258 PAIN 
 
 tion by percussion is more important in this condi- 
 tion than examination by palpation. 
 
 The explanation of the fact that in spite of the 
 diffuse nature of the process the maximum pain, on 
 percussion, extends along the linea alba probably 
 lies in the circumstance that here the muscular de- 
 fense is least effectual, especially in cases where 
 there is some separation of the recti. Probably the 
 same explanation holds good for a similar localiza- 
 tion of the greatest tenderness along the linea alba 
 in gastric ulcer. 
 
 Whenever, therefore, one wishes to examine for 
 pain in cases suspicious of hepatic congestion, it is 
 advisable to percuss along the liaea alba. 
 
 If cases dependent upon uncompensated cardiac 
 lesions are examined in this way while they are 
 under treatment with digitalis, it is often possible 
 to notice that the pain will diminish from day to 
 day if approximately the same force of percussion 
 is used. In this way we have a very simple means 
 of controlling the processes of compensation of the 
 right heart. At the same time the influence exerted 
 by the therapy upon the tenderness throws definite 
 light upon the etiology of the condition. 
 
 The position of the body has a definite influence 
 upon the intensity of the suffering. The upright 
 position naturally leads to a greater stagnation of 
 blood in the liver, while the horizontal position 
 allows of a better outflow of blood. 
 
 Dietetic conditions also may have a definite effect 
 upon the hypersemia of the liver and therefore upon 
 the pains (spices, large quantities of meat, etc.). 
 
DIGESTIVE SYSTEM 259 
 
 Occasionally mechanical and dietetic conditions 
 may be combined (bodily exertion immediately after 
 meals). 
 
 The physical signs accompanying increase of the 
 pain are chiefly enlargement and firmer consistency 
 of the organ. The latter condition is frequently 
 noticed by the patient himself, who may observe 
 a diffuse firmness in the epigastrium after exertion. 
 
 In many cases, of course, the congestion of the 
 liver is merely a secondary factor in the general 
 clinical picture, and it may be easy to explain the 
 enlargement of the organ without paying much at- 
 tention to the character and quality of the pains. 
 The enlargement of the liver falls in naturally with 
 the cyanosis and the oedema. On the other hand, 
 there are cases in which the hepatic congestion and 
 the suffering resulting from it may be predominant. 
 
 The cases chiefly to be considered in this con- 
 nection are especially those of acute pericarditis, 
 which are frequently characterized by epigastric 
 rather than by cardiac symptoms ; and these epigas- 
 tric symptoms, on closer analysis, can be recognized 
 as being due to hepatic congestion. The same is 
 true of the" symptoms accompanying many cases of 
 adherent pericardium, and in these often the diag- 
 nosis of hepatic congestion can be made before the 
 condition of the heart is recognized. 
 
 Again there are cases in which, even when the 
 signs of an insufficiency of the right ventricle are 
 perfectly clear, there may be much doubt as to 
 whether the existing enlargement of the liver is to 
 
a60 PAIN 
 
 be explained by simple congestion, or whether other 
 pathological processes, for instance cirrhosis, may 
 have a part in it. In just these cases the examina- 
 tion of the organ for its sensitiveness and the zones 
 of distribution of these pains, as determined by 
 physical examination, may lend invaluable aid. 
 
 The pathological basis of the pain of congestion 
 lies in the acute or subacute distention of the organ 
 and its peritoneal coverings. This, however, pre- 
 supposes the possibility of distending the organ 
 itself. In cases where there has been much forma- 
 tion of fibrous tissue, as in cirrhosis, distention is 
 not possible, and even an acute cardiac insuflciency 
 is unable to produce any marked degree of pain. 
 Therefore, whenever acute general congestion ex- 
 ists without any marked degree of pain in the liver, 
 we must always be suspicious of a preexisting cir- 
 rhosis. It is well, however, to be cautious xa. those 
 cases where the cardiac lesion has developed in very 
 chronic stages and has carried in its train a consid- 
 erable degree of connective tissue formation (car- 
 diac cirrhosis). 
 
 Occasionally inflammatory factors| such as acute 
 perihepatitis, may contribute to the production of 
 the pain. Such complications are characterized by 
 a sudden increase in the subjective pain without 
 a corresponding exacerbation of the cardiac condi- 
 tion. In contradistinction to the dull, aching pres- 
 sure produced by stretching of the capsule, this pain 
 is acute and stabbing, and because of its peritoneal 
 and inflammatory nature it is increased upon deep 
 
DIGESTIVE SYSTEM 26l 
 
 respiration (rubbing of peritoneal surfaces). This 
 pain is independent of digitalis treatment, but on 
 the other hand is rapidly and effectually controlled 
 by local treatment. When perihepatitis is present 
 it is almost impossible to lie upon the painful side. 
 Friction sounds accompany the pains only when 
 there is a fibrinous exudation of considerable quan- 
 tity and the fibrinous masses are of favorable con- 
 sistency. 
 
 Further details of the pains accompanying peri- 
 hepatitis will be discussed when speaking of syphilis 
 of the liver. 
 
 (b) Biliary Congestion. — In the same way that 
 an overfilling of the blood vessels may lead, by a 
 secondary stretching of the capsule, to liver pains, 
 so the condition of congestion in the bile ducts may 
 give rise to a very similar state of affairs. The 
 suffering produced by biliary congestion, however, 
 rarely equals in intensity that produced by conges- 
 tion in the blood vessels, largely because of the 
 differences of pressure in the two conditions. 
 Nevertheless pain over the liver upon percussion 
 along the linea alba is not uncommon in those dis- 
 eases which are accompanied by congestion of bile 
 (catarrhal jaundice, Hanot's cirrhosis, carcinoma of 
 the head of the pancreas, etc.). 
 
 These conditions are also accompanied by the 
 gall-bladder pains which we have mentioned above, 
 which occur without true colicky attacks. These 
 may exist in varying degrees, from the simple sensa- 
 tion of pressure to conditions approaching gall- 
 
262 PAIN 
 
 bladder colic. It is therefore always important to 
 percuss along the linea alba as well as over the gall- 
 bladder itself. 
 
 Since stagnation of the bUe is often directly the 
 result of inflammation of the mucous membrane of 
 the passages, and since, on the other hand, biliary 
 congestion favors inflammation of these passages, 
 it is not surprising that these conditions are fre- 
 quently accompanied by perihepatitis and the pains 
 characteristic of this condition. Therefore the pa- 
 tient who is suffering from Hanot's cirrhosis often 
 complains of a sharp pain along the right costal 
 margin or in the region of the right hypochondrium. 
 This pain is often dependent upon movements which 
 cause peritoneal friction, such as running, coughing, 
 sneezing, or deep respiration. Sometimes, though 
 rarely, it radiates towards the right shoulder. 
 Such variation is entirely consistent with its sub- 
 diaphragmatic position. The pains which occur in 
 the back and are increased by stooping must be 
 explained by the distention of the liver capsule. 
 
 We have already mentioned that gall-bladder 
 colic may, though rarely, be part of the clinical 
 picture of a Hanot's cirrhosis. 
 
 Tenderness on percussion over the liver, along 
 the linea alba and over the gall-bladder as well, is 
 occasionally found in cases of catarrhal jaundice, 
 and is directly proportionate to the degree of biliary 
 congestion. 
 
 In cases where the inflammatory processes are 
 not limited to the larger passages alone but extend 
 
DIGESTIVE SYSTEM 263 
 
 into the bile capillaries, extension takes place into 
 tlie peritoneal coverings, and thus a new reason 
 for tenderness is added. Therefore, whenever the 
 pain is extremely acute without great enlargement 
 of the organ, it is logical to think of an inflamma- 
 tory perihepatitis. In such cases also the gall- 
 bladder becomes involved and there is local tender- 
 ness to palpation and percussion, and local pain in 
 the gall-bladder region upon jarring of the body. 
 When this occurs it is important to think of the pos- 
 sibility of preexisting lesions in the gall-bladder, 
 such as gall-stones, since ordinarily the gall-bladder 
 pains are not an accompaniment of catarrhal icterus. 
 
 In considering conditions which lead to abnormal 
 stretching of the liver capsule, special attention is 
 due to the cystic new growths of the liver, and par- 
 ticularly to the development of echinococcus cysts. 
 The pains which occur in this condition remind us in 
 many of their peculiarities of the phenomena con- 
 sidered under the heading of gall-bladder colic. 
 
 In rare instances the passage of small cysts 
 through the bile ducts may give rise to attacks of 
 pain. More frequently, however, pains in this con- 
 dition are due to pressure and consequent stenosis 
 of the gall-ducts. Likewise, sudden changes in vol- 
 ume of the echinococcus cysts frequently occur, and 
 these give rise to inflammatory swelling of the liver 
 tissue surrounding the growth. The attacks of pain, 
 which often occur suddenly, are usually localized 
 in the right hypochondrium under the right costal 
 border, and radiate towards the right shoulder blade 
 
264 PAIN 
 
 and the sternum. The pain may also begin in the 
 back and radiate forward on both sides; more or 
 less constant pain in both scapulae and ia the back 
 may be present. 
 
 The similarity to gall-stone colic may be accen- 
 tuated by the occurrence of nocturnal attacks. The 
 attacks may be colicky, often severe enough to cause 
 syncope; again they may be of a more constant dull 
 character. Mechanical factors materially influence 
 the pains. Thus the pain is often at its maximum 
 when the patient lies on the left side, and in this 
 position has a sensation of a heavy mass being 
 dragged from right tO' left. Jarring of the body 
 increases the pain. Thus sneezing, coughing, per- 
 cussion upon the right loin, or any exertion causes 
 pain. Motions which are dependent upon contrac- 
 tion of the abdominal musculature, bending, lifting, 
 etc., lead to stabbing sensations over the liver. The 
 echinococcus cyst itself is sensitive in but few of the 
 cases. Accompanying the attacks of pain, syncope 
 may occur ; sensations of suffocation and rise of tem- 
 perature are not rare. Singultus may occur and 
 give a clue to the subdiaphragmatic nature of the 
 condition. Great attention must be paid to those 
 symptoms which emanate from the stomach and 
 often lead to an erroneous diagnosis of gastric 
 disease. These are due in most cases to the crowd- 
 ing of the stomach by the cystic sac, which produces 
 the symptoms of slight obstruction and gastric peri- 
 stalsis. This error can be well guarded against 
 if, on principle, in all cases of apparent gastric dis- 
 
DIGESTIVE SYSTEM 265 
 
 ease, we examine the liver and the spleen as well 
 as the stomach. 
 
 The statements made in regard to the pain 
 accompanying distention of the liver capsule are 
 hard to reconcile with those cases of carcinomatous 
 infiltration of the liver which are unaccompanied 
 by pain, even when the liver is enormously enlarged. 
 The same is true of most cases of fatty or hyalin 
 infiltration of the liver. The strange behavior of 
 these diseases is probably explained by the more 
 gradual enlargement which the liver undergoes. In 
 carcinoma, especially, the liver is not enlarged in 
 toto but m different places at different times, so that 
 the peritoneal coverings have an opportunity to 
 adjust themselves to the changed conditions. If car- 
 cinoma of the liver is accompanied by pains at all, 
 they are usually traceable directly to stenosis along 
 the bile-ducts (carcinoma of the pancreas or the bile- 
 ducts) or to the perihepatitis. Occasionally, too, 
 carcinoma of the liver may be complicated by gall- 
 stones, which then would account for the pain. The 
 sharp pains which indicate perihepatitis seem to be 
 associated chiefly with secondary carcinoma of the 
 liver, especially when the primary growth is an ulcer- 
 ating neoplasm of the gastro-intestinal tract. It 
 stands to reason that in such cases the conditions are 
 favorable for secondary inflammatory processes. In 
 cases of this kind occasionally sharp and prolonged 
 attacks of pain occur, and these are dependent upon 
 all those motions which give rise to peritoneal fric- 
 tion, thus pointing to the peritoneal cause of the 
 
266 PAIN 
 
 suffering. Pain is caused especially by those carci- 
 nomatous nodules which lie subperitoneally and 
 secondarily involve the peritoneum. 
 
 There are many cases in which it is important to 
 determine whether, with the existence of a gastric 
 carcinoma, the liver has already been involved or 
 not. In these we are forced to pay particular atten- 
 tion to the existence of pain in the right hypochon- 
 drium, since it is hardly ever possible to discover 
 by physical examination carcinomatous nodules sit- 
 uated under the dome of the diaphragm; the same 
 applies to circumscribed tenderness over the palpa- 
 ble liver surface. Acute and paroxysmal attacks of 
 pain of a moderate colicky nature are characteristic 
 chiefly of neoplasms which have caused stenosis of 
 the bile passages. Chief among these are the neo- 
 plasms situated in the pancreas. 
 
 Carcinoma of the gall-ducts occasionally runs its 
 course without either subjective or objective pain. 
 Local pain involving the gall-bladder and in part the 
 right lobe of the liver accompanies all those cases, 
 however, in which inflammatory changes have taken 
 place within or about the gall-bladder. In these 
 cases, toO', mild attacks of gall-bladder colic may 
 occur even without the existence of a gall-stone. 
 
 The fact that the left-sided position is particu- 
 larly painful in many cases of carcinomatous en- 
 largement of the liver is explained upon purely me- 
 chanical grounds. In this position the heavy organ 
 drops tpwards the left side and the patient feels 
 a drawing pain which extends from right to left. If 
 
DIGESTIVE SYSTEM 267 
 
 tlie capsule of tlie liver is inflamed this change of 
 position of the liver gives rise to extreme pain, and, 
 in such cases, the patient voluntarily prefers to lie 
 flat upon his back; thus immobilizing the organ. 
 Very frequently stooping gives rise to great pain 
 in the back. 
 
 Attacks of pain of intestinal origin are not rare 
 in carcinoma of the liver. These are due, on the 
 one hand, to direct infiltration of the colon from the 
 gall-bladder and consequent moderate obstruction. 
 On the other hand, there frequently exists a tendency 
 to meteorism which leads, by a local collection of 
 flatus, to attacks of a colicky nature. These attacks 
 are easily controlled by emptying the bowels. 
 
 Much more marked than in carcinoma of the liver 
 are the pains which accompany liver gummata, and 
 these are so regular that in all cases where pains 
 occur in the liver region it is necessary to think of 
 this possibility. 
 
 A local perihepatitis is almost regularly present 
 because of the inflammatory nature of the new 
 growth, and in this secondary phenomenon lies the 
 causes of the pain. This is made particularly evi- 
 dent by the factors which influence the pain. Pain 
 is initiated or increased by deep respiration, by 
 rapid walking, by jarring of the body, by walking 
 downstairs, by slipping of the right foot, and by 
 laughing or coughing. 
 
 Just as direct pressure upon the painful area 
 increases the pain, so motions which indirectly give 
 rise to greater pressure increase it as well. Occa- 
 
a68 PAIN 
 
 sionally, too, the taking of food will cause increased 
 suffering (perihepatic adhesions). 
 
 A great deal of differential knowledge may be 
 gaiaed by the therapy. The pains are almost imme- 
 diately relieved by iodides and (lq one of the 
 author's cases) by arsenic. If the pains are situ- 
 ated on the right side under the costal margin, there 
 is radiation into the right shoulder blade and into 
 the back. If the pain, in addition to this radiation, 
 assumes the nature of a colicky attack and is accom- 
 panied by vomiting, slight fever, and icterus, the 
 danger of confusing it with gall-bladder colic is 
 plain. Here only an exact physical examination can 
 make the differentiation, by revealing a circum- 
 scribed tumor upon the liver surface. Very fre- 
 quently, however, the pains are situated along the 
 left costal margin, because of the frequent involve- 
 ment of the left lobe of the liver. They are then 
 more constant in their nature, without colicky at- 
 tacks. They may be sharp or dull without giving 
 rise to radiation, and tenderness over the gall- 
 bladder region may be entirely absent. 
 
 In contradistinction to echinococcus, in the syphi- 
 litic condition the tumor itself is markedly sensitive. 
 
 PANCREAS. 
 
 In this organ, in which we have neither the 
 mechanism of muscular contraction nor the intimate 
 relation to the peritoneum found in the liver, there 
 would seem to be very little basis for the develop- 
 ment of characteristic pains. On the other hand, 
 
DIGESTIVE SYSTEM 269 
 
 experience tells us that certain lesions of the pan- 
 creas are accompanied regularly by attacks of pecu- 
 liarly intense pain. The most important among 
 such lesions are pancreatic cysts. 
 
 In accounting for this it is of primary impor- 
 tance to consider the intimate relations which the 
 pancreas holds to the nervous system in general 
 and to the solar plexus in particular; and it is quite 
 Ukely that, occasionally, we are confronted with 
 purely neuralgic conditions. This, however, does 
 not exclude the possibility that occasionally pains 
 may be produced in the pancreas by exactly the same 
 mechanism by which they are produced in the liver ; 
 that is, by cramp-like contractions and increased 
 pressure in the excretory ducts. Because of the 
 disproportionate structure of the muscular appa- 
 ratus of these ducts, however, it is hardly possible 
 to explain in this way any of the very intense 
 paroxysmal attacks. 
 
 Again, it is quite easy to understand that many 
 of the pains occurring with pancreatic lesions may 
 emanate from neighboring organs, rather than from 
 the pancreas itself. 
 
 In this connection the very intimate topographi- 
 cal relation of the terminal end of the ductus ohole- 
 dochus to the head of the pancreas is important; 
 the close apposition of these two' structures makes 
 it self-evident that any patholo^cal changes in the 
 head of the pancreas would lead to compression of 
 the common bile duct; and this, of course, would 
 lead to stenosis with consequent colicky attacks in 
 the gall-ducts. 
 
270 PAIN 
 
 We must remember, however, that frequently 
 diseases of the gall-passages and of the pancreas 
 may be present at the same time. In cysts of the 
 pancreas, the pancreatic nature of the disease may 
 be particularly obscured by pressure upon portions 
 of the gut, giving rise to paresis, peritonitis, aad 
 their consequent train of symptoms. Because of the 
 very intimate relationship of vascular disease to the 
 general pathology of the pancreas, we must occa- 
 sionally think of pains arising in the vessels. 
 
 From these considerations it naturally becomes 
 dear that any attempt to separate purely local pan- 
 creatic pains from those depending upon the neigh- 
 boring organs must be extremely difficult. 
 
 The law which states, in a general way, that 
 organ pains correspond in localization tO' the organ 
 from which they emanate, is borne out by pancreatic 
 conditions. So, because of the chiefly left-sided posi- 
 tion of the pancreas, the pains which arise in it are 
 situated in the left half of the epigastrium, to the 
 left of the umbilicus, or even in the left loin. Occa- 
 sionally with these, radiations may be observed 
 which are symmetrical with those occurring in gall- 
 bladder colic. 
 
 It has been mentioned above that occasionally 
 the colic accompanying pyloric stenosis may behave 
 in the same way {v. page 175). This left-sided char- 
 acter of the pain in pancreatic lesions might under 
 certain conditions be of gastric origin, in that the 
 pathological changes in the pancreas have second- 
 arily produced a pyloric stenosis by compression 
 
DIGESTIVE SYSTEM 271 
 
 and spasm. At all events it is necessary to pay very 
 close attention to the presence of gastric distention, 
 peristalsis, or sarcinas in the vomitus or feces. 
 
 It is easy to understand that, corresponding with 
 the retroperitoneal position of the organ, pains in 
 the back should frequently occur. These pains 
 sometimes radiate forward and around the waist. 
 Sensitiveness to pain will change in its localization 
 according to the position of the lesion in the pan- 
 creas. Since it is necessary, in palpating, to exert 
 deep pressure towards the vertebral column, the 
 localization of the tenderness is of little diagnostic 
 value. It is important also to look for sensitiveness 
 to pressure and percussion along the upper lumbar 
 vertebrae, a symptom which I have had occasion to 
 notice in several cases of diabetes. This is proba- 
 bly to be regarded as a reflex manifestation corre- 
 sponding to the phenomena occurring with gastric 
 ulcer and gall-bladder inflammations. 
 
 Whenever the sensitiveness is in the epigastrium, 
 it is necessary, owing to the close relation of vascu- 
 lar disease to disease of the pancreas, to think of 
 the possibility of purely vascular pain (hemor- 
 rhages or atheroma of the aorta). When sensitive- 
 ness occurs along the right costal border, even when 
 sure of the presence of pancreatic disease, we must 
 not neglect to search carefully for tumefaction of 
 the gall-bladder. This may easily follow constric- 
 tion of the common bile-duct in the head of the 
 pancreas. 
 
 A regular relation of the pains in diseases of the 
 pancreas to the taking of food could logically be 
 
272 PAIN 
 
 assinned since the food, passing out of the stomach 
 two or three hours after a meal, may readily cause 
 pain by reflexly inciting pancreatic secretion, and 
 therefore producing hypersemia of the organ ; but, of 
 course, whenever such a direct relation between the 
 meal and the attack of pain occurs it would be more 
 reasonable to think of secondary pyloric stenosis 
 or gastralgia. 
 
 It has frequently been noticed that the pain in 
 the back emanating from the pancreas occurs with 
 especial frequency at night; and this is explained 
 by the fact that the dorsal position is most apt to 
 cause discomfort. 
 
 The quality of the pain is of great diagnostic 
 importance, in that it frequently occurs with great 
 suddenness and severity and is accompanied by signs 
 of collapse. 
 
 The factors influencing the pain are naturally 
 dependent upon the mechanism underlying each in- 
 dividual attack. In cases in which we are dealing 
 with true neuralgia without the presence of other 
 factors, it is quite impossible to influence the- pains 
 in any way except by occasionally effectual narcotics. 
 
 In cases where the pain is due to pressure of 
 tumors (cyst or neoplasms), or is caused by peri- 
 toneal adhesions to the surrounding organs (as in 
 pancreatic abscesses), the conditions are quite dif- 
 ferent. In such cases purely mechanical causes, 
 jarring and tugging upon compressed nerves in 
 rapid change of position, stooping, coughing, or deep 
 breathing, may exert a very marked influence upon 
 
DIGESTIVE SYSTEM 273 
 
 the pains. Thus in the case of cysts and neoplasms 
 the dorsal position is very painful, and turning 
 upon the side brings almost immediate relief. When- 
 ever we are sure of the presence of a pancreatic 
 lesion and we can obtain immediate relief from the 
 pains by the belching following the administration 
 of alkaloids, we may conclude that there is present 
 a secondary stenosis of the duodenum with conse- 
 quent distention of the stomach. 
 
 When the pains have a purely vascular origin we 
 may expect them occasionally to be initiated by 
 the hyperaemia accompanying digestion. 
 
 Since, in a general way, the diagnostic aid given 
 us by the pain in these cases is extremely small, it 
 is very important to consider closely all other pos- 
 sible clues. We must remember that a large propor- 
 tion of the cases of pancreatic disease occurs in very 
 stout alcoholic individuals ; and that these are espe- 
 cially prone to arteriosclerosis and therefore to 
 haemorrhage and necrosis. 
 
 It is well also to think of the possibility of a 
 pancreatic lesion in all cases of apparent peritonitis, 
 or intestinal obstruction. The same holds true of 
 all cases of colicky abdominal pains which follow a 
 trauma, blows in the epigastrium, etc. If in these 
 cases no indican is found in the urine, but glycosuria 
 appears spasmodically or constantly after the attack 
 of pain, the suspicion of a pancreatic lesion becomes 
 strong. This opinion is much strengthened if, in 
 addition to these signs, the stools show an insuf- 
 ficient digestion of albumins and fats, and physical 
 
 18 
 
a74. PAIN 
 
 examination justifies the consideration of pancreatic 
 disease. 
 
 In spite of all these things it will often be impos- 
 sible to distiagnish diseases of the pancreas from 
 peritonitis, acute intestinal stenosis, cholelithiasis, 
 gastralgia, etc. 
 
 Some of the lesions of the pancreas are accom- 
 panied by pains of definite quality which, while not 
 entirely characteristic, may still give much diag- 
 nostic aid. 
 
 (a) Carcinoma of the Head of the Pancreas. — 
 Pain in the back with occasionally definite relation 
 to the position of the body may occur. This is by 
 no means a rule. The first pains seem frequently 
 to occur in the neighborhood of the gall-bladder be- 
 cause of the overdistention or stenosis of the com- 
 mon bile-duct. The pains seem to be dependent 
 chiefly upon mechanical conditions, such as the posi- 
 tion of the body, and are similar in this respect to 
 those occurring in the gall-bladder. Again the first 
 pains may be dependent entirely upon the local 
 perihepatitis which accompanies the subperitoneal 
 metastases. 
 
 In this way, in some cases, the entire attention 
 of the physician may be concentrated upon the liver 
 and gall-passages, and the pancreatic lesion may 
 escape detection. In the same way the attention 
 may be directed chiefly toward the pylorus or duode- 
 num when subjective or objective symptoms of ste- 
 nosis occur in these places. When this occurs, how- 
 ever, the pains are much less severe than in the 
 
DIGESTIVE SYSTEM 275 
 
 primary ulcerative or stenotic processes of these 
 organs. 
 
 (b) Pancreatic Cyst. — ^In tMs condition very sud- 
 den attacks of pain occur, sometimes under the left, 
 sometimes under the right costal border, accompa- 
 nied by syncope, collapse, vomiting and diarrhoea. 
 These attacks may in part be due to sudden increase 
 of tension whenever the cyst contents rapidly in- 
 crease in volume. Again, they may be neuralgic 
 in their nature, or may consist in the colic following 
 secondary stenosis of the gut. 
 
 (c) Suppurative Pancreatitis. — Not rarely the 
 acute attack of pain which occurs in thes& cases is 
 followed by icterus. This would naturally lead to 
 the danger of confusing the condition with choleli- 
 thiasis. The error can be guarded against only by 
 very careful palpation and localization of the sensi- 
 tive point. 
 
 (d) Hemorrhages. — ^When we are dealing with 
 drunkards, very fat people, or individuals with 
 marked arterial changes, all sudden attacks of epi- 
 gastric pain accompanied by collapse and dangerous 
 symptoms must be considered as possibly due to a 
 haemorrhage into the pancreas. It is almost never 
 possible to make this diagnosis with certainty. 
 
 (e) Pancreatic Calculi. — Attacks of pain which 
 are due to stones in the pancreatic duct usually be- 
 gin in the left half of the epigastrium and radiate 
 over the left shoulder. This left-sided localization 
 occasionally permits their differentiation from the 
 very similar attacks of gall-stone colic, a differen- 
 
S76 PAIN 
 
 tiation which is rendered very diflScult by the fact 
 that occasionally pancreatic concretions are accom- 
 panied by icterus. The absence, too, of sensitiveness 
 to pressure over the gall-bladder would be of great 
 aid. Differentiation from ulcerations similarly 
 localized, for instance those occurring in the py- 
 lorus, can be made by considering the independence 
 of the pancreatic pains from the quality and quan- 
 tity of the food. The greatest weight in making 
 these difficult diagnoses must, of course, be laid 
 upon the secondary symptoms. 
 
 Diarrhoea must be very carefully inquired for, 
 since it is rather a rare symptom in the other 
 varieties of colic. In addition to this careful exam- 
 ination must be made for the detection of glycosuria 
 and of excess of fat in the stools. The stools, too, 
 should be searched for bUe-free concretions consist- 
 ing of carbonates and phosphates of calcium. 
 
CHAPTER VIII. 
 
 Urinary System and Spleen. 
 KIDNEY. 
 
 In discussing the factors which produce pain in 
 the urogenital system, we may avoid much repetition 
 by calling attention to the close analogy existing 
 between this system and that of the liver and gall- 
 ducts. The pelvis of the kidney, the ureter and the 
 bladder find close analogies in the gall-bladder, the 
 gall-passages and the duodenum, and in a general 
 way the conditions producing colicky pains along 
 these hollow muscular organs are the same. It may 
 be assumed that conditions which produce aji in- 
 crease of pressure upon the capsule of the liver, 
 such as congestion of blood or bile, or tumor forma- 
 tion, may find close analogies in the kidney itself. 
 The same holds good of perihepatitis and peri- 
 nephritis. For this reason we can follow approxi- 
 mately the same classification. 
 
 I. True Kidney Pains. 
 
 Here the pain is caused by acute or chronic 
 tension upon the kidney capsule or inflammatory 
 changes in the surrounding tissue. In some cases 
 also there may be direct injury by destructive proc- 
 esses of the renal plexus. At any rate it is never 
 correct to speak of renal colic; for in the kidney 
 itself the conditions for the production of such 
 
 277 
 
«78 PAIN 
 
 colicky pains are absent, such paias occurring only 
 in hollow organs. 
 
 While it is impossible to differentiate by their 
 pains alone the various conditions which produce 
 such stretching of the capsule of the kidney, it is for 
 practical reasons better to consider the conditions 
 separately. 
 
 (a) Embolism of the Renal Arteries. — It is ex- 
 tremely rare for this lesion to be accompanied by 
 pain. In the year 1901 I was able to find in the 
 literature only seven reported cases, and therefore 
 it may seem wrong to begin our considerations with 
 this condition. But in kidney infarcts the pain 
 occurs in such a characteristically sudden way that 
 it furnishes a most clear-cut subject for study. 
 
 The pain in this condition is distinguished from 
 all other true kidney pains only by the great sudden- 
 ness of its onset (apoplectiform). In other respects 
 every one of the details which are observed in kidney 
 pains occurs, and for this very reason a close de- 
 scription of the condition will serve most excellently 
 to illustrate the others. 
 
 Subjective pains, as well as the objective ones 
 produced by pressure, palpation and percussion, cor- 
 respond in a general way to the position of the 
 organ in front and behind. The kidney extends 
 vertically from the middle of the eleventh thoracic 
 vertebra to the lower limit of the body of the second 
 lumbar vertebra. In an upward direction, therefore, 
 it extends to above the twelfth thoracic vertebra. 
 Its posterior surface for a short distance is apposed 
 
URINARY SYSTEM AND SPLEEN 279 
 
 to that part of the diaphragm at which the lumbar 
 and costal portions of this organ join. The greater 
 part of it lies against the quadratus lumborum. 
 Since the kidney varies much in its localization we 
 must occasionally be prepared to find abnormal local- 
 ization of the pain. Thus a low position of the kid- 
 ney may give rise to pains in the ileocsecal region. 
 It must be remembered also that in some cases the 
 kidney may have projections towards the median 
 line (horse-shoe kidney), or occasionally in the pel- 
 vis, or the sacrum, along the position of the sacro- 
 iliac junction. These abnormal positions would 
 naturally bring with them abnormal positions of the 
 pain. 
 
 The kidney pain is especially easy to recognize 
 when we are dealing with the right kidney and the 
 pains are projected forwards. This occasionally 
 happens in- renal infarcts. If we consider the sec- 
 ondary symptoms, such as vomiting, pain in the liver 
 due to congestion, tenderness along the gall-bladder 
 and appendix, and fever, the danger of confusion 
 with gall-bladder or appendicular pain is extremely 
 probable. 
 
 It seems to the author especially important to 
 note that the pain in disease of the kidney is located 
 particularly in the flank ; while along the mammary 
 line in front, or in the lumbar region behind, the 
 tenderness to pressure or percussion is much less 
 marked. 
 
 Another source of frequent error lies in the fact 
 that pressure of the abdomen often gives rise to a 
 
280 PAIN 
 
 very diffuse pain (especially when the infarction is 
 bilateral). This is explained by the fact that the 
 pressure reaches the diseased organ indirectly 
 through the interposed organs. For the more exact 
 localization of the pain in these cases percussion is 
 more useful than palpation. 
 
 The patient in cases of true kidney pain almost 
 always localizes the pain deeply, away from the 
 abdominal wall, a fact which often helps greatly in 
 differentiating it from neuralgia or myalgia. 
 
 Very occasionally there is sensitiveness in the 
 lower iutercostal spaces as far up as the scapular 
 angle posteriorly, and about four centimeters above 
 the costal border anteriorly. This must be regarded 
 as merely a reflex pain, since it occasionally occurs 
 in pyelonephritis without the existence of a second- 
 ary pleural inflammation. 
 
 Sensitiveness to pressure is found chiefly in: 
 (1) the flank, in the axillary line; (2) the angle 
 between the lateral border of the erector spinse and 
 the twelfth rib; (3) anteriorly in the region below 
 the gall-bladder corresponding to the position of the 
 kidney. 
 
 A characteristic radiation does not accompany 
 these true kidney pains and therefore is not present 
 with renal infarcts. This is due to the absence of a 
 path of transmission (ureter) ; yet in rare cases 
 there may be sensations in the thigh. When these 
 do occur, they can be regarded as due to pressure 
 upon the twelfth dorsal nerve and branches of the 
 lumbar plexus, by thickening of the capsule. 
 
URINARY SYSTEM AND SPLEEN 281 
 
 The factors influencing the pains of renal infarct 
 are chiefly mechanical. Normally the kidney is sup- 
 posed to be entirely immovable. This is quite theo- 
 retical, however, and practically we may find all 
 degrees of mobility. It is not surprising, therefore, 
 that in cases of inflammatory changes within the 
 kidney or about the capsule (partial necrosis of the 
 renal tissue, tuberculosis, etc.), forcible manipula- 
 tion of the organ is accompanied by more or less 
 pain; thus, too, a definite position of greatest pain 
 is developed quite acutely in cases where enterop- 
 tosis and weakness of the abdominal walls are pres- 
 ent. The patients are unable to lie on either side 
 without suffering, and it is peculiar that pain is 
 most severe when lying upon the healthy side. In 
 this position they have the sensation of a painful 
 tugging extending from the diseased side towards 
 the healthy. The actual descent of the kidney 
 downwards toward the side upon which he lies is 
 felt acutely and distinctly by the patient. 
 
 In the same way definite painful positions are 
 present in tuberculosis, in renal tumors and in pyelo- 
 nephrosis; only occasionally does the position of 
 greatest pain correspond with the diseased side. If 
 change of position and slight tugging by reason of 
 the weight of the organ itself are able to cause pain, 
 it is all the more reasonable to believe that forcible 
 jarring would cause localized pain in the neighbor- 
 hood of the kidney; and this actually occurs with 
 coughing, vomiting, riding in a carriage, jumping, 
 or making a false step. All motions which call for 
 
a82 PAIN 
 
 contraction of the ileopsoas muscle, such, as rising, 
 and stretching of the flexed thigh, will of course 
 give pain because of the close apposition of the 
 kidney to the muscle. 
 
 It is hardly necessary to mention that pressure 
 in the kidney region, or percussion with the clenched 
 fist would cause pain. Strong percussion is espe- 
 cially helpful in localizing the exact extent of the 
 pain and in demonstrating its diminution during con- 
 valescence. It is worth mentioning, too, that in 
 cases of renal infarct the objective pain is present 
 for some time after the subjective has disappeared. 
 
 The pain accompanying renal infarct resembles, 
 in the suddenness of its onset, colic of the ureter, 
 but is sharply differentiated from the latter condi- 
 tion by the fact that the pain itself, after the onset, 
 is not colicky but stabbing, aching and constant. 
 
 In attributing any pain to renal infarction, we 
 must consider the condition of the heart (existence 
 of a mitral stenosis). We must note particularly 
 the sudden onset of the pain and the subsequent 
 absence of any paroxysmal quality. Most abdom- 
 inal pains are of a colicky nature, and the absence 
 of the paroxysmal element is of great differential 
 importance. 
 
 It is, furthermore, very important to determine 
 whether or not there is difficulty of micturition. 
 Urination becomes difficult (renal dysuria) and can 
 be accomplished only in the standing position and 
 with great exertion; occasionally there are symp- 
 toms of moderate incontinence. The quantity may 
 
URINARY SYSTEM AND SPLEEN 283 
 
 be at first diminished or there may even be complete 
 anuria. The frequent desire to urinate seems to 
 be absent in these cases, a feature which is of great 
 differential value since pains arising in the excretory 
 passages are usually accompanied by this symptom. 
 
 The characteristic features of the urine analysis, 
 I have found to be the following : 
 
 There is often a sudden and copious albuminuria, 
 as high as 2 per cent, which very rapidly diminishes. 
 There is occasionally a very slight haematuria, often 
 discovered only by microscopical examination. Oc- 
 casionally, also, epithelial casts may be found in the 
 sediment. 
 
 The consideration of these secondary symptoms 
 which point to the urogenital system will guard us 
 against confusion with the colics of the gall-bladder 
 and appendix, an error which is the more easUy 
 made when the embolus is situated on the right side. 
 
 The vomiting and hiccoughing which occur with 
 the onset, can lead easily to the false diagnosis of 
 acute peritonitis. This is especially so when the 
 infarct is bilateral and in consequence the abdom- 
 inal tenderness is very diffuse. 
 
 The pain accompanying renal infarct is sharply 
 differentiated from the paius which occur along the 
 ureter (nephrolithiasis) by the complete absence 
 of paroxysms, the continuous character of the pains, 
 and the slight tendency to radiation. In ureteral 
 colic the pain is of a remarkably intermittent type 
 and radiations are very frequent. In renal infarc- 
 tion the kidney is especially sensitive to pressure, 
 
284 PAIN 
 
 whereas in the other condition tenderness may occur 
 only along the course of the ureter. 
 
 It is quite impossible to differentiate the pain of 
 renal infarct from that accompanying other intra- 
 renal conditions. All other diseases which occur 
 in this location may give rise to similar pains, and 
 for that reason the description just given may serve 
 as a type for all true "nephralgia." I will there- 
 fore spend little time in discussing the other patho- 
 logical conditions which occur in the kidney and are 
 accompanied by pain. 
 
 (b) Acute and Chronic Nephritis, Pyelitis, and 
 Paranephritis. — ^Acute paroxysmal pains may occa- 
 sionally, though rarely, accompany the non-suppura- 
 tive inflammations of the kidney. These are then 
 due to pericapsular inflammation, and damming back 
 of the urine, with acute congestion and increase in 
 the capsular tension. Thus acute hyperaemia, as it 
 occurs in cases of nephritis, may give rise to intense 
 pains which are similar to those just described in 
 renal infarct, and these pains may be one-sided in 
 spite of symmetry in the pathological process. It 
 is therefore advisable to be very cautious in the 
 diagnosis of calculus when sudden- colicky pain 
 occurs in the neighborhood of the kidney in acute 
 nephritis, even when, as in one of my own cases, 
 radiation occurs into the thigh. Such an occurrence, 
 while it must be thought of, is nevertheless extremely 
 rare in all cases of non-suppurative nephritis. I 
 have seen only one such case. 
 
URINARY SYSTEM AND SPLEEN 285 
 
 Of much greater frequency are those uncertain 
 dull back-aches, the relation of which to the kidney 
 is subject to great doubt and must b© judged individ- 
 ually in each case. It is very rare that we have any 
 definite factor which points to the kidney as the 
 source of the pain. I have seen cases, however, in 
 which the patient has stated that excessive drinking 
 has increased the pain, while, on the other hand, 
 discharge of the urine has decreased it considerably. 
 The simultaneous occurrence of backache and renal 
 cedema is also noteworthy. In persons with the 
 uric acid diathesis pain in the kidney region is often 
 associated with scanty urine and an abundant sedi- 
 ment of uric acid. 
 
 In contrast to lumbago, the pain in nephritis and 
 pyelonephritis is not at all influenced by stooping; 
 while, on the other hand, walking about, severe exer- 
 tion, and pressure increase the pains, just as in the 
 case of lumbago. In these conditions, too, the pain 
 is occasionally one-sided. As a matter of practical 
 importance it is well to examine the urine for al- 
 bumin in all cases where a pain suggestive of lum- 
 bago exists, and this, especially, when no other 
 clearly rheumatic pains are present. 
 
 It is also important, whenever albuminuria has 
 been discovered, to examine the kidney for tender- 
 ness. Occasionally, hyperaemia of the kidney and 
 consequently increased intracapsular pressure will 
 give rise to sensitiveness on palpation. Percussion 
 in the loin is best made with the clenched fist. By 
 
286 PAIN 
 
 palpation, in front it is often possible to press 
 directly upon the lower pole of the kidney. When- 
 ever slight pressure in the loin or slight jarring in 
 this neighborhood causes pain and we can determine 
 the presence of hypergesthesia along the ileohypo- 
 gastric and genitocrural nerves, we must think of 
 the possibility of paranephritic suppuration. In 
 such cases the patient often lies with the thigh flexed 
 and adducted, has chills, and suffers great pain upon 
 change of position. 
 
 (c) Renal Congestion. — Just as the liver is the 
 seat of pain when it is congested in consequence of 
 cardiac insufficiency, so the kidney may be the seat 
 of pain under similar conditions. This, however, 
 occurs much more rarely. The pains in the back 
 are then very promptly relieved by digitalis. 
 
 (d) New Growths of the Kidney. — ^Pain in the 
 lumbar region and the flank, when, unilateral, must 
 occasionally arouse suspicion of an early neoplasm 
 of the kidney and should lead to a careful palpation 
 of the organ. 
 
 Increase in the intracapsular tension in conse- 
 quence of the enlargement of the new growth, con- 
 gestion or haemorrhage into the tumor, may give rise 
 to pain, even in the early stages. In these cases, too, 
 the pains havethe characteristics of true kidney pains 
 in the special sense of the word, and correspond to 
 the pains described for renal infarct. In conse- 
 quence of the increased weight of the organ the tug- 
 ging pains accompanying change of position will be 
 
URINARY SYSTEM AND SPLEEN 287 
 
 more noticeable than in infarction, so that the patient 
 cannot bear to lie on the side opposite to that of the 
 diseased kidney. The pain is often provoked by 
 bending, lifting, or the carrying of a heavy weight. 
 This may be due either to temporary passive hyper- 
 semia or to direct pressure by the contracting abdom- 
 inal muscles. In these cases, too, there may occa- 
 sionally be sensitiveness to pressure in the corre- 
 sponding thigh. 
 
 When the new growth penetrates into the pelvis 
 of the kidney and secondary hemorrhage occurs, a 
 new source of pain arises. This is a form of ureteral 
 colic and may lead to difficulty in distinguishing the 
 condition from nephrolithiasis. 
 
 In August, 1902, I was consulted by a Hungarian gentleman 
 aged forty-four years. His first attack of pain had been in Marcfh, 
 1902, and had involved the lower abdomen, with radiation into the 
 right testicle which was very tender. There was vomiting and 
 backache, especially on the right side. Since then he had had three 
 similar seizures of great intensity, coming on in the evening after 
 a day of unusual exertion. During the attacks there was no dis- 
 turbance of urination, but the urine was bloody in appearance and 
 contained shreds of tissue. During the past two years he had 
 often suffered from pain along the outer side of the right thigh, 
 especially when seated. In September, 1902, the backache became 
 continuous. The pain was least severe when he was lying quietly 
 in the dorsal position, but was made much Worse when he turned 
 on the left side and then there was an unbearable sensation as if 
 something heavy were being drawn over to the middle of the abdo- 
 men. On October 8 there was very violent backache with pain in 
 the right thigh. On October 25 an attempt at defecation caused 
 severe pain in the back on both sides. The patient died two days 
 later, and at the autopsy a hypernephroma was found on the 
 right side. 
 
 (e) Tuberculosis of the Kidney. — In many cases 
 
288 PAIN 
 
 tuberculosis of the kidney occurs without local pain. 
 Nevertheless cases occur in which pain is one of the 
 earliest symptoms. "Whenever considerable capsu- 
 lar or pericapsular inflammation occurs, nephralgia 
 will be present, and such pains, in the presence of a 
 tuberculous tendency or of tuberculosis in other 
 parts of the body, must always arouse suspicion. 
 The pain seems to be in many cases extremely 
 acute, and is described as boring like that of a boil. 
 
 Just as in new growth, so in tuberculosis of 
 the kidney sudden paroxysmal attacks may occur. 
 These occur whenever by ulceration and erosion of 
 a blood vessel a haemorrhage takes place into the 
 pelvis from one of the papillae. 
 
 The localization of the subjective and objective 
 pains in this condition corresponds more or less 
 closely to that described for renal infarct. The 
 painful sensations which occasionally occur in the 
 bladder and urethra, without any disease in these 
 organs, must be explained by radiation, and consist 
 chiefly in a painful desire to urinate, and burning 
 pain before and after micturition; so that these 
 pains may simulate a cystitis. 
 
 (f) Paroxysmal Hcemoglohinuria. — In this con- 
 dition there is occasionally an acute hyperaemia of 
 the kidney with consequent intracapsular pressure ; 
 the pain in the back which occurs is probably to be 
 interpreted upon this basis. 
 
 The subjective pain which occurs in one or both 
 kidneys is often accompanied by sensitiveness. 
 
URINARY SYSTEM AND SPLEEN 289 
 
 The pain is then dependent upon motion, such as ris- 
 ing from a stooping position, bending forward and 
 turning towards the painful side. 
 
 (g) Movable Kidney. — It must be remembered, 
 in considering movable kidney, that many patients 
 in whom an enormous amount of freedom of motion 
 of the kidney exists are almost entirely free from 
 pain. This fact ought to be considered very seri- 
 ously, because it is a quite common error that when 
 a movable kidney is present in a patient, this is taken 
 as the cause for any existing pain. In most cases 
 it is not the wandering kidney which causes the 
 pains. The individuals in whom they are present 
 are usually of an extreme neurasthenic type, and 
 suffer from a general enteroptosis. These are the 
 conditions which should be treated rather than that 
 of the movable organ itself. It stands to reason that 
 in this condition there is a constant tugging on the 
 renal plexus and indirectly therefore upon the solar 
 plexus. This leads naturally to hypersesthenia in 
 the abdominal sympathetic system and consequent 
 irritability of the stomach, gall-bladder and genitals. 
 In this sense, a movable kidney and enteroptosis 
 may be very disagreeable complications of gastric 
 ulcer or cholelithiasis. Whenever an abnormally 
 movable kidney is also tender and sensitive to pres- 
 sure, it is well to think of diseases of this kidney, 
 such as calculi, pyelitis, or tuberculosis. 
 
 In referring any existing pain to the mobility of 
 the kidney, it is important to determine whether 
 
 19 
 
290 PAm 
 
 motions -wMcli directly result in tugging or jarring 
 of the organ, such as walking downstairs, rapid 
 change of position, etc., are the ones which cause the 
 pain; and it is never just to attribute pains which 
 are present during absolute quiet to this cause. It 
 must be remembered, however, that other diseases 
 which are often accompanied by enteroptosis, such 
 as ulcer, chronic appendicitis, and gall-bladder dis- 
 ease, may also be dependent upon such jarring 
 movements. 
 
 The exact diagnosis in these cases is often ex- 
 tremely difficult, and it is better, therefore, to let 
 the therapeutic interference precede the diagnosis 
 rather than vice versa. Whenever the pain is re- 
 lieved when the kidney is immobolized by a binder, 
 the diagnosis, of course, is cleared up. 
 
 It is surely very rare that torsion of the pedicle 
 of a movable kidney occurs ; and it is well to think 
 of this only after the exclusion of other causes for 
 the attack. Whenever this does occur the pain that 
 accompanies it can be explained in two ways: 
 1. Acute venous stasis. 2. Acute development of 
 ureteral obstruction with secondary hydronephrosis. 
 In both cases local sensitiveness would be easily ex- 
 plained. In the second case, however, an attack of 
 polyuria would theoretically be expected towards 
 the end of the attack. On the other hand, it is well 
 to remember that in neurasthenic individuals, among 
 whom the large majority of movable kidneys occur, 
 polyuria is not a rare symptom. 
 
URINARY SYSTEM AND SPLEEN 291 
 
 II. Pains Caused by Distention and Muscular 
 
 Spasm along the Urogenital Tract 
 
 (Renal Pelvis and Ureter). 
 
 The pains which are considered in this connec- 
 tion are in their genesis closely related to those 
 occurring in the gall-bladder system, and may easily 
 he classified in the same way. The pelvis of the kid- 
 ney may be regarded as analogous to the gall- 
 bladder and the urinary bladder to the duodenum. 
 
 The characteristics which distinguish the pains 
 in these passages from the true kidney pain (ne- 
 phralgia) are the marked tendency to colicky attacks 
 and the tendency to radiation; for we have here in 
 contradistinction to the kidney itself a channel for 
 radiation along the ureter and bladder. The chief 
 causes * which may give rise to colicky attacks in the 
 genito-urinary ducts are analogous to those which 
 give rise to similar pains in the gall-duct system. 
 
 1. Stenotic Processes. — The most important 
 causes for stenosis are: (a) Calculi, blood clots, par- 
 ticles of new growth, and aortic aneurysm (on the 
 left side), (b) Kinking and torsion, (c) Carci- 
 noma of the bladder at the points of entrance of the 
 ureters. (This would be analogous in the bile pas- 
 sages to carcinoma at the papilla of Vater or in 
 the head of the pancreas.) 
 
 ♦Observations in cases of lead poisoning (v. page 221) and in 
 phosphaturia lead me to believe that there may also be sensory 
 neuroses of the ureters. 
 
292 PAIN 
 
 2. Inflammatory Processes, Ascending and De- 
 scending. — Pyelitis witli or without the formation 
 of calculi ; this may or may not extend into the small 
 tubules of the kidney (pyelonephritis). Ureteritis 
 is entirely analogous to cholecystitis and cholan- 
 geitis, while the pyelonephritis can be compared with 
 Hanot's biliary cirrhosis. 
 
 All these conditions, and especially the formation 
 of calculi in the kidney pelvis, give rise to colicky, 
 paroxysmal pains. On the other hand, they may 
 also give rise to more constant pains, not colicky in 
 their nature, the understanding of which is of ex- 
 treme importance. These more constant paias are 
 probably due to a moderate degree of distention 
 along the ureters or pelvis. It must be remembered, 
 too, that any pathological process in the renal pelvis 
 easily involves the kidney itself, even when it is only 
 a temporary damming back of urine or an active 
 hypersemia; and this, in its turn, can give rise to 
 the true kidney pain which we have spoken of before. 
 
 As a practical matter it is almost impossible to 
 separate the purely stenotic and the inflammatory 
 processes which occur along the renal pelves and the 
 ureters. They often occur at the same time, for 
 stagnation, as is well known, carries with it the 
 predisposition to infection. For this reason we 
 may disregard this purely artificial distinction in 
 the consideration of the pain. 
 
 (a) The Foemation of Calculi in the Pelvis of 
 THE Kidney. — Just as in describing the true kidney 
 pain, the pain caused by infarct of the kidney was 
 
URINARY SYSTEM AND SPLEEN 
 
 used as a type, so the pains occurring in the pelves 
 and ureters are well typified in a general way by the 
 pains caused by a calculus in the renal pelvis. 
 
 For practical reasons it is well to divide such 
 pains into (1) spontaneous attacks of paroxysmal 
 pain or colic, (2) more constant pains not colicky 
 in their character and often elicited by physical 
 examination. 
 
 (1) The localization of the colicky pains is rather 
 apt to be confusing to the diagnostician. Sometimes 
 these pains occur first in the region of the gall- 
 bladder along the right costal border. Occasionally 
 they have their seat more deeply in the ileocaecal 
 region or, if left-sided, just above the left Poupart's 
 ligament. In comparatively rare cases the lumbar 
 region may be the starting point of the pains. This 
 is not at all surprising when we consider that the 
 lesion upon which the pain is based has its seat, not 
 in the kidney itself, but in the ureter. 
 
 More important than the actual location of the 
 pain is the radiation, which unfortunately is not 
 always present. This occurs into the thigh of the 
 same side, chiefly radiating down the anterior or 
 external surface, and rarely extending further down 
 than the knee. 
 
 We must be on the watch, too, for radiations into 
 the bladder and the genitals, with occasional cramp- 
 like sensations in these organs. It is very important 
 to remember that painful sensations in the testicles, 
 ovaries and thighs may for a long time precede the 
 first attack. These pains occur especially at night 
 
294 PAIN 
 
 and their diagnostic importance must not be under- 
 estimated. 
 
 The pain not infrequently radiates into the lum- 
 bar regions; upward it rarely reaches higher than 
 the angle of the scapula. Whenever the attacks 
 occur spontaneously they seem to be dependent upon 
 mechanical agencies rather than upon digestive 
 causes. 
 
 Motions which give rise to a sudden stiffening 
 of the abdominal walls, lifting, or throwing, seem 
 frequently to have a causal relation to the begin- 
 ning of an attack. On the other hand, I have seen 
 cases in which attacks have been initiated by the 
 drinking of sour wine, the taking of sour food, such 
 as vinegar, and occasionally the drinking of beer. 
 Such digestive influences upon the attacks occur nat- 
 urally in cases in which, in addition to calculus for- 
 mation, there is an inflammatory change of the 
 mucous membrane of the pelvis and ureter which 
 is irritated by the reaction of the urine passing 
 through it. 
 
 In February, 1906, a man of about twenty years came to me 
 on account of cramps in the stomach. The first attack was said to 
 have come on at the age of three years after a dietary indiscretion. 
 Lately attacks had appeared after periods of constipation or after 
 eating fatty meat. The patient was sensitive to cold water, easily 
 fermentable foods, vinegar, and spices. The cramps would also 
 sometimes follow lifting a heavy object with the right hand. This 
 very fact aroused suspicions as to the patient's own diagnosis of 
 " stomach cramps " made in consequence of the apparent relation 
 of the condition to the ingestion of food, and further examination 
 left no doubt as to the existence of a stone in the left kidney. I 
 saw the patient again a year later and he told me that in May, 1906, 
 he had passed a calculus the size of a pea. 
 
URINARY SYSTEM AND SPLEEN 295 
 
 Whenever a paroxysm ceases with, great sudden- 
 ness we are led to believe that a calculus has been 
 discharged into the bladder. 
 
 The secondary symptoms chiefly to be consid- 
 ered are those which arise from the urogenital sys- 
 tem and therefore point directly to the origin of the 
 colicky attack. Chief among these are desire for 
 frequent micturition and retention of urine. In 
 tuberculosis of the kidney, kidney infarct, and other 
 conditions of nephralgia or true kidney pain, the 
 desire to urinate may occasionally entirely disap- 
 pear. 
 
 Sometimes there is definite sensitiveness of the 
 testicle on the affected side with occasional swelling. 
 Swelling and sensitiveness in the urethra may be 
 the premonition of an attack. Very definite clews, 
 of course, are given by haematuria, albuminuria, ura- 
 turia, phosphaturia, oxaluria, and cystiuuria. 
 
 Keflex symptoms, aroused in other organs by 
 the renal condition, may considerably cloud the diag- 
 nostic picture. Meteorism with constipation, diffuse 
 distribution of the pains, with collapse, may simu- 
 late acute intestinal obstruction and, in just such 
 cases, the extreme sensitiveness of the testicles is of 
 distinct diagnostic importance. The distended ab- 
 domen itself is often sensitive to pressure, and in 
 such cases distention and sensitiveness are usually 
 localized more on one side than on the other. Occa- 
 sionally there may be no pain in the kidney region 
 itself. Diarrhoea may accompany the attacks, and 
 gastric symptoms, such as nausea and vomiting. 
 
296 PAIN 
 
 occasionally occur, but are mucli less frequent than 
 in connection with the colics of the biliary system, 
 and, during the attacks of renal pain, the diges- 
 tive system is often entirely normal, not even the 
 appetite being changed. In many cases there are 
 subjective sensations, such as a sensation of cold, 
 etc., in the thigh of the same side. There may also be 
 motor symptoms, such as spasm in the muscles of the 
 calf or the thigh of the same side. 
 
 Sensitiveness to pressure along the ureter on 
 external examination per rectum or per vaginam is 
 of the greatest importance, and from this examina- 
 tion alone the diagnosis of an obstructing calculus 
 can often be made. 
 
 (2) More constant pains (without paroxysmal 
 quality). Under this heading we include chiefly 
 pain which is not subjectively present but is discov- 
 ered on palpation. "We have already called atten- 
 tion to the sensitiveness of the testicle. In addition 
 to this there is usually sensitiveness of the ureter, 
 leading on the right side to pain in the neighborhood 
 of the appendix; on the left side in the neighbor- 
 hood of the sigmoid flexure. 
 
 The sensitiveness to pressure in the flank and to 
 percussion in the lumbar region is of great impor- 
 tance. 
 
 In one of my cases there was first lumbago-like pain on the 
 right side and the patient kept the body bent over to this side. 
 Some time later there was a, typical attack of colic on the right side. 
 
 The maximum point of sensitiveness is often 
 located just above Poupart's ligaxaent. Occasion- 
 
URINARY SYSTEM AND SPLEEN 297 
 
 ally when the condition exists on the right side the 
 gall-bladder is very sensitive and errors may arise 
 from this fact. When this is the case, however, very 
 often sensitiveness in the gall-bladder radiates 
 towards the urinary bladder and this, of course, is 
 of great importance. 
 
 These more constant pains may often be started 
 by the patient's lying on one side. When the 
 process is bilateral lying on either side is painful. 
 In some cases no fixed position can be held for any 
 length of time without great pain. We spoke of 
 such positions of greatest pain when dealing with 
 cholecystitis, and here again symptoms of this kind 
 are due probably to changes in the pelvis of the 
 kidney; they may also be caused by secondary in- 
 volvement of the kidney in the form either of an 
 acute dammiag back of the urine, or an acute conges- 
 tion of the kidney itself. Coughing, deep breathing, 
 and jarring of any kind may give pain in nephro- 
 lithiasis. 
 
 The unilateral neuralgia of the testicle which 
 occurs chiefly at night, and the so-called rheumatic 
 pains in the thigh, may often precede the true colicky 
 attacks by many years. The sensations of weakness, 
 nausea, etc., which usually accompany the colicky 
 attacks may be present by themselves frequently, 
 and are then, almost invariably, wrongly interpreted. 
 
 Under this heading, too, we must consider that 
 pain in the lumbar region which frequently accom- 
 panies the condition. This is present especially in 
 the lying and sitting postures, and is less marked 
 
298 PAIN 
 
 when walking. Alone, of course, the recurrence 
 of such a pain can give us no diagnostic clue ; but, in 
 connection with other symptoms, such as testicular 
 pain and paraesthesia of the thigh, it may give much 
 additional support to our diagnosis. 
 
 (b) Pyelitis. — Of chief importance are the 
 ascending catarrhs of the urinary passages, usually 
 preceded by a history of an old gonorrhoea, so that 
 in many cases the ureter and the bladder itself may 
 be regarded as diseased together. This variety of 
 pyelitis is the most frequent. The pain occurring 
 in this condition is almost identical with that occur- 
 ring in cases of calculi. This fact is of particular 
 pathological interest, since it lends support to the 
 opinion that pains of this description are, in these 
 cases as well as in gall-bladder condition, caused by 
 the inflammatory lesions rather than by the mere 
 mechanical pressure of calculi. 
 
 Changes of the kidney in all their transitions 
 from a simple inflammatory hyperaemia to a fully 
 developed pyelonephritis may accompany this con- 
 dition. A part, therefore, of the clinical picture is 
 made up of the true kidney pain itself. The local- 
 ization of the pain is much the same as that men- 
 tioned above. Occasionally, however, cases occur 
 in which the pain and sensitiveness take place in the 
 region of the gall-bladder and appendix and thus 
 lead to error in diagnosis. 
 
 The radiation is identical with that which occurs 
 in calculi of the renal pelvis. Eadiation may occur 
 at the same time as the colicky attacks or may be 
 
URINARY SYSTEM AND SPLEEN 299 
 
 entirely independent of them. It may be localized 
 chiefly on the outer side or occasionally on the inner 
 side of the thigh of the same side. Prolonged sit- 
 ting occasionally initiates these radiating pains. 
 
 In isolated cases it is not so much the sensation 
 of pain as the sensation of weakness and fatigue in 
 the lower extremity of the same side as the disease 
 which gives rise to a suspicion of a lesion in the 
 renal pelvis. 
 
 Sometimes sensitiveness occurs along the dorso- 
 lumbar portion of the spinal column. Pain occur- 
 ring while the patient is lying on his side is located 
 usually in the side opposite to that of the lesion. 
 Frequently the pain which occurs in this posture is 
 present only during the acute attack and disappears 
 when the attack is over. 
 
 There is often a tendency towards relaxation of 
 the abdominal muscles on the diseased side. The 
 patients lean toward that side while walking or sit 
 in a cramped position. Sudden stretching of the 
 abdominal muscles often brings about an attack of 
 intense pain and syncope, in cases which have been 
 before that almost free from pain. In doubtful 
 cases it is often advisable to test cautiously the 
 influence of lifting or carrying weights on the back. 
 Violent jarring, such as is produced by stamping 
 the foot, jumping, etc., will frequently give rise to 
 pain. In contradistinction to lumbago, the pain is 
 not increased by stooping, even when there has pre- 
 viously been severe pain in the lumbar region. 
 
300 PAIN 
 
 Catching cold and exposure to wet often give rise 
 to attacks of pain. This is probably due to the fact 
 that these conditions may provoke an acute exacer- 
 bation of a chronically inflamed condition of the 
 mucous membrane. 
 
 It need hardly be emphasized that careful micro- 
 scopical examination of the urine and careful atten- 
 tion to the temperature are desirable. Pyemic tem- 
 perature frequently occurs and the individual par- 
 oxysmal attacks may be accompanied by a chill and 
 subsequently sweating. Fever may precede the at- 
 tacks for some time, for the infectious agent, which 
 not frequently is B. coli or staphylococcus, plays 
 an important role in these cases. 
 
 The most important secondary symptoms are fre- 
 quent desire to micturate and ardor urinae. 
 
 (c) Hemobbhage feom the Kidneys. — Bleeding 
 from the kidney can unquestionably give rise to 
 paroxysmal attacks of pain, so that the expression 
 Nephralgie hcematurique is fully justified. 
 
 It is very important to remember that cases of 
 prolonged and constant hsematuria exist, so-called 
 " essential hsematuria," without a lesion in the kid- 
 ney and without any accompanying pain. Hsema- 
 turia, therefore, gives rise to pain only when other 
 underlying factors are present. The most impor- 
 tant of these is the presence of blood coagula 
 (malignant tumors, ulcerative erosions of renal 
 capillaries, as in tuberculosis of the papillae, etc.). 
 The clots in these cases produce the same patholog- 
 
URINARY SYSTEM AND SPLEEN 301 
 
 ical condition in the ureters as calculi, and occa- 
 sionally cause obstruction. In addition to this, sud- 
 den profuse bleeding may cause severe distention 
 and in this way give rise to paroxysmal pains. 
 It is a general fact that under suitable conditions 
 bleeding into hollow muscular organs may by acute 
 distention give rise to paroxysmal pains. 
 
 A true kidney pain, that is, nephralgia in the true 
 sense of the word, is occasionally caused by bleeding 
 from vascular tumors of the kidney, by " essential 
 haematuria," or by acute exacerbations of chronic 
 nephritis. 
 
 November 6, 1903, a roofer, thirty-two years old, stated that 
 three days previously in carrying a weight of forty pounds on his 
 shoulder up to the third story of a house he was taken with pain 
 in the right testicle, along the inner side of the thigh, and above 
 Poupart's ligament. On reaching the third story and putting down 
 his load the pain ceased. An hour later he noticed that the urine 
 was red, and that evening he voided pure blood. There had been no 
 previous symptoms pointing to the urinary tract. On examining the 
 patient the right testicle was found to be tender, and there was a 
 zone of hjfpersesthesia along the inside of the right thigh. The 
 bleeding still continued on November 30. Partly by exclusion, and 
 partly in consequence of an active tuberculin reaction, the hemor- 
 rhage was held to be the first symptom of a renal tuberculosis, in 
 spite of the absence of pyuria. At the .operation in Gussenbauer's 
 clinic on December 1 there was found cheesy degeneration of the 
 two upper papillae, with erosion of the vessels and dissemination of 
 tubercles over the lining mucosa of the renal pelvis. 
 
 Nephralgia in the strict sense of the term may 
 be caused by a sudden rise in intracapsular pressure 
 due to parenchymatous hemorrhage in such con- 
 ditions as vascular new growths, "essential haema- 
 turia," or acute exacerbation of a chronic nephritis. 
 
302 PAIN 
 
 URINARY BLADDER. 
 
 The chief characteristic of pain in the bladder 
 is the direct relation which it has to the function 
 of the organ, that is, urination. The problem of 
 diagnosis is simpler by far in this organ than in 
 any of the other hollow muscular organs, since 
 pathological changes in micturition can be closely 
 observed by both patient and physician. The 
 mechanism of the pain, therefore, can be more ex- 
 actly studied, and the conditions prevalent here can 
 serve to throw light upon similar pains occurring 
 in the gall-bladder and stomach. 
 
 The conditions which give rise to bladder pains 
 are the following: 
 
 1. Catarrhal and Ulcerative Changes in the 
 Mucous Membranes of the Bladder and the Ure- 
 thra. — These are chiefly caused by acute and chronic 
 forms of cystitis following urethral infections, in- 
 flammatory conditions due to calculi, foreign bod- 
 ies, tuberculosis, neoplasms, etc. Urethral stric- 
 tures and enlargement of the prostate, benign or 
 malignant, are important in that they predispose to 
 cystitis. 
 
 2. Perivesical Inflammations. — These are 
 chiefly diseases of the female genitals and diseases 
 of neighboring parts of the intestine (rectum and 
 appendix). 
 
 The pain is often directly related to the contrac- 
 tion of the bladder muscle and reaches its maximum 
 at the height of contraction, that is, during the end 
 of micturition and immediately after it. 
 
URINARY SYSTEM AND SPLEEN 
 
 Distention af the bladder wall whenever sudden 
 may also cause great pain. This is closely analo- 
 gous to conditions existing in the gastro-intestinal 
 tracts and the bile-ducts. 
 
 The localization of the pain, both subjective and 
 objective, corresponds to the location of the organ, 
 occurring behind the symphysis. In prostatic dis- 
 ease it is occasionally located in the perineum. Ea- 
 diation occurs along the urethra and into the glands, 
 into the testicles, and iuto the inguinal regions. 
 Sometimes the pain radiates into the anus and the 
 perineum. When this happens it may be explained 
 by the common innervation of these regions by the 
 sacral plexus. 
 
 Eeflexly radiation may occur upwards into the 
 hypochondriac regions, downward into both thighs, 
 and into the regions innervated by the sciatic and 
 the anterior crural nerves. This, for instance, is 
 the case in prostatic tumors. 
 
 It must not be forgotten that in rare instances 
 prostatic tumors may occur without pain. The gen- 
 eral condition of the nervous system seems to have 
 great bearing upon this feature. 
 
 As we have said, bladder contraction is the most 
 important factor in producing the pain. The more 
 forcibly, therefore, this contraction occurs (as in 
 stricture, enlargement of the prostate, and calculi), 
 and the more severe the inflammation of the mucous 
 membrane, the more violent will be the attacks. In 
 cases where the mucous membrane of the bladder 
 itself is intact, and the pain is due only to tugging 
 
304 PAIN 
 
 on the perivesical adhesions, the attacks are never 
 very severe. 
 
 Jarring and sudden changes of position, when 
 they have any relation to the pain at all, poiat 
 toward the existence of calculi. It is always neces- 
 sary to examine by palpation above the symphysis 
 and per rectum or vaginam. 
 
 Cold drafts, wetting the feet, etc., may reflexly 
 give rise to bladder peristalsis. 
 
 The physical and chemical properties of the urine 
 may also exert marked influence upon the paia. 
 Concentration of the urine, as in fever with serous 
 exudation (as in tuberculous peritonitis) or in con- 
 sequence of severe perspiration, may give rise to 
 paiu in an irritable bladder. Spicy food and certain 
 drugs, such as urotropin, in large doses, give rise 
 to similar sensations. 
 
 The most important secondary symptoms to be 
 considered are pyuria and bacteriuria. Whenever 
 these two conditions are absent, we should suspect 
 calculi or perivascular inflammations; haematuria, 
 too, for obvious reasons, is not rare. Whenever this 
 occurs, together with pains in the bladder, a vascu- 
 lar origin of the pain is most likely. Frequent mic- 
 turition is, next to pyuria, the most usual of the 
 secondary symptoms. 
 
 The fact that the pains are usually in direct rela- 
 tion to the bladder function, makes an error in diag- 
 nosis rather rare ; yet it is well to remember that the 
 symptoms of disease of the bladder itself are so 
 similar to those of disease of the prostate and pos- 
 
URINARY SYSTEM AND SPLEEN 305 
 
 terior urethra, that a separation from these is almost 
 impossible without the aid of objective symptoms. 
 Examination of the prostate is, therefore, essential. 
 
 Tenderness of the bladder upon examination per 
 vaginam or per rectum would point to organic dis- 
 ease. The pain occasionally radiates into the rec- 
 tum and is in direct relation to defecation. This 
 occurs chiefly in diseases of the prostate and in 
 vesical calculi, and may lead to an erroneous diag- 
 nosis of intestinal disease. Eadiations into the gen- 
 itals and thighs may occasionally be misconstrued 
 as ureteral colic. Only careful physical examination 
 can guard us against these errors. 
 
 It is hardly necessary to attempt to analyze the 
 differences between the pain, of these conditions and 
 that dependent on causes operating through the 
 central nervous system, of the nature of the gastric 
 crises in tabes for example, for the possibility of 
 confusion in this respect is seldom likely to occur. 
 Dysuria is sometimes observed, however, in cases of 
 chronic lead poisoning. 
 
 In the section of true kidney pains, we called 
 attention to the fact that neoplasms of the bladder 
 may, by obstruction to the ureters, give rise to 
 ureteral colic and sensitiveness of the kidneys them- 
 selves on one or both sides. Conversely, tubercu- 
 lous disease of the kidney may frequently be accom- 
 panied by the subjective symptoms of cystitis, and, 
 even when the bladder and urethra are entirely nor- 
 mal, pains may be produced in them by pressure 
 upon the diseased kidney. 
 
 20 
 
306 PAIN 
 
 SPLEEN. 
 Pathological processes in the spleen often give 
 rise to pain at extremely early stages of their de- 
 velopment, and, in correspondence with the position 
 of the organ, such pain is localized in the left hypo- 
 chondrium. Since we are dealing with a ductless 
 gland the pains produced here cannot possess the 
 manifold variety of those occurring in organs with 
 muscular ducts. Here there are but two factors to 
 be considered: 
 
 1. Distention of the spleen capsule with enlarge- 
 ment of the organ. 
 
 2, Inflammation of its peritoneal coverings 
 (perisplenitis). 
 
 The conditions which are accompanied by pain 
 in the spleen are chiefly: 
 
 (a) Myelogenous Leuhasmia. — In this condition 
 the pain in the spleen is frequently one of the first 
 symptoms. Sudden and intense pain is caused by 
 inflammation of the capsule with or without the 
 formation of infarcts. Pseudolfeuksemia and polycy- 
 themia also give rise to pain in the spleen ; chlorosis 
 and pernicious anasmia more rarely. 
 
 (b) Cirrhosis of the Liver. — Splenic involve- 
 ment is most frequently found in cases of syphilitic 
 cirrhosis, and in such cases the perisplenitis goes 
 hand in hand with the existing perihepatitis. Many 
 of the so-called Banti's cirrhoses (hereditary lues) 
 come under this heading. Splenic pains occasionally 
 accompany Hanot's cirrhosis, but are hardly ever 
 present in the atrophic variety of Laennec. 
 
URINARY SYSTEM AND SPLEEN 307 
 
 (c) Paroxysmal Hcemoglolinuria. — During at- 
 tacks of paroxysmal haemoglobmuria splenic pains 
 may occasionally be noticed. 
 
 (d) Infectious Processes. — The infectious proc- 
 esses which are most commonly accompanied by 
 splenic pain are typhoid fever and malaria. 
 
 Occurring m the left axillary line, the splenic 
 pains in these diseases are often erroneously re- 
 garded as evidences of a pleurisy or a lower lobar 
 pneumonia. This error is more easily made since 
 in cases with splenic swelling fine crepitant rales 
 often occur along the line of separation between the 
 lung and the spleen, due to atelectasis of the margin 
 of the lung. 
 
 Whenever we are attemptiag to obtain a history 
 of a previous attack of malaria, it is well to inquire 
 whether at the time of the chill there were pains in 
 the splenic region. Sharp pains along the right 
 costal border often occur together with these and 
 are due to hepatic swelling. 
 
 Pain on palpation along the left costal border 
 in a patient who is running a temperature and in 
 whom we can exclude pleurisy and subphrenic ab- 
 scess, usually points to marked swelling of the 
 spleen. 
 
 (e) Heart Disease.-^ln patients with heart le- 
 sions (mitral stenosis, etc.) acute pains occurring in 
 the region of the spleen or sensitiveness in the inter- 
 costal spaces corresponding with the position of the 
 spleen, should always arouse the suspicion of splenic 
 infarction. This suspicion is strengthened by symp- 
 toms of emboli in other regions (renal arteries, etc.). 
 
308 PAIN 
 
 Progressive increase of the pain in a case of 
 recent endocarditis points to the possibility of sec- 
 ondary abscess formation. 
 
 Since the position and size of the spleen are 
 subject to great variation in the different patho- 
 logical conditions, it is natural that the exact topog- 
 raphy of the pains should show corresponding varia- 
 tion. In all cases, however, the pain is felt in the 
 left side along the lower thoracic and upper abdomi- 
 nal regions. Whenever pain occurs in this situation 
 examinations should be made for sensitiveness under 
 the left costal border and in the lower intercostal 
 spaces from the eighth downward. 
 
 Splenic tumors may occasionally give rise to 
 dorsal pain, especially after prolonged lying on the 
 back. When the spleen is so large that it sinks for 
 any considerable distance below the costal border, 
 as in leuksemia for instance, it is important to deter- 
 mine whether the sensitiveness is of diffuse or cir- 
 cumscribed nature. Circumscribed pains of this de- 
 scription are occasionally due to splenic infarct or 
 local perisplenitis. 
 
 Every now and then pain occurs along the angle 
 of the left scapula or between the shoulder blades. 
 In some cases there is marked pain in the left shoul- 
 der, often so severe that motion of the left arm 
 (becomes difficult. 
 
 Such radiations may occur spontaneously or may 
 be caused by sudden stooping, trauma, or lying on 
 the left side. In such cases localized points of sensi- 
 tiveness can be determined. The most common situa- 
 
URINARY SYSTEM AND SPLEEN 809 
 
 tions of these are over the acromion process and at 
 the junction of the external and middle third of the 
 upper edge of the trapezius muscle. The conditions 
 prevalent here are exact counterparts of those exist- 
 ing ia the right shoulder with perihepatitis. 
 
 The quality of the pain is usually described by 
 the patient as stabbing or tearing. Mechanical 
 motions often initiate attacks of pain. The mechani- 
 cal factors to be considered are : 
 
 1. Compression of the organ produced by stoop- 
 ing, quick turning to- the left of the trunk upon the 
 hips, lifting of the left arm, etc. In contrast to this, 
 relaxation of the abdominal muscles relieves the 
 pain, and in consequence patients often walk in a 
 stooping position. Palpation and percussion in- 
 fluence the pain in a similar way. 
 
 2. Change of Position of the Organ. — Lying on 
 the left or right side usually produces pain and a 
 sensation of tension in the left side. This is espe- 
 cially the case when the stomach is empty, the full 
 stomach acting as a sort of cushion. For obvious 
 reasons deep breathing will cause pain when peri- 
 splenitis is present. 
 
 3. Sudden Jarring. — ^All varieties of jarring will 
 give rise to pain, prolonged walking, running, riding 
 in a carriage, hiccoughing, sneezing, etc. 
 
 Occasionally, besides the mechanical means of 
 starting the pain, digestive conditions will influence 
 it. Abnormally large quantities of food will give 
 rise to pain by causing secondary hypersBmia of the 
 organ. This is especially the case when inflamma- 
 
310 PAIN 
 
 tory adhesions exist between the stomach and the 
 spleen. 
 
 The influence of drugs on the diagnosis is not 
 negligible since the pain caused by increased tension 
 of the capsule is diminished by all those drugs which 
 produce a diminution in the size of the spleen. Such 
 are arsenic and quinine. 
 
 The most frequent secondary symptoms occur- 
 ring with splenic pain are increased size of the 
 spleen as detected by percussion and palpation, fric- 
 tion sounds produced by perisplenitis, and a systolic 
 murmur heard over the splenic vessels. 
 
 The most important condition to be considered 
 in differential diagnosis is pleurisy. Differentiation 
 is especially difficult in the case of acute disease, 
 such as malaria and typhoid fever. The pains in 
 these cases are felt in the axillary and intercostal 
 regions. They are dependent upon deep breathing. 
 Lying on the left side is usually painful and occa- 
 sionally produces a cough. There are fine crepitant 
 rales over the area of pain, due to atelectasis caused 
 by the large size of the spleen. By these signs one 
 is led to suspect pleurisy or early pneumonia and to 
 forget the fact that the pain may be due to an 
 increased tension upon the splenic capsule. 
 
 In the same way infarcts of the lung and spleen 
 may often be mistaken for one another in patients 
 with heart disease. In such eases examination of 
 the spleen reveals its sensitiveness. Much informa- 
 tion, too, can be gathered by careful examination of 
 the intercostal spaces in the axillary line in order to 
 
URINARY SYSTEM AND SPLEEN 311 
 
 determine whether or not they are sensitive. When 
 the condition is one of splenic pain the sensitiveness 
 in the intercostal spaces is limited pretty well to 
 the area of dulness of the organ. 
 
 Splenic pain is occasionally misinterpreted as 
 arising in the stomach, since, as has already been 
 mentioned, the taking of food often increases the 
 pain or initiates an attack. In a general way this 
 can be avoided by remembering that in splenic con- 
 ditions the quantity of the food, entirely independent 
 of its quality, gives rise to an attack. In cases 
 where radiation of the pain into the left shoulder 
 takes place, a diagnosis of articular rheumatism 
 is occasionally made. The absence, however, of 
 change in the joint itself, the entire freedom of 
 motion, and the determination of the above-men- 
 tioned points of tenderness (at the acromion and 
 along the border of the trapezius) will aid in the 
 differentiation. 
 
CHAPTER IX. 
 
 Respiratory and Circulatory Systems. 
 
 THE LUNGS. 
 
 Pain may unquestionably occur in the trachea 
 and the two main bronchi. At any rate, it is cus- 
 tomary to interpret the retrosternal pain occurring 
 almost regularly with acute bronchitis during the 
 stage of dryness and congestion, as emanating from 
 these organs. On the other hand, distinctive proc- 
 esses which involve the air vesicles of the lung, such 
 as lymphosarcoma and pulmonary abscess, may run 
 their entire course without any pain. It is, there- 
 fore, perfectly safe to claim that lesions occurring 
 in the parenchyma of the lung itself do not give rise 
 to pain. 
 
 The production of pain in disease of the lung is, 
 therefore, dependent entirely upon involvement of 
 the pleura. This, of course, is most frequently of 
 an inflammatory nature. 
 
 These simple facts give the key to the compre- 
 hension of all pains which occur in connection with 
 pulmonary disease and permit us to understand their 
 nature and radiations. 
 
 It must not be forgotten that the visceral and 
 parietal pleura are in very intimate relation with 
 many nerves (brachial plexus, intercostal and 
 phrenic nerves), and that they likewise have close 
 anatomical relation to the intercostal muscles and 
 
 312 
 
RESPIRATION AND CIRCULATION 313 
 
 diaphragm. For these reasons the occurrence of 
 secondary neuralgias and myalgias is more than 
 likely. 
 
 Since, therefore, the pains accompaayirig all the 
 various lesions of the lung are dependent upon the 
 inflammatory pleurisy, it is simplest to describe them 
 all together in a general "way, pointing out, as we 
 proceed, the various features of differentiation. 
 
 As regards localization, these pains correspond 
 almost exactly with the situation of the pleural in- 
 flammation, and the greatest intensity of the pain, 
 both subjectively and objectively, coincides with the 
 most marked auscultatory sounds. 
 
 Disease of the pleura over the upper lobes (tu- 
 berculosis and neoplasms) evidences itself chiefly 
 by pain in the region of the shoulder, in the supra- 
 and intraclavicular fossae and in the supraspinous 
 regions. These pains should be looked for espe- 
 cially in cases in which we suspect early tuberculosis. 
 
 The pains in the shoulders, which so often occur 
 in tuberculous patients at the very beginning of the 
 disease, are probably caused in most cases by the 
 adhesions at the apex of the lung found so fre- 
 quently at autopsy. The inflammatory process oc- 
 curring along the summit of the pleura may involve 
 secondarily the brachial plexus and the upper inter- 
 costal nerves. For this reason tenderness along the 
 brachial plexus and along the upper intercostal 
 spaces is frequently present in cases of tuberculosis 
 and is in many cases one of the first symptoms. The 
 point of tenderness which was mentioned as a reflex 
 
314 PAIN 
 
 symptom of hepatic and splenic enlargements (at the 
 jimction of the outer and middle thirds of the upper 
 border of the trapezius muscle) can occasionally be 
 demonstrated in these cases as well. 
 
 It need hardly be mentioned that carcinoma de- 
 veloping in the apex of the lung might give rise to 
 secondary injury of the brachial plexus and conse- 
 quent neuralgia in the arm. 
 
 When the pleura are diffusely diseased, as in 
 pleurisy and pyopneumothorax, the subjective paia 
 and tenderness often fail to show a correspondiugly 
 diffuse character. On the contrary, they are usually 
 located in the axilla or in front, rarely posteriorly, 
 and, when this does occur, only iu the last intercostal 
 spaces. 
 
 This is due to a number of causes. Chief among 
 these, probably, is the fact that the respiratory 
 excursions of the lung reach their greatest develop- 
 ment at the bases and thus the greatest motion of the 
 pleural leaves upon each other takes place in the 
 costophrenic sinuses. 
 
 Whatever the reason may be, the facts remain 
 that pains which arise ia the pleura are frequently 
 found only in the axillary line, and that sensitive- 
 ness to pressure is limited to the area below the fifth 
 intercostal space. The latter fact may in part be 
 due to the absence of a muscular covering over these 
 spaces. 
 
 Occasionally, cases of diffuse pleurisy and 
 pleuropneumonia of the lower lobe occur, in which 
 the tenderness is limited to the abdomen, just below 
 
RESPIRATION AND CIRCULATION 315 
 
 the costal border. This may lead to errors in diag- 
 nosis. In such cases upward pressure in the flani;, 
 hypogastrium, and (in right-sided cases) even the 
 ileocaecal region, will give rise to pain. 
 
 This peculiar distribution of the pain is probably 
 due to involvement of the diaphragmatic pleura. 
 The diaphragm forms a sort of bridge across which 
 the thoracic pain enters the abdominal regions. 
 Even the subjective pain in pleurisy may in a good 
 many cases be localized along the costal border. 
 
 One of the favorite seats of pain, in left-sided 
 pleurisy is the region of the heart apex. This may 
 be due to the fact that during systole the apex of 
 the heart, by friction, increases the inflammation 
 and, therefore, in spite of the diffuse nature of the 
 pleurisy, may give rise to circumscribed pain. 
 
 Eetrofstemal position of the pain is rare. It does 
 occur, however, and is usually associated with in- 
 flammation of the mediastinal pleura and with le- 
 sions of the mediastinal lymph nodes. In such 
 cases, however, it would also be necessary to think 
 of pericarditis. 
 
 The pain occurring in the interscapular space in 
 pulmonary tuberculosis may also occur in diffuse 
 pleurisy. 
 
 The quality of the pain is rarely characteristic, 
 and it is very difficult to differentiate it from that 
 of intercostal neuralgia or myalgia. As a general 
 rule we must say that the pain is of a sharp and 
 stabbing character. 
 
316 PAIN 
 
 Special characteristics of the pain are present 
 only in rapidly developing pnenmotliorax, where the 
 pain, just like the pain accompanying perforation 
 of the gut into the peritoneum, is extremely acute 
 and diffuse, and involves the entire half of the 
 thorax. Added to this there is a peculiar sensation 
 of internal soreness or tearing. Similar pain, how- 
 ever, may be observed in subpleural cavities without 
 perforation, and the confusion may be increased by 
 the occurrence of collapse. Similar acute attacks 
 of pain occasionally accompany the perforation of 
 an empyema. 
 
 The factors most markedly influencing the pleural 
 pain are: 
 
 1. Pressure. — There are cases of pleurisy in which 
 even a light touching of the skin of the thorax with 
 a needle, with the bare hand, or with the bed-cover, 
 may give rise to the most intense pain (empyema). 
 On the other hand, there may be all transitions from 
 this extreme condition of sensitiveness to an absolute 
 lack of pain. The factor determining this, of course, 
 is the degree of acuteness and severity of the inflam- 
 matory process. The condition is unquestionably 
 analogous to a similar condition in the peritoneum. 
 The area of sensitiveness to pressure is usually much 
 more diffuse than the area of subjective pain. In 
 every individual case it is important to observe the 
 zone of sensitiveness and to observe its increase or 
 decrease during the course of the disease. In 
 pleuropulmonary disease the pain which occurs in 
 the abdomen is hardly ever spontaneous and is dis- 
 
RESPIRATION AND CIRCULATION 317 
 
 covered only by examination. Wliile the dia- 
 phragm, as mentioned above, is usually the means 
 of transmission of such pain to the abdomen, in 
 right-sided lesions it is always necessary to consider 
 the possibility of secondary liver pain due to peri- 
 hepatitis or hepatic congestion. 
 
 Sensitiveness to pressure is limited chiefly to the 
 axillary and anterior aspects of the thorax, and 
 favors the lower intercostal spaces. This is true 
 at any rate of cases of acute pleurisy. In apical 
 tuberculosis when pleural adhesions are developing, 
 the sensitiveness to pressure is usually localized in 
 the subclavicular or subspinous fossae, and in the 
 upper anterior intercostal spaces. The same is true 
 of cavity formation in apical tuberculosis. These 
 objective pains are of especial importance for early 
 diagnosis, since they may appear when subjective 
 pains are still absent. 
 
 The pain may be definitely ascribed to a pleural 
 lesion whenever sensitiveness to pressure and crepi- 
 tant rales are found in one and the same spot. It 
 is occasionally diflScult to exclude intercostal neural- 
 gia. (For a discussion of this refer to the chapter 
 on the subject, page 107.) 
 
 Whenever pressure upon the rib itself is painful, 
 it is obvious that (having excluded periostitis) we 
 must assume the existence of a secondary intercostal 
 neuralgia. 
 
 In pericarditis the pain seems to be chiefly sub- 
 jective, modified little, if at all, by pressure; it is 
 
818 PAIN 
 
 located more anteriorly and retrostemally, rather 
 than in the axilla. 
 
 2. Position and Motion. — Lying upon the dis- 
 eased side causes pain hy direct pressure. Tor a 
 consideration of this position, therefore, the remarks 
 made in the precediug paragraphs may be consulted. 
 
 When the patient lies on the healthy side, how- 
 ever, different conditions prevail. In this position 
 the patient frequently suffers great distress, which 
 gives him the impression that the pain is drawing 
 over intO' the healthy side. 
 
 Such sensations are chiefly present in cases of 
 pleural exudate, more rarely with cavities, and must 
 be ascribed to a shifting of the organs in the media- 
 stinum. When the patient lies upon the healthy 
 side, also, the work of the diseased side is increased 
 and the paia occurring with respiration is neces- 
 sarily greater. In some rare cases lying upon the 
 abdomen relieves the pain. (This was the case in 
 a patient with pleural pain in the neighborhood of 
 the heart apex.) 
 
 The pain is increased when the patient is upright 
 and his head is bent forward. This is due to the 
 increased costal respiration. Stooping occasionally 
 gives rise to pain. 
 
 3. Inspiration and Expiration. — Coughing and 
 sneezing come under this heading, since all these 
 forcible movements in the pleura presuppose an 
 analogous action of the muscles of inspiration. 
 
 In cases of pyopneumothorax, however, there is 
 no increase of the pain with deep inspiration. This 
 
RESPIRATION AND aRCULATION 319 
 
 is, in part, due to immobilization of the correspond- 
 ing half of the thorax, and in part to a lack of con- 
 tact between the leaves of the pleura. 
 
 Whenever a chill or any febrile movement is fol- 
 lowed by sharp pain in the axillary regions, the diag- 
 nosis of pleural pain is obvious, and the first sus- 
 picions are, of course, of pneumonia or pleurisy. 
 Yet it is important to remember that occasionally 
 a malarial chill is accompanied by pain in the lower 
 intercostal regions and in the axillary portions of 
 the left chest. These pains we have already referred 
 to as emanating from the spleen and due to tension 
 in the splenic capsule. The presence of herpes and 
 the fine crepitant rales of atelectasis at the base of 
 the left lung (pushing upward of the diaphragm 
 by the enlarged spleto) increase the possibility of 
 error. 
 
 Whenever pains occur along the lower portions 
 of the thorax it is wise to think of the subdiaphrag- 
 matic organs and their appendages. 
 
 The sensitiveness which accompanies acute right- 
 sided pneumonia and pleurisy is occasionally local- 
 ized in the ileocecal region. This is especially fre- 
 quent in children and may lead to a false diagnosis 
 of appendicitis. 
 
 The interpretation of thoracic pains is far more 
 difficult in chronic conditions which run their course 
 without fever. In such cases it is always difficult 
 to decide whether the pains have a pleural origin 
 (such as the chronic pleural adhesions so often 
 found in tuberculous individuals) or whether we are 
 
SaO PAIN 
 
 dealing with an absolutely independent neuralgia 
 or myalgia. 
 
 When there have been very severe coughing 
 spells it is always well to think of myalgia due to 
 fatigue (analogous to the pains in the calves of the 
 legs following long walking tours). It is perfectly 
 obvious that the pain due to a muscular or nervous 
 cause may be initiated by the same factors that give 
 rise to pleural pain (respiration, etc.). On the one 
 hand, there may be absolutely no physical signs in 
 the chronic adhesive pleurisies; on the other, the 
 pain in intercostal neuralgia, by limiting respiratory 
 excursion, may lead to secondary atelectasis with 
 crepitant rales. It is very important, therefore, to 
 determine whether the lower border of the lung 
 moves properly with respirations. Examination of 
 the domes of the diaphragm with X-ray is also 
 advisable. 
 
 Careful differential diagnosis in all these cases 
 is almost impossible, but there are a number of 
 points which may be of great help. 
 
 1. One-sided objective or subjective pain, local- 
 ized in the axilla, points with great probability to a 
 pleural origin. 
 
 2. The same is true of one-sided pain limited 
 to the apex of the lung, especially when this is accom- 
 panied by anaemia, emaciation and neurasthenia, 
 even when the physical examination of the lung is 
 negative. 
 
 3. Careful investigation of the previous history 
 must be made as regards overexertion of the muscles 
 
RESPIRATION AND CIRCULATION 321 
 
 of the arm or chest, and exposure to draughts. In- 
 quiry must be made as to rheumatic or neuralgic 
 tendencies, and symptoms of these diseases in other 
 parts of the body must be looked for. These, when 
 present, point toward neuralgic or myalgic origin 
 of the pain. 
 
 4. "Whenever lying on the diseased side causes 
 coughing, it is obvious that the pain emanates from 
 the pleura. 
 
 In the preceding section we have differentiated 
 pleural pains from those not localized in the pleura, 
 but we have paid no attention to the differentiation 
 of the specific pleural lesions which may produce 
 such pains. 
 
 In eases in which there is unquestionably a lesion 
 of the lungs and the pleura, the exact nature of the 
 lesion can be determined only by careful analysis 
 of the pain. The very absence of pain in such cases 
 is of great diagnostic significance. Thus, whenever 
 large areas of dullness occur entirely without sub- 
 jective or objective pains, although it is not possible 
 absolutely to exclude inflammatory pleurisy, never- 
 theless it is advisable to think of neoplasms, echino- 
 coccus, dermoid cysts, and pulmonary abscesses, 
 processes which are not necessarily accompanied by 
 severe inflammations along the pleura and may 
 therefore develop with little or no pain. Dullness 
 along the base of the lung without sensitiveness over 
 the lower intercostal spaces points to the existence 
 of a subphrenic abscess. 
 
 21 
 
322 PAIN 
 
 Symptoms of pneumonia with infraclavicular 
 pains should lead us to think immediately of a begin- 
 ning apical pneumonia. 
 
 Analysis of the pain often aids in differentiating 
 a cavity from a pneumothorax, a differential diag- 
 nosis which is sometimes extremely difficult. This is 
 true, too, of cases in which we are trying to decide 
 whether a sudden profuse expectoration is due to 
 the evacuation of a cavity or to the rupture of a sac- 
 culated empyema. In the latter case the act of 
 rupture is accompanied by intense pains and the 
 sensitiveness along the intercostal spaces corre- 
 sponding to the sacculation is immediately dimin- 
 ished, just as after the incision of an abscess. 
 
 Cavities, on the other hand, since they are more 
 centrally situated, hardly ever lead to much sensi- 
 tiveness of the corresponding costal spaces, and give 
 rise to no attacks of pain during the act of evacua- 
 tion. 
 
 AORTA. 
 
 The phenomena which have occupied our atten- 
 tion in the preceding chapters, pains occurring in 
 the alimentary tract, liver and kidney, have had 
 three fundamental factors in common: 
 
 1. Local spasm in a hollow muscular organ. 
 
 2. Local distention of its capsule or walls. 
 
 3. Inflammatory processes in their serous cover- 
 ings. 
 
 The second and third of these factors, as we have 
 seen, may combine in many of these conditions. 
 
RESPIRATION AND CIRCULATION 323 
 
 It is beyond doubt that diseases of the thoracic 
 or abdominal aorta (such as aortitis or aneurysm) 
 may give rise to pain. The question naturally 
 arises, therefore, whether the mechanism of this 
 pain is entirely a new one, or whether it is caused 
 by factors similar to those occurring in the other 
 conditions. 
 
 Anatomically, the severe inflammations of the 
 aorta may involve the vessel wall in toto or m part. 
 Such inflammatory conditions are comparable with 
 the third factor given above. 
 
 It is a matter of fact, too, that added to the in- 
 flammatory processes constant or paroxysmal over- 
 stretching of the inflamed aortic wall may occur 
 (by aneurysm or increased tension). The condition 
 of tension may be chronic (arteriosclerosis), or there 
 may be a sudden increase of pressure with increased 
 action of the heart and increased resistance in the 
 capillaries (vasomotor disturbances, such as cramps 
 or paresis). These conditions are comparable to 
 those mentioned under the second group (see above) 
 which dealt with overdistention. 
 
 Since, therefore, we have the two elementary 
 factors, two and three actually present and fre- 
 quently acting in unison, the question arises whether 
 the sympathetic nerve endings embedded in the vas- 
 cular wall are capable of conveying painful sensa- 
 tions. This question can be answered decidedly iu 
 the affirmative. Definite affirmative evidence is 
 offered by the pressure pain which is found in in- 
 flammatory processes of the peripheral arteries 
 
324. PAIN 
 
 (carotid, etc.). Similar support for this opinion 
 is found in the tenderness which unquestionably 
 occurs in the suprasternal fossa over the aortic arch 
 or over the abdominal aorta, in conditions of chronic 
 aortic inflammation. 
 
 The etiological factors in aortic pain are, there- 
 fore : 1. Inflammatory and degenerative processes in 
 the aortic wall. 2. A condition of hypersesthesia 
 of the sympathetic network embedded in the aortic 
 wall. 3. Chronic or temporary, local or general, in- 
 crease of internal pressure in the aorta. 
 
 These factors need not necessarily occur in com- 
 bination, but when present in combination, of course, 
 produce the most favorable conditions for the occur- 
 rence of pain. Thus, a priori, we may assume that 
 two and three together would be sufficient to produce 
 attacks of pain in individuals of a neuropathic tem- 
 perament. 
 
 The fact that occasionally aortic processes may 
 run their course without pain does not contradict 
 these statements. One might just as well say that 
 articular inflammation is not the cause of the pains 
 of arthritis because occasionally a case of arthritis 
 runs its course without pain. 
 
 The conditions of primary importance in this con- 
 nection are usually spoken of as "angina pectoris." 
 The name is purely symptomatic and has no relation 
 to the etiology. 
 
 The mechanism which gives rise to the pain in 
 these cases may be subject to considerable variation. 
 The anatomical basis imderlying the pains of angina 
 
RESPIRATION AND CIRCULATION 325 
 
 pectoris (excluding, of course, all those cases which 
 are essentially neuralgic) seems to consist of two 
 main features. These are disease of the wall of the 
 aorta itself (the ascending aorta and arch espe- 
 cially) and disease of the coronary arteries. 
 
 There can be little doubt about the production 
 of pain by disease of the aortic wall. Such pain may 
 be of many kinds, and angina pectoris is, in a way, 
 only a special form of aortic pain. Chronic dilata- 
 tion of the ascending aorta or of the aortic arch fre- 
 quently gives rise to constant pain which, in its 
 localization and radiation, is entirely similar to that 
 which characterizes attacks of angina pectoris. 
 
 We have already called attention to the fact that 
 the general etiology of the aortic pains stands in 
 close analogy to the pains produced in other organs. 
 Quite frequently severe attacks of angina pectoris 
 can be explained at autopsy by gross pathological 
 lesions either of the coronary arteries themselves or 
 of their mouths (usually narrowing of the entrances 
 to the arteries by atheroma or vegetations). Etio- 
 logical relationship unquestionably exists between 
 these lesions and the attacks. Nevertheless, in many 
 cases tiiere is, at the same time, gross pathological 
 change of the aorta itself, and it is hard to decide 
 which of the symptoms are due to the aortic lesions 
 and which are more directly referable to the disease 
 of the coronary arteries. Generally speaking, it 
 is quite likely that the coronary arteries are more 
 directly responsible for the attacks, for it is prob- 
 able that, during these, ischaemia of the heart muscle 
 
S26 PAIN 
 
 occurs, resulting in a condition more or less analo- 
 gous to intermittent claudication. It seems to me, 
 for this reason, that whenever attacks of angina pec- 
 toris are accompanied by signs of cardiac insuffi- 
 ciency, irregular pulse and general collapse, it is 
 logical to think primarily of disease of the coronary 
 arteries. 
 
 The problem is much more difficult when with 
 severe attacks of pain there is no cardiac insuffi- 
 ciency. In such cases the heart is usually regular, 
 the pulse is full and of good force, and it is likely 
 that, when this occurs, the pain is of purely aortic 
 origin, without coronary involvement. 
 
 General Symptoms. — The pains which accom- 
 pany aortic lesions are, in a general way, alike, in 
 spite of the variety of pathological conditions upon 
 which they depend. 
 
 They are situated usually over the diseased 
 organ, and, therefore, are felt in most of the cases 
 retrosternally. Sometimes there is only a feeling of 
 slight discomfort; in other cases there may be an 
 extremely painful sensation of oppression. 
 
 The conditions for diagnosis are very much more 
 difficult here, of course, than in other organs, because 
 direct examination by palpation is impossible. This 
 should, however, be attempted as well as practicable 
 by pressure into the suprasternal fossa and upon the 
 abdomen. 
 
 Acquaintance with the most common directions 
 of radiation is important, ^ince radiating pains may 
 occasionally occur without other symptoms. Eadia- 
 
RESPIRATION AND CIRCULATION 327 
 
 tion is usually along arterial chaimels, especially 
 •vrhen the aortic process is continued, as in arteritis, 
 into other vessels (carotid and subclavian). In such 
 cases the vessels involved are sensitive to pressure. 
 
 Tugging on the vessels by turning the head or 
 lifting the arm is painful, and subjective pain pos- 
 sibly due to vascular spasms may be felt to extend 
 even as far as the branches of the larger trunks. 
 When the carotid artery is the channel of radiation, 
 symptoms may occur in the parts supplied by this 
 vessel. There are occasionally unilateral or bilat- 
 eral pains in the teeth of the upper and lower jaws. 
 Eadiation may occur into the temporal artery and, 
 in addition to pain, may give rise to buzzing in the 
 ears. When the subclavian is involved similar 
 symptoms may occur in the upper extremities. 
 
 It is quite reasonable, therefore, to assume that 
 the radiations accompanying aortic pain occur along 
 vascular channels. This, however, does not exclude 
 the possibility that radiations may occur along the 
 brachial plexus and the intercostal nerves as well: 
 Frequently the left brachial plexus is exquisitely 
 tender, both during and between attacks. This may 
 in part be a reflex pain, but in part certainly it is 
 due to direct mechanical injury of these plexuses 
 (large aneurysms). 
 
 Pains in the brachial and cervical plexus, of 
 course, can hardly be explained by direct mechanical 
 injury. 
 
 Again, pains in aortic disease can be explained 
 on the basis of localized nutritive disturbances. 
 
328 PAIN 
 
 brouglit about by diminished blood supply. This is 
 especially probable when fever or metabolic disease 
 is present. Such nutritive changes may be caused 
 by independent lesions in the arteries branching 
 out from the diseased aorta, and then would be 
 simply accidental incidents in the clinical picture. 
 But they may also be more directly related to the 
 aortic lesion, in that the mouths of the large branches 
 may be narrowed. Such narrowing occurs quite 
 frequently at the mouth of the left subclavian artery 
 in cases of chronic aortitis, and occasionally leads 
 to complete stenosis. In patients who are at the 
 same time suffering from rheumatism and gout, 
 these localized nutritive changes are of especial im- 
 portance. The two conditions together — ^metabolic 
 and aortic disease — ^bring on pains in the region of 
 the shoulder girdle and in the thoracic walls; and 
 while the pain is actually caused by the secondary 
 condition (gout and rheumatism), it finds its ulti- 
 mate explanation in the aortic disease. Such an 
 analysis may seem a trifle overrefined, but it is ex- 
 tremely important in the treatment of the pains. 
 
 In a large majority of the cases of aortic disease, 
 a definite history of syphilis can be elicited. This is 
 especially true in patients who are still below middle 
 life. Whenever apparently rheumatic pains occur 
 in the shoulder or along the upper extremity in such 
 individuals, the pains are probably, as a whole or in 
 part, dependent upon atheroma of the thoracic 
 aorta; such suspicions are definitely strengthened 
 by the discovery of other symptoms of aortic disease, 
 
RESPIRATION AND CIRCULATION 
 
 sucli as increase of arterial tension, aortic pulsation 
 in the snprastemal fossa, etc. 
 
 The radiating pains considered above are usually 
 associated with more centrally situated pains which 
 correspond in their localization with the diseased 
 portion of the aorta. Along the ascending aorta they 
 occur chiefly as deeply situated sensations of pres- 
 sure along the lower end of the sternum. When the 
 arch of the aorta is diseased the pains are situated 
 along the manubrium, while disease of the descend- 
 ing aorta causes pain chiefly in the back between the 
 two scapulae. These last pains are situated usually 
 to the left of the vertebral column. Disease of the 
 abdominal aorta occasionally gives rise to pain in 
 the left loin or in the epigastrium. 
 
 There is thus great variety in the topographical 
 characteristics of the aortic pains. Although ia 
 general they are localized ia the thorax they are 
 present occasionally in the neck, head, and upper 
 extremities, following in part the vascular channels 
 and in part the nerve trunks. 
 
 The factors which give rise to attacks of aortic 
 pain are very few, and for this reason they are of 
 extreme importaiice diagnostically. 
 
 While the causes leading to an attack may seem 
 to be of many kinds, yet, upon closer analysis, they 
 will all be found dependent upon a temporary in- 
 crease of the strain put upon the aortic wall either 
 by an absolute or by a relative increase of the intra- 
 arterial pressure. The causes initiating an attack 
 may be of an extremely transitory nature, just as a 
 
330 PAIN 
 
 single forcible clenching of the teeth may give rise 
 to a prolonged paroxysm of trigeminal neuralgia. 
 The chief factors to be considered are : 
 
 1. Increased muscular exertion, such as rapid 
 "walking, lifting a weight, walking upstairs, rapid 
 turning in bed, playing the piano, etc. 
 
 2. The position of the body. The horizontal posi- 
 tion, for instance, produces slowing of the pulse, and 
 is usually accompanied by a greater volume of car- 
 diac contraction, and consequently increased pres- 
 sure. In cases of this description the patient usually 
 experiences relief on assuming the sitting posture. 
 One of my patients, however, found that he could 
 secure greater comfort by bending the body forcibly 
 backward. 
 
 3. Unusual distention of the stomach and intes- 
 tine. Improvement occurs usually after vomiting 
 and the expulsion of gas or fseces. Severe attacks 
 of aortic pain can unquestionably be caused by 
 chronic constipation and meteorism, by excessive 
 meals, especially when taken in the evening, and by 
 the ingestion of flatulent food. These considera- 
 tions are of extreme importance and require at- 
 tention both in warding off the onset of attacks 
 and in attempting to relieve them when already 
 present. 
 
 The explanation of this, in many cases, probably 
 lies in the high position of the diaphragm accom- 
 panying abdominal distention. In consequence of 
 this there is diminished respiratory suction upon the 
 
RESPIRATION AND aRCULATION 331 
 
 large veins, wMch leads to stasis. This, reflexly, by 
 way of tlie medulla, acts upon arterial conditions 
 which, naturally affect the aorta. Prolonged and 
 rapid expiration, such as accompanies continued 
 speaking, seems occasionally to have somewhat the 
 same effect. 
 
 4. Chemical poisons : Alcohol, nicotine, lead, gout 
 and rheumatism are etiological factors of consider- 
 able importance. 
 
 One of my patients found that smoking a cigarette aiter break- 
 fast would bring on an attack, and in the case of another the seiz- 
 ures increased in frequency and severity after the instillation of 
 atropine into the eye. 
 
 5. Temperature. The extremes of temperature 
 act in the same way. Hot rooms or cold draughts, 
 cold sponging, cold bed, etc., may give rise to aortic 
 pain or may occasionally alleviate existing aortic 
 pain; in some cases the harmful influence of cold 
 weather is undeniable. Steam baths are sometimes 
 remarkably well borne, but in general must be re- 
 garded as being contraindicated. 
 
 6. Psychic influences (excitement, bad dreams). 
 While these influences are chiefly important in their 
 relation to the functional aortalgias, they may never- 
 theless be of significance also in pains of true aortic 
 lesions. Here, however, they are of less importance 
 than other influences, though every organic disease, 
 and especially any morbid process that is connected 
 
332 PAm 
 
 intimately witli the circulatory apparatus, is neces- 
 sarily more or less in close functional relation to 
 tlie nervous system. 
 
 7. Pains in other organs wMcli lead to consequent 
 increase of blood pressure. Among the conditions 
 particularly likely to come in question are cholelith- 
 iasis, gastric ulcer, etc. 
 
 One patient under my care regularly had an attack of angina 
 before each menstrual period. 
 
 There is no characteristic time for the occurrence 
 of the attacks of angina pectoris. Whenever the 
 condition is based upon actual organic disease, at- 
 tacks can often be produced with the regularity of 
 well-planned experiments, if any one of the factors 
 just mentioned is exerted with sufficient energy. 
 This regular dependence upon clearly distinguish- 
 able causative factors is the chief differential 
 characteristic between the functional angina and 
 that of the true organic variety. 
 
 In rare cases attacks may occur regularly at 
 night or during the early morning hours, and these 
 may be explained by the horizontal position of the 
 body and the sudden change of this position during 
 sleep. The occurrence of distressing dreams may 
 also be of significance in explaining the onset of noc- 
 turnal seizures. 
 
 In patients suffering from metabolic disease the 
 attacks are especially frequent at night and during 
 the early moriling. In many cases they occur during 
 
RESPIRATION AND CIRCXJLATION 93S 
 
 the hours of the first physical activity and decrease 
 during the course of the day. This is probably due 
 to the fact that occasionally the pathological lesion 
 in the aorta is actually caused by the metabolic con- 
 dition (gouty arthritis). 
 
 As the disease progresses the seizures are prone 
 to increase in frequency and as time goes on the in- 
 tervals between the attacks steadily become shorter 
 and shorter. 
 
 Chief among the secondary symptoms found with 
 aortic pains is increased arterial tension. In cases 
 where the attacks are characterized by collapse and 
 where they are dependent more directly upon coro- 
 nary arteriosclerosis, this does not hold good. The 
 pulse and respiration may be either increased in 
 frequency or slowed'. 
 
 Pulmonary oedema does not form part of the 
 typical clinical picture, but is not an infrequent 
 complication in cases where for any reason there is 
 an already existing tendency toward pulmonary 
 congestion. 
 
 The patients themselves during the attack may 
 seem slightly frightened, or they may go into col- 
 lapse with nausea, trembling, and severe perspira- 
 tion. The characteristic aspect of patients with the 
 most severe attacks is silent terror and an expres- 
 sion of the greatest alarm. Such cases are often 
 complicated by disease of the coronary arteries, and 
 are in marked contrast to the loud, melodramatic 
 
334 PAIN 
 
 behavior of patients suffering from the funcfional 
 forms of aortic pain. 
 
 The paroxysmal attacks of vascular pain which 
 we have just considered may be regarded as the most 
 severe development of the disease. All degrees of 
 pain, however, may be found accompanying the 
 various aortic lesions. These are best considered 
 in direct connection with the various pathological 
 processes. 
 
 Aneurysm op the Aoeta. — The pain produced 
 by aneurysm is at first probably due to the stretching 
 of the diseased aortic wall. On the other hand, it 
 may also be due to the progressive nature of the 
 process, an extension quite analogous to that occur- 
 ring with malignant new growth. The diffuse and 
 even distention of the aorta may give rise to pain 
 independently of further extension. The cases of 
 chief interest to us here, however, are the progres- 
 sively extending ones. 
 
 The mechanism of these pains is the same as that 
 which we described in speaking of aortic pains in 
 general ; but here we have, in addition to other fac- 
 tors, the element of progressive extension of the 
 aneurysmal sac and consequent pressure upon sensi- 
 tive structures. This source of pain must especially 
 be considered in cases which are accompanied by 
 constant pain, and a recognition of this will, of 
 course, materially influence prognosis. 
 
 Patients suffering from aneurysms , occasionally 
 suffer from a pain in the shoulder or in the upper 
 extremity, which comes and goes irregularly. Such 
 
RESPIRATION AND CIRCULATION 335 
 
 variation makes us question the correctness of our 
 diagnosis. The irregularity can often be explained, 
 however, by temporary exacerbations in the in- 
 flammatory process of the aorta and the perivascu- 
 lar inflammations. These pains usually correspond 
 absolutely with the position of the aneurysmal sac. 
 Therefore they are located with especial frequency 
 along the clavicle and are accompanied by sensitive- 
 ness in the corresponding brachial plexus, the upper 
 intercostal spaces and ribs. Occasionally pain may 
 occur opposite the coracoid process in Mohrenheim's 
 fossa. When it extends into the back, it is usually 
 situated over the left scapula, in the space between 
 the scapula and the vertebral column, or just below 
 the scapula angle. Qpcasionally there may be pain 
 in the supraspinous fossa. 
 
 Retrosternal pain in the region of the heart, in 
 the shoulder and upper extremity and in the inter- 
 costal spaces, however, is so common in simple 
 chronic aortitis that it is hardly necessary always to 
 think of aneurysm when this occurs. It is logical 
 to think of aneurysm only when the symptoms are 
 constant and no free intervals occur. The same con- 
 siderations apply to the pains radiating into the neck 
 and occipital region. It is the constancy of the pain 
 rather than its localization which makes the differ- 
 entiation between chronic aortitis and aneurysm. 
 The factors modifying the pain in aortic aneurysm 
 are the same as those mentioned in speaking of 
 simple aortic pains. 
 
3S6 PAIN 
 
 Whenever pain in the shoulder is complained 
 of, diagnosis should be made with extreme care. 
 Such pains often occur as an early symptom of 
 aneurysm, but are frequently interpreted as rheu- 
 matic, and the treatment to which the patient is sub- 
 jected (massage, gymnastics, and hot baths) directly 
 aggravates the aneurysmal dilatation. Especial 
 care should be taken to determine whether the pain 
 is increased by forcible exertion, rapid walking, or 
 running upstairs, and improved by rest ; or whether 
 a paroxysm is accompanied by cardiac symptoms, 
 such as palpitation, etc. When the pain is due to 
 aneurysm, too, the motions of the shoulder joint are 
 usually free; this, however, is not a very useful point 
 since there are many exceptions, cases in which this 
 reflex pain in the shoulder joint leads to limitation 
 of movement. Eotatory movements of the shoulder 
 in such cases, especially abduction of the arm from 
 the chest above the horizontal position, often lead 
 to pain in Mohrenheim's groove. This may possibly 
 be due to direct tugging upon the subclavian artery. 
 Similar tugging upon the carotid by turning and 
 backward bending of the head may produce pain in 
 the neck and occiput. 
 
 The error of confusing the shoulder pain pro- 
 duced by aneurysm with rheumatic pain is especially 
 frequent because exposure to cold and draught often 
 produce an exacerbation, and a local counter-irrita- 
 tion is often followed by distinct improvement. It 
 is not at all out of the question that in many of these 
 cases there may actually be rheumatic or gouty pains 
 
RESPIRATION AND CIRCULATION SST 
 
 in the joints, since there is often such a diathesis 
 underlying the vascular disease. The shoulder joint 
 is unquestionably in such cases a point of least 
 resistance because of the diseased arteries which 
 supply it. 
 
 A very important diagnostic feature of the pains 
 accompanying aortic aneurysm is their reaction to 
 changes of position of the body. 
 
 In speaking of general aortic pains, we called 
 attention to the fact that there is a marked differ- 
 ence between the upright and the prone positions in 
 their influence upon arterial pressure. There are, 
 on the other hand, cases of aneurysm in which mere 
 shifting of position when the patient is lying down 
 will influence the pain ; these are entirely analogous 
 to similar phenomena occurring in the abdominal 
 conditions, such as gastric ulcer and renal disease. 
 Lying upon the side is often accompanied by great 
 pain, which is usually present when the patient is 
 lying on the side opposite to the lesion. This gives 
 him the sensation of something sinking toward the 
 healthy side. This is unquestionably due to the 
 change of position of the aneurysmal sac and traction 
 upon the periarterial adhesions. It is very impor- 
 tant, therefore, in cases suspicious of aneurysm, to 
 observe the influence of changes of position upon the 
 pains. 
 
 Theoretically it is quite obvious that any agencies 
 which would exert traction upon the sac, such as deep 
 breathing, coughing and sneezing, would give rise 
 to pain, and practical experiments bear this out. 
 
 22 
 
338 PAIN 
 
 The pain may be especially dependent upon respira- 
 tion, and it is of particular diagnostic significance 
 when deep breathing gives rise to extrathoracic 
 pains (for instance, in the back of the neck). 
 
 The pain occasionally accompanying the act of 
 swallowing is probably explained by the motion of 
 the larynx during this act, and consequent traction 
 upon the left bronchus and tugging upon the aorta. 
 This pain occasionally radiates into the shoulder 
 blade or into the intraclavicular region. 
 
 Percussion and palpation over the intercostal 
 spaces, the ribs and the vertebral column in the 
 region of the aneurysm occasionally produce great 
 suffering. 
 
 While the aneurysmal process is an entirely con- 
 stant state of affairs, the pain need not be entirely 
 constant. Variations are especially frequent in 
 those pains which are based upon reflex causes 
 (brachial and cervical plexuses, subclavicular and 
 carotid regions). 
 
 Variations, too, in the pathological conditions 
 underlying the pains explain such changes. These 
 are chiefly changes in dilatation of the aneurysmal 
 sac and fluctuations ia the inflammatory process 
 occurring in the aorta. These fluctuations may be 
 very similar to those occurring in rheumatic condi- 
 tions. Changes in the pain may be due, on the other 
 hand, directly to variations in the occasionally com- 
 plicating rheumatism. 
 
 The quality of the pain is not at all imiform. 
 Usually the patients complain of pulsating, boring 
 
RESPIRATION AND CIRCULATION 
 
 pains, or, again, of a shooting or stabbing as with 
 needles. Almost invariably they localize their pains 
 deeply. 
 
 We may frequently be led in the right direction 
 by considering the regions secondarily involved in 
 aneurysmal pain, the shoulder pains being particu- 
 larly important. In this connection special atten- 
 tion must be paid to the mechanical influences of 
 motion or body position, which will help us tremen- 
 dously even when other secondary symptoms are 
 absent. 
 
 Other important symptoms which are occasion- 
 ally associated are variable hoarseness, which is 
 directly dependent in its intensity upon physical 
 exertion, difficulty in swallowing, especially the swal- 
 lowing of cold fluids, and associated especially with 
 particular positions of the head. There are often, 
 too, a dry hacking cough, which is influenced defi- 
 nitely by the position of the body, cardiac palpita- 
 tion, and increase of the shoulder pain following 
 rapid walking, variations in the pulse, sometimes 
 referable to the sympathetic system, and dilated 
 veins. 
 
 For rapid diagnosis it is always important to 
 examine the aorta carefully in the suprasternal fossa 
 and in the intraclavicular space on both sides by 
 palpation and inspection. 
 
 Chbonic Aortitis. — ^In cases of aneurysm of the 
 aorta we had to deal chiefly with a constant pain. 
 In the cases of chronic aortitis, on the other hand, 
 we deal with a characteristic paroxysmal pain. The 
 
340 PAIN 
 
 chief condition under consideration here is that 
 which is known commonly as angina pectoris, and 
 which is unquestionably often accompanied by dis- 
 ease of the coronary arteries. In order to avoid 
 repetition we may refer to the section upon aortic 
 pains in general. We have already called attention 
 in that section to the secondary pains and to their 
 channels of radiation. 
 
 The considerable variations in the localization 
 of the attacks may be due to the varying localization 
 of the disease in the aorta. The central point of 
 these attacks of pain, that is, the locality from which 
 the attack emanates, is frequently below the sternum. 
 Often the pain is in the lower portion of the sternum 
 and extends symmetrically on both sides, covering 
 thus an oval area; more rarely it extends to the 
 suprasternal fossa. Occasionally, again, the attack 
 may begin with stabbing pains in the heart itself or 
 in the right mammary line. 
 
 The point of origin does not, however, occur 
 always in the thorax. It may be located in the epi- 
 gastrium, and these cases are the ones which are the 
 most' easily misinterpreted. Kadiation most fre- 
 quently occurs retrosternally in an upward direction. 
 
 Whenever the epigastric tyipe of angina pectoris 
 occurs it is well to seek an explanation in two proba- 
 bilities: (1) involvement of the abdominal aorta, es- 
 pecially at the point of origin of the coeliac axis; 
 (2) coincident disease of the stomach itself (chronic 
 gastritis, ulcer, atony, etc.). 
 
 The possibility of sclerosis of the gastric arteries 
 must also be considered. 
 
RESPIRATION AND CIRCULATION 341 
 
 It is important to determine whether or not the 
 initial epigastric pain is truly gastric or hepatic ia 
 nature (as by hepatic congestion or cholelithiasis) 
 and whether the angina pectoris is thereby second- 
 arily initiated. 
 
 There are two chief types of radiations, which, 
 by the way, may be entirely absent at the beginning, 
 and occur only later in the disease. 
 
 1. The symmetrical type. Radiations which are 
 equally severe in both shoulders, both arms (espe- 
 cially the ulnar surfaces) in the scapular region, both 
 sides of the neck, both sides of the jaw and both 
 temples. 
 
 2. The asymmetrical type, which involves chiefly 
 the left side of the body; radiations occurring into 
 the left shoulder and the left arm, the back be- 
 tween the vertebral column, the left shoulder blade 
 and the left side of the neck. 
 
 "While there are cases in which there is a complete 
 absence of radiation there are, on the other hand, 
 cases in which the attack begins in the peripheral 
 zone and centers towards the aorta (for instance, 
 from one carotid artery or from one arm) . 
 
 These unusual peripheral types (sensations in 
 the regions of the teeth, wrist, olecranon, etc.) are 
 of the greatest practical importance, since they are 
 so easily misinterpreted, and may in many cases be 
 the forebodings of sudden death, 
 
 A patient of mine stated that the initial symptom was a peculiar 
 drawing sensation in the little finger of the left hand, which was 
 particularly apt to come on while walking. 
 
842 PAIN 
 
 In the histories of the patients with chronic 
 aortitis and coronary sclerosis we may often trace 
 the earliest beginnings of the fully developed attacks 
 to stages where there were centrally localized pains 
 only. These early stages consist usually in slight, 
 hardly noticeable, sensations of pressure behind the 
 lower part of the sternum, or occasional mild, stab- 
 bing pains in the heart produced by rapid motion, 
 occurring especially in the morning. From these 
 very slight beginnings there gradually develops the 
 terrible picture of a severe angina. The intervals 
 between the attacks decrease and slighter stimuli 
 suffice to induce them. 
 
 The basis for the causative factors consists in the 
 increased blood pressure and secondary distention 
 of the diseased aortic walls, and upon the nerve end- 
 ings embedded in them. The more frequently the 
 attacks occur, the more slight the stimuli necessary 
 for attacks become, the more serious is the prog- 
 nosis. The prognosis is especially bad in cases 
 where the attacks are accompanied by great nausea. 
 The secondary symptoms which are most important 
 in rapid diagnosis are an accentuated, ringing 
 second aortic sound, increased tension in the arte- 
 ries, and angiosclerotic pallor of the face. G-out and 
 syphilis are commonly found in the past history. 
 
 Disease op the Aortic Valves (Endocarditis) 
 WITHOUT Disease op the Aortic Wall. — There are 
 unquestionably cases of aortic pain corresponding 
 in their localization and general behavior with the 
 pains which we have described, without the presence 
 
RESPIRATION AND . CIRCULATION 343 
 
 of any traceable disease of the aorta itself or the 
 coronary arteries. In some of these cases there 
 may be simply diseases of the aortic valves, in others 
 even these may be absent. Such cases give striking 
 proof of the nervous origin of angina pectoris and 
 aortic pain in general. The origin of the pain in 
 such cases is unquestionably in the cardiac and 
 aortic plexuses of the sympathetic system. In or- 
 ganic disease of the aorta these may be the sites of 
 actual neuritis and, therefore, react acutely to in- 
 jury, to disturbances of the circulation in the vasa 
 vasorum, or especially to distention of the aortic 
 walls. They may, on the other hand, without trace- 
 able anatomical reason, be the seats of neuritis, 
 especially in persons who are subject to general 
 irritability of the nervous system. Such attacks of 
 pain may be known as functional angina or false 
 angina; but we must clearly understand that while 
 the special pathological changes in these conditions 
 are very different, the general origia of the pains 
 may be much the same. 
 
 The stimulus initiating such attacks of functional 
 aortic pain, therefore, may often be increase of blood 
 pressure, due to spasms in the peripheral vessels. 
 It is certainly not a chance occurrence that func- 
 tional angina is found most frequently in young 
 neurasthenic individuals with disease of the aortic 
 valves. The neurotic disposition prepares the field 
 and the pathological pressure in the aorta gives 
 the actual stimulus. 
 
344. PAIN 
 
 The differentiation between functional and or- 
 ganic angina pectoris is of extreme prognostic im- 
 portance and is recognized by the analysis of the 
 factors initiating an attack and of the secondary 
 symptoms. As far as the initiating stimuli are con- 
 cerned, however, it is quite important to remember 
 that both the conditions have many of these in 
 common. 
 
 As for angina pectoris which is based upon actual 
 organic disease, we may say that we are dealing with 
 an exact problem. The patient himself knows that 
 if he runs a certain distance at a definite speed he 
 will have an attack. He can make a definite calcu- 
 lation, as it were, of the factors which will give rise 
 to the attack. 
 
 The functional angina, on the other hand, is en- 
 tirely beyond control, is irregular, and is uncertain. 
 In all respects functional angina pectoris is a sort 
 of farcical parody of the tragic true angina. Even 
 the most severe cases lack the serious character of 
 the true organic angina. The blood-pressure is not 
 usually increased; the face is often flushed instead 
 of pale. Instead of seriousness and quiet, there is 
 restlessness and noise. The heart action is usually 
 rapid. 
 
 The extremes of the two cases, therefore, are not 
 hard to differentiate; but unfortunately a mixture 
 of the two conditions is very common. There are 
 cases in which a general neurosis becomes localized 
 in the diseased aorta and adds the characters of a 
 well-developed functional condition to the early 
 
RESPIRATION AND CIRCULATION 345 
 
 symptoms of a true angina. Such cases are often 
 falsely diagnosed and are taken for pseudo-angina 
 until sudden death occurs. No general differential 
 symptoms can he formulated for these. Only the 
 most careful individual study of the symptoms and 
 the most concentrated analysis of the problem can 
 guard us against error. 
 
 Functional angina is especially likely when we 
 are dealing with neurasthenic patients below thirty, 
 when syphilis can be excluded, and especially when 
 there is excessive use of tobacco. This is likely even 
 when an aortic valvular lesion is present. Above 
 thirty, and especially above forty, the differential 
 diagnosis becomes particularly difficult. 
 
 True angina must always be considered most 
 seriously, even in the presence of neurotic symp- 
 toms, when there is arterial tension, a history of 
 syphilis, or when gout or rheumatism is present. 
 
 PERIPHERAL VESSELS. 
 
 It is well known and based on many clinical ob- 
 servations that severe pains may be caused by disease 
 of the peripheral arteries, veins, or lymph vessels. 
 It would be quite incomprehensible if this were not 
 the case, since the nerve trunks themselves possess 
 their own vessels, and it goes without saying that 
 when these are diseased, either primarily or second- 
 arily, errors of nutrition must occur in the nerves, 
 and these therefore become the seats of pain. 
 
 In this connection the very intimate relations 
 between the vessels and the nerves must be carefully 
 
346 PAIN 
 
 considered. On the other hand, changes in the ves- 
 sels and circulation may cause disease in the nerves, 
 while disease in the nerves may cause disease in the 
 vessels. The pathogenesis of the pains, therefore, 
 is extremely difficult to determine. 
 
 Clinical experiment alone can lead us to the cor- 
 rect interpretation. It is a fact that subjective and 
 objective pains occur along the peripheral vessels 
 when they are involved in inflammations (phlebitis, 
 lymphangitis, arteritis), and there is no reason for 
 not interpreting such pains as irritability of the 
 sensory fibers supplying the vessel walls. In some 
 cases, of course, it is necessary to think of a direct 
 extension of the inflammatory process from the ves- 
 sels to the nerves which accompany them. Many 
 cases of neuralgia are probably traceable to such 
 changes in the vessels accompanying the involved 
 nerves. 
 
 It is unquestionable that sclerotic changes in the 
 peripheral arteries, both in the extremities and in 
 the internal organs, may give rise to acute neuralgic 
 attacks of pain. The most striking and fundamen- 
 tal example of this is Charcot's intermittent claudi- 
 cation, since this can be directly observed. 
 
 After a few minutes of walking the patient has 
 pains in his calves which force him to stand still. 
 The pain then disappears ; the patient continues his 
 walk, but in a few moments the same symptoms 
 occur; and with the absolute regularity of a well- 
 planned experiment the same symptoms follow the 
 same exertion again and again. 
 
RESPIRATION AND dRCULATlON 347 
 
 Physical examination in these cases shows scle- 
 rotic changes in the vessels, either local with the 
 formation of aneurysm, or diffuse changes in the 
 ilia^ arteries extending downward with or without 
 stenosis, or more or less severe vasomotor phe- 
 nomena (coldness, pallor, redness and cyanosis of 
 the toes) ; death finally occurs with gangrene of the 
 toes. 
 
 The mechanism of the pain in these cases is not 
 easy to explain. Are we dealing with chronic nutri- 
 tional disturbances in the sensory nerves which 
 reach their greatest height during the circulatory 
 changes accompanying muscular action, or are we 
 dealing with acute ischemia of the active masses of 
 muscle due to arterial spasms 1 
 
 The mechanism of the pain is not necessarily 
 uniform. But, at any rate, it is certain that the 
 clinical observations cannot be explained without the 
 assumption of vascular spasms, to which sclerotic 
 vessels are always subject. Otherwise the constancy 
 of the anatomical changes would have to be fol- 
 lowed by a constancy of the clinical symptoms, while 
 as a matter of fact clinical experiment teaches us 
 that proper treatment may often give the most 
 remarkable results in a short time. Improvement 
 may even occur spontaneously. 
 
 This unquestionably functional factor in the 
 causation of intermittent claudication makes it 
 almost impossible to deduct the cause of a given 
 pain from definite anatomical conditions of the arter- 
 ies. Unquestionably severe atheroma may be pres- 
 
^48 PAIN 
 
 ent in the vessels of the leg without the existence 
 of any pain. For this reason, even in cases where 
 angina pectoris has been observed during life, it is 
 not always a foregone conclusion that the finding 
 of coronary sclerosis at autopsy absolutely explains 
 the symptoms. 
 
 The pains occurring in intermittent claudication, 
 too, find their analogy in diseases of the viscera. 
 
 It may be considered an established fact that 
 diseases of cardiac, gastric, or intestinal arteries 
 may give rise to painful interferences with function. 
 
 In order to draw an intelligent parallel, however, 
 between the intermittent claudication of the lower 
 extremities and the pathological conditions of inter- 
 nal organs, we must consider only those cases in 
 which there is real similarity between the existing 
 stimulus and the therapeutic influences. The at- 
 tacks of pain must occur at the height of the mus- 
 cular exertion, that is, at the height of digestion, 
 as in arteriosclerotic intestinal pains, and be accom- 
 panied by disturbance of motility in the sense of 
 spasm and loss of function. 
 
 In the heart this might become evident by cardiac 
 insufficiency with arhythmic feeble pulse. In the in- 
 testine it might be noticed as a stenosis or distention 
 which could simulate peritonitis ; and this, as a mat- 
 ter of fact, actually occurs in a number of cases. 
 
 It is true, too, that cases of this order can be 
 therapeutically influenced (erythrol tetranitrate). 
 
 Probably in all these conditions the organic basis 
 of the pains consists in an active intermittent spasm 
 of the vessels. 
 
RESPIRATION AND CIRCULATION 349 
 
 Either in the last stages of these conditions or 
 even as an entirely independent condition, pains may 
 occur in which the vessels play a more passive role. 
 Closure of the vessels by thrombosis or embolus 
 may give rise to pain in consequence of anaemic 
 necrosis of the sensory nerve endings and their 
 dependent tissue regions. 
 
 The severe pain occurring in gangrene of the 
 toes and the sudden pains which occur in the lower 
 extremities, with embolus or thrombosis of the lower 
 portion of the abdominal aorta, would belong to this 
 order. 
 
 The accompanying symptoms, coldness of the 
 affected area and a loss of the motor and sensory 
 functions, will usually clear up the diagnosis. 
 
 Similar processes in the chest, abdomen and vis- 
 cera will, of course, give rise to great diagnostic 
 difficulties. 
 
 Stenoses of the mesenteric arteries frequently 
 lead to the erroneous diagnosis of intestinal obstruc- 
 tion and peritonitis. Whenever sudden colicky 
 pains, either with or without bloody diarrhoea, occur 
 in patients with noticeable arterial disease, it is 
 always important to think of the possibility of dis- 
 ease of the mesenteric vessels. 
 
 Closure of the veins as well as of the arteries may 
 give rise to severe pains, A notable example of 
 this is the headache accompanying thrombosis of 
 the lateral sinus, and the phlegmasia alba dolens 
 following closure of the large veins of the leg. 
 
CHAPTER X. 
 
 Cutaneous Tenderness in Visceeal Disease. 
 
 While the fact that diseases of the internal 
 organs may be accompanied by areas of cutaneous 
 tenderness or pain more or less remote from the 
 actual seat of disturbance had previously been com- 
 mented on by various observers, notably Hilton, 
 Dana, Boss, and Mackenzie, it is largely through the 
 brilliant researches of Henry Head that the real 
 significance of this phenomenon has been made dear. 
 His explanation for this transference of sensation 
 is that a painful stimulus to an internal organ causes 
 centripetal impulses, ordinarily below the threshold 
 of consciousness, to be conducted to a certain seg- 
 ment of the spinal cord. Here a more or less diffuse 
 disturbance is induced which involves also the fibres 
 connecting a definite district of the surface of the 
 body with the same segment. As the function of 
 sensation has been very highly developed in the skin 
 its sensory and localizing power is enormously in 
 excess of that of the viscera, so that the painful 
 sensation is referred in consciousness not to its true 
 source, but to the site from which such messages 
 are habitually received, — i.e., the surface of the body. 
 According to the intensity of the visceral stimulus, 
 actual pain may be experienced, or there may result 
 only a state of hyperaesthesia or hyperalgesia which 
 
 350 
 
VISCERAL DISEASE S51 
 
 manifests itself by an increased susceptibility to 
 stimuli, so that contacts which would ordinarily evoke 
 only sensations of touch now give rise to actual pain. 
 In order to discover the presence of such areas of 
 tenderness and ascertain their boundaries, the exam- 
 iner may use a pin with a round head of such size 
 as to feel blunt when applied to normal skin. Pres- 
 sure is made with this here and there over the sus- 
 pected region, and if hyperalgesia exists the patient 
 complains of a sensation as if a bruised spot were 
 touched, while if the poiat of the instrument is 
 applied the pain is far in excess of that normally 
 produced. 
 
 Head was led to investigate the subject by the 
 observation that the distribution of the lesions in 
 cases of herpes zoster corresponded with the areas 
 of cutaneous pain or tenderness occurring in certain 
 visceral disorders, and by comparing the areas in- 
 volved in a large number of cases of herpes zoster 
 with' the disturbances of sensation in a series of 
 cases of nervous disease with gross lesions of the 
 spinal cord, he was able to map out on the surface 
 of the body the skin units or dermatomes in com- 
 munication with the various segments of the cord. 
 These areas correspond, not to the peripheral distri- 
 bution of the posterior roots, but to the segments of 
 the cord itself from which the roots in part arise. 
 The skin areas as traced by Head on the trunk 
 form more or less horizontal zones of irregular out- 
 line, while about the neck and on the limbs their 
 eccentricity of contour is still more pronounced. The 
 
852 PAIN 
 
 whole area is not necessarily involved in every case, 
 but each seigmental district possesses one or more 
 maximal points ia which the tendency to exhibit pain 
 or tenderness is most acute and which give the clue 
 to the area concerned. 
 
 Subsequent observers have verified Head's con- 
 clusions ia most particulars, and while the limits 
 of the various areas as given by different authors do 
 not in all cases coincide absolutely, it is probable that 
 the maximal points on Head's diagrams are correct. 
 For practical purposes, at any rate, the chief interest 
 attaches to these, so that for this reason, and for the 
 sake of greater clearness, on the following figures 
 only the so-called maxima are indicated. It must be 
 remembered, however, that for the present at least, 
 the evidence afforded by the demonstration of areas 
 of cutaneous tenderness or pain is valuable chiefly 
 in the positive sense and that their absence does not 
 preclude the existence of visceral disease. Further- 
 more, in any given case these areas do not neces- 
 sarily preserve their integrity indefinitely, but as 
 the nervous system becomes impaired as the result 
 of prolonged illness, first, the corresponding dis- 
 trict of the opposite side of the body may become 
 involved and later on still more marked generaliza- 
 tion may occur until the pain and tenderness invade 
 areas that bear no relation to the affected organ. 
 A poiut of practical importance is that counter- 
 irritation over the cutaneous area may have thera- 
 peutic value, not only in the immediate relief of 
 pain, but also in influencing the underlying condition. 
 
VISCERAL DISEASE 353 
 
 In this connection Mackenzie's acute observa- 
 tions and conclusions deserve mention. It is gen- 
 erally conceded that visceral disorders can give 
 rise to so-called somatic or referred pains through 
 the mechanism explained above, but it is also held, 
 as a matter of course, that axjtual pain can be ex- 
 perienced in the organ itself. Mackenzie, however, 
 denies the existence of this splanchnic pain and 
 contends that the pain of visceral disease is not felt 
 as such in the organ, but is referred to the periph- 
 eral distribution of the cerebrospinal nerves in the 
 external body wall. Through an error of subjec- 
 tive localization the sensation is then interpreted as 
 having its site in some adjoining internal struc- 
 ture, for example the stomach in gastric ulcer, or 
 the heart in angiua pectoris. 
 
 23 
 
354 PAIN 
 
 SEGMENTAL DISTRIBUTION OF REFERRED PAIN AND 
 TENDERNESS IN VISCERAL DISEASE. 
 
 (Compiled from Head.) 
 
 See diagrams figures 1, 2, and 3. 
 
 Heart. — ^Third cervical and first, second, and third dorsal seg- 
 ments. 
 
 Lungs. — Third and fourth cervical and first to ninth [sometimes 
 tenth] dorsal segments, especially the third, fourth, and fifth. 
 
 Breast. — Fourth and fifth dorsal segments. 
 
 (Esophagus. — Fifth, sixth, and eighth dorsal segments. 
 
 Stomach. — Third and fourth cervical and sixth, seventh, eighth, 
 and ninth dorsal segments. Cardiac end from the sixth and seventh, 
 and the pyloric end from the ninth. 
 
 Intestines. — Down to the upper part of the rectum: Ninth, tenth, 
 eleventh, and twelfth dorsal segments. Rectum: Second, third, and 
 fourth sacral segments. 
 
 Liver and Gall-iladder. — Seventh, eighth, ninth, and tenth dorsal 
 segments, and perhaps the sixth. 
 
 Kidney and Ureter. — Tenth, eleventh, and twelfth dorsal seg- 
 ments. The nearer the lesion lies to the kidney the more is the 
 pain and tenderness associated with the tenth dorsal segment. The 
 lower the lesion in the ureter the more does the first lumbar segment 
 tend to appear. 
 
 Bladder. — ^Mucous membrane and neck of the bladder: First, sec- 
 ond, third, and fourth sacral segments. Overdistention and ineffec- 
 tual contraction: Eleventh and twelfth dorsal and first lumbar 
 
 Prostate. — Tenth, eleventh, and twelfth dorsal, first, second, and 
 third sacral, and third lumbar segments. 
 
 Epididymis. — Eleventh and twelfth dorsal and first lumbar seg- 
 ments. 
 
 Testis. — Tenth dorsal segment. 
 
 Ovary. — Tenth dorsal segment. 
 
 Uterine Appendages. — Eleventh and twelfth dorsal and first lum- 
 bar segments. 
 
 Uterus. — In contraction: Tenth, eleventh, and twelfth dorsal and 
 first lumbar segments. Os uteri: First, second, third, and fourth 
 sacral segments, and very rarely the fifth lumbar. 
 
VISCERAL DISEASE 
 
 ASSOCIATED PAINFUL AREAS ABOUT THE HEAD RELATED 
 
 TO VISCERAL DISEASE. 
 
 (Head.) 
 
 See diagram figure 4. 
 
 Area on Body. 
 
 Associated Area on 
 Head. 
 
 Organs in Particular Relation with 
 these Areas. 
 
 Cervical 3 and 4 
 
 Fronto-nasal 
 
 Apices of lungs, stomach, liver, 
 aortic orifice (?) 
 
 
 
 Dorsal 2 and 3 . 
 
 Mid-orbital 
 
 Lung, heart, arch of the aorta. 
 
 Dorsal 4 
 
 Doubtful 
 
 Lung. 
 
 Dorsal 5 ....... . 
 
 Fronto- temporal. 
 
 Lung and occasionally the heart. 
 
 Dorsal 6 
 
 Fronto-temporal. 
 
 Lower lobe of lung, and heart. 
 
 Dorsal 7 
 
 Temporal 
 
 Bases of lungs, heart, and stomach. 
 
 Dorsal 8 
 
 Vertical 
 
 Stomach, liver, and upper part of 
 the small intestine. 
 
 Dorsal 9 
 
 Parietal 
 
 Stomach, and upper part of the 
 small intestine. 
 
 Dorsal 10 
 
 Occipital 
 
 Liver, intestine, ovary, and testicle. 
 
356 
 
 PAIN 
 
 AREAS OF REFERRED PAIN AND TENDERNESS IN AFFEC- 
 TIONS OF THE HEAD AND NECK. 
 (Head.) 
 See diagram figure 4. 
 
 
 Maximum Point 
 
 
 Maximum Point 
 
 Organ Involyed. 
 
 of Referred Pain and 
 
 Organ Involved. 
 
 of Referred Pain and 
 
 
 Tenderness. 
 
 
 Tenderness. 
 
 Ciliary muscle. 
 
 Midorbital. 
 
 Upper teeth . . . 
 
 Frontonasal, naso- 
 
 (Disorders of 
 
 
 
 labial, temporal. 
 
 accommoda- 
 
 
 
 maxillary, or 
 
 tion.) 
 
 
 
 mandibular. 
 
 Cornea 
 
 Frontonasal. 
 
 Lower teeth. . . 
 
 Mental, Uyoid, su- 
 perior laryngeal, 
 and in the ear. 
 
 Iris 
 
 Frontotemporal , 
 temjDoral, and 
 
 Tongue, ante- 
 rior part. 
 
 Mental. 
 
 
 
 
 maxillary. 
 
 
 
 Vitreous body 
 
 Temporal. 
 
 Tongue, lateral 
 
 H y i d, superior 
 laryngeal, and in 
 
 (Glaucoma.) 
 
 
 part. 
 
 
 
 
 the ear. 
 
 Retina 
 
 Vertical. 
 
 Tongue, poste- 
 
 Superior laryngeal , 
 
 
 
 rior part. 
 
 hyoid, occipital. 
 
 Tympanic mem- 
 
 Hyoid. 
 
 Tonsil ; 
 
 Hyoid and in the 
 
 brane. 
 
 
 
 ear. 
 
 Middle ear .... 
 
 Vertical and be- 
 
 Nose, olfactory 
 
 Frontonasal and 
 
 
 hind the ear. 
 
 portion. 
 
 midorbital. 
 
 
 
 Nose, respira- 
 
 Nasolabial (occa- 
 
 
 
 tory portion 
 
 sionally) . 
 
 
 
 and poste- 
 
 
 
 
 rior nares. 
 
 
 
 
 larynx 
 
 Superior and in. 
 ferior laryngeal 
 (in destructive 
 lesions). 
 
V 10 
 
 X> 12 
 
 Lt 
 
 D 11 
 
 FiQDBB 1. — C S and C 4 .third and fourth cervical ; D 1 to D IS, first to 
 twelfth dorsal ; L 1 and L S, first and second lumbar ; S S and S 4, third and 
 fourth sacral. 
 
D 11 
 
 FiorsD 2, — C, cervical; D, dorsal; L, lumbar; S, saoraL 
 
FiGtJKE 3. — D, dorsal ; L, lumbar. 
 
Neuritis of Bra- 
 chial Plexus. 
 
 Neuritis. 
 
 Neuralgia. 
 
 Progressive Muscu- 
 lar Atrophy 
 
 Syringomyelia. 
 
 Disease of Verte- 
 brae. 
 
 Occupation Neu- 
 
 Tabes. 
 
 isteomalacia. 
 
 Disease or Injury 
 of the Cord (es- 
 pecially Tabes). 
 
 Figure 6. — Possible Areas of Pain or Tenderness in Diseases of the Nervous 
 
 System, Etc. 
 
Neurasthenia. 
 
 Meningitis. 
 
 Cerebellar Disease. 
 
 Sub-occipital Neu- 
 ralgia. 
 
 Disease of Cervical 
 Vertebrse. 
 
 Affections of Naso- 
 pharynx. Nose, 
 and Middle Ear. 
 
 Uremia. 
 
 Sypbilis. 
 
 Osteomalacia 
 
 Hypertension 
 ■ Headache. 
 Neurasthenia. 
 
 Neuritis of B i 
 chial Plexus, 
 
 Neurasthenia. 
 
 Railway Spine. 
 
 Meningitis. 
 
 Myelitis or Tu- 
 mors of Cord. 
 
 Disease of Verte- 
 brse. 
 
 Typhoid Spine. 
 
 Spondylitis Defor- 
 mans. 
 
 Lumbo-abdominal 
 Neuralgia. 
 
 Lumbago. 
 
 Figure 6. — Possible Areas of Paik or Tenderness in Diseases of the Nervous 
 
 System, Etc, 
 
Hepatic Conges- 
 tion. 
 
 Gallstone Disease. 
 
 Intestinal Ulcera- 
 tion. 
 
 Ulcer of Stomacli. 
 
 Lead colic. 
 
 Pancreatic D i s - 
 ease. 
 
 Appendicitis. 
 
 Kenal Affectio] 
 
 Ulcer of Stomach. 
 
 Gallstone Disease, 
 
 Intestinal Ulcera- 
 tion, 
 
 Pancreatic Disease. 
 
 Appendicitis. 
 
 Hernia. 
 
 Affections of Rec- 
 tum. 
 
 Vertebral Disease. 
 
 Constipation, 
 Gastric Disorders. 
 
 Constipation. 
 
 Colitis. 
 
 Gastric Disorders. 
 
 Gastralgia and 
 Functional Disor- 
 ders of Stomach. 
 
 Gastric Distention. 
 
 Ulcer of Stomach 
 or Duodenum. 
 
 Carcinoma of Sto- 
 mach. 
 
 Ulcer, New Growth 
 or Stricture of 
 Esophagus. 
 
 functional Disor- 
 ders of Stomach. 
 
 Gastritis. 
 
 Ulcer and Carcino- 
 ma of Stomach. 
 
 Pyloric Colic. 
 
 £nteroptosis. 
 
 Splenic Disease, 
 
 Movable Kidney, 
 
 Renal Colic. 
 
 Ulcer of Stomach. 
 
 FlQUBB 7." 
 
 Colitis, 
 
 Testicular or Ovarian Affections. 
 
 Renal Colic. 
 
 Hernia. 
 
 Constipation, 
 
 -Possible Abe as of Pain or Tenderness in Diseases op the AnDOMiNAii 
 Organs. 
 
Pregnancy. 
 Uterine or Ova- 
 rian Disease. 
 
 Head's Triangle in 
 Ulcer of Stomach. 
 
 Gallstone Disease 
 and Affections oj 
 
 Gall-bladder. 
 
 Pancreatic Diseas< 
 
 Cystitis. 
 Tuberculosis or 
 Carcinoma of Bladder. 
 Vesical Calculus. 
 Prostatic or Adnexal Disease, 
 
 Gastralgia. 
 
 Ulcer of Stomach. 
 
 Carcinoma of Sto- 
 mach. 
 
 Flatulence. 
 
 Enteroptosis. 
 
 Dietl's Crises. 
 
 Lead Colic. 
 
 Peritonitis. 
 
 Tuberculous Peri- 
 tonitis. 
 
 Intestinal Obstruc- 
 tion. 
 
 Intestinal Ulcera- 
 tion. 
 
 Enteritis. 
 
 Hernia. 
 
 Pancreatic Disease. 
 
 Tabes. 
 
 Spinal Disease. 
 
 Gout. 
 
 Ovaritis. 
 
 FiGCRB 8. — FosBiBLs Abeab OP Pain or Tenderness in Diseases of the Abdominal 
 
 Organs. Etc. 
 
Splenic Affections. 
 
 Gastric Disorders. 
 
 Constipation. 
 
 "larcinoma of Colon or 
 
 FancreaH. 
 Movable Kidney. 
 Pyelitis. 
 Subphrenic Abscess. 
 
 Renal Colic. 
 
 Ftat^BE 0, — FossiBLEi Akeas of Pain or Tenderness in Diseases of the 
 Abdominal Organs. 
 
Gallstone Disease and Af- 
 fections of Gall-bladder. 
 
 Hepatic Disease: Cir- 
 rhosis, Congestion, Syph- 
 ilis, Carcinoma, Abscess, 
 Echinococcus etc. 
 
 Subi)hrenic Abscess. 
 
 Carcinoma of Pylorus or 
 Colon. 
 
 Movable Kidney. 
 
 Pyelitis. 
 
 FiGtJRs 10, — P0SSIBI.B Areas of Pain or Tenderness in Diseases of the 
 Abdominal Organs. 
 
Gastric Affectio] 
 Constipation. 
 
 Ulcer of the Sto- 
 mach. 
 
 Spleen. 
 PancreasT 
 
 Lumbago. 
 
 Flatulence. 
 
 Constipation- 
 Renal Oalculua or 
 New Growth. 
 
 Movable Kidney. 
 
 Pyelitis. 
 
 Acute Nephritis. 
 
 Lumbar Abscess. 
 
 Vesical Calculus. 
 
 Cystitis. 
 
 Prostatic New 
 Growth or Sup- 
 puration. 
 
 Ischiorectal Ab- 
 
 Fever, (Acute In- 
 fectious Dis- 
 eases etc.)' 
 
 Anemia. 
 
 Gout. 
 
 Esophagus: In- 
 fl animation, 
 Stricture, New 
 Growths, Ulcer- 
 ation, etc. 
 
 Gastric Affections. 
 
 Flatulence. 
 
 Pancreatic Disease. 
 
 Liver and Gall- 
 bladder. 
 
 Colon. 
 
 Kidney. 
 
 Renal Affections. 
 
 Relaxation of 
 Sacro-iliac Lig- 
 aments. 
 
 Disease of Pelvic 
 Viscera. 
 
 Rectal Carcinoma 
 or Ulceration. 
 
 Hemorrhoids. 
 
 Ischiorectal Ab- 
 
 FlGtTRB 11.- 
 
 Coccygodynia. 
 Anal Fissure. 
 Hemorrhoids. 
 Rectal Fistula. 
 Ischiorectal Abscess. 
 
 -PossiBiiE Areas of Pain or Tenderness in Diseases op the Abdominai. 
 Organs, Etc. 
 
Diaphragmatic 
 Pleurisy. 
 
 Mediastinal 
 Growths. 
 
 Enlarged Bron- 
 chial Glands. 
 
 Bronchitis. 
 
 Miliary Tuhercu 
 loais. 
 
 Pleurisy. 
 Apical Lesions. 
 New Growths, 
 
 Pleurisy. 
 
 New Growths of 
 Lung or Pleura. 
 
 Di aphragmatic 
 
 Pleurisy. 
 
 Prolonged Cough- 
 ing or Vomiting. 
 
 Pneumonia, 
 . 'leurisy. 
 Diaphragmatic 
 Pleurisy. 
 
 FiGTJBE 12. — Possible Areas of Pain or Tenderness in Diseases of the Lungs and 
 
 FliEURA. 
 
Pleural Affections, 
 
 Muscular Pain after Pro- 
 longed Coughing or 
 Vomiting. 
 
 Pneumonia. 
 
 Tuberculosis. 
 
 Emp:^ema. 
 
 f leurisy. 
 
 New Growths of Pleura or 
 
 Mediastinum. 
 Enlarged Bronchial 
 
 Glands. 
 Pleurodynia. 
 
 Figure 13. — Possible Areas of Pain ob Tenderness in Diseases op the Lungs 
 
 AND Pleura. 
 
Diaphragmatic 
 
 Pleurisy. *" 
 
 Tuberculosis. 
 Pleural Adhesions, 
 Glandular Enlarge- 
 ments. 
 
 Pleurisy. 
 New Growths. 
 Apical Lesions. 
 
 Mediastinal 
 Growths. 
 
 FiGUHE 14. — Possible Areas of Pain or Tenderness in Diseases of the Lungs and 
 
 Flettba. 
 
Atheroma of Aorta 
 and Large Ves- 
 sels. 
 
 Aneurysm, of In- 
 nominate. 
 
 Arch, of Aorta. 
 
 Ascending Aorta. 
 
 Valvular Lesions. 
 
 Pericarditis. 
 
 Angina Pectoris. 
 
 Aneurysm, of Ab- 
 dominal Aorta or 
 Goeliac Axis. 
 
 Spasm of Mesen- 
 teric Vessels. 
 
 Aneurysm of 
 
 ' .orta. 
 
 Atheroma of 
 
 Aorta. 
 Aneurysm of 
 
 Aorta. 
 bigina Pectoris. 
 Joronary Sclerosis. 
 Valvular Lesions. 
 
 Atheroma of 
 Aorta. 
 
 Aneurysm of 
 Aorta. 
 
 Coronary Sclerosis. 
 
 Angina Pectoris. 
 
 Pericarditis. 
 
 Myocarditis. 
 
 Endocarditis. 
 
 Valvular Lesions 
 (especially Aor- 
 tic). 
 
 Functional Dis- 
 ease of the 
 Heart. 
 
 Anemia. 
 
 Gout. 
 
 Figure 15. — Possible Areas of Pain or Tenderness in Diseases of the Heart and 
 
 Vessels. 
 
Pericarditis. 
 .neurysm of Thoracic 
 Aorta. 
 
 FiauKifl 16. — Possible Areas of Pain or Tendehm-ss in Diseases of the Heaut 
 AND Vessels. 
 
Atheroma of Aorta. 
 Aneurysm of Aorta or 
 
 Coeliac Axis. 
 Valvular Xiesions (espe- yi' 
 
 cially Aortic). V''^ 
 
 Figure 1 7. — Possible Aseas of Pain or Tenderness in Diseases op the Hearx 
 
 AND VeBSELS. 
 
Peri carditis, 
 
 Descending Aorta. 
 
 Abdominal Aorta. 
 
 Atheroma of Aorta, 
 
 Aneurysm of Aorta, 
 
 or Innominate. 
 
 Atheroma of Aorta. 
 
 .Aneurysm of Tho- 
 racic or Abdom- 
 inal Aorta. 
 
 FiGURBi 18. — 'Possible Abeas of Pain or Tenderness in Diseases of the Heart and 
 
INDEX 
 
 Abdomen, 60 
 
 Abdominal disorders, 30, 44, 63, 
 
 109 
 Adhesions, peritoneal, 272 
 Anaemia, 87 
 
 Aneurysm of aorta, 344 
 Angina pectoris, 41 
 Aorta, 52, 322 
 Aortitis, chronic, 339 
 Apices, pulmonary, 51 
 Appendicitis, 248 
 Appendix, 206 
 Arm, 105 
 Arthralgias, 119 
 
 Biliary congestion, 261 
 Brain tumor and hydrocephalus, 
 79 
 
 Calculi, 275, 292 
 Cancer, gastric, 187 
 Carcinoma of colon, 249 
 
 of gall-ducts, 266 
 Catarrhal and ulcerative changes 
 
 in bladder and urethra, 302 
 Circulatory apparatus, 29, 53 
 Cirrhosis of the liver, 306 
 CoUc, 57 
 
 and thoracic processes, 63 
 
 doubtful cases of, 73 
 Colicky pains, 71 
 Collapse, 57 
 
 Congestion, hematogenous, 256 
 Cysts, 269 
 
 Defecation, 45 
 Deglutition, 47 
 Drugs and chemicals, 41, 310 
 
 Embolism of the renal arteries^ 
 
 278 
 Epigastrium, 56, 57, 271 
 
 midline of, 238 
 Epigastric pain, 30 
 
 Face, 102 
 
 Pood, influence of, 36, 67 
 
 Gall-bladder, 238 
 
 colic, 236 
 Gall-stones, 69 
 Gastralgias, 140 
 Gastric crises, 46 
 
 disorders, 55 
 
 pain, 43 
 
 Hemorrhage, 275, 301 
 Headache, 76 
 
 and constipation, 81 
 
 caused by chemical poisons, 
 85 
 
 of reflex nature, 88 
 Hsemoglobinuria, paroxysmal, 307 
 Heart or epigastrium, 41 
 Heart disease, 307 
 Hernias, 68 
 Hysteria, 251 
 
 Infectious processes, 307 
 Inflammations of aorta, 323 
 Intercostal spaces, 107 
 Intestine, malignant new growths 
 
 of, 224 
 Intestinal stenoses, 68, 197 
 ulceration, 197 
 
 Kidney, 250, 277, 284, 299 
 Lead colic, 217 
 
 357 
 
358 
 
 INDEX 
 
 Lead colic, individual symptoms 
 
 and analysis, 218 
 Lesions, abdominal, 45 
 aortic, 326 
 of lungs, 321 
 organic, 40 
 Liver, 52, 54, 233 
 
 capsule, distention of, 235 
 inflammatory processes, 
 235, 256 
 Lumbar region, 61, 63, 239 
 Lungs, 312 
 
 Mediastinum, 53 
 Menstruatioh, 48 
 Motion, organs of, 28 
 Myalgias or muscular pains, 124, 
 
 128, 129 
 Myelogenous leuksemia, 306 
 
 Nephritis, 284 
 
 Neuralgias, 67, 97, 100, 107, 110 
 New growths, cystic, 65 
 Nocturnal pains, 73 
 
 Obstruction, intestinal, 273 
 
 Occipital region, 104 
 
 CEsophagus, 54 
 
 Osteomalacia, 136 
 
 Ostalgias or bone pains, 131, 139 
 
 Pain, sensation of, 15-21 
 
 of colic, 71 
 Pancreas, 268, 274 
 Percussion, 34 
 Peripheral vessels, 345 
 Perivesical inflammations, 302 
 Pleura, 314, 321 
 Pleural pain, 316 
 
 Pneumonia, 322 
 
 Position, 24, 58, 80 
 
 Pressure, 32, 280 
 
 Pyelitis, 298 
 
 Pyloric stenosis, colic of, 175 
 
 Renal infarct, 281, 284 
 Respiration, 49 
 Retrosternal region, 53 ■ 
 
 Scapula, and intrascapular region, 
 
 54 
 Shoulder, 51 
 
 Spasm in bile-passages and gall- 
 bladder, 233 
 
 of the urogenital tract, 291 
 Spleen, 306 
 
 Stenotic processes, 291 
 Stomach, 54 
 
 and intestine, 90 
 Suppurative processes, 31 
 
 True kidney pains, 277 
 Tuberculosis of the kidney, 287 
 
 Ulcer, duodenal, 248 
 
 gastric, 154 
 Ulceration, gastric and duodenal, 
 42 
 
 intestinal, 197 
 
 tuberculous intestinal, 186 
 Uremia, 85 
 Urinary bladder, 302 
 Urination, 282 
 
 Vagus, 113 
 Valves, aortic, 342 
 Visceral disease, 350-356 
 Vomiting, 47