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SYMPTO^ilS 
 
 AND THEIR INTEHPRETATION 
 
TO THE 
 MEMORY OP MY TEACHER 
 
 Professor W. R. SANDERS. 
 
SYMPTOMS AND THEIR 
 INTERPRETATION 
 
 BY 
 
 James Mackenzie, M.D.,LL.D. [Aber.-i-^Edin.} 
 
 Ledurer on Cardiac Research. London Hospital ; Physician to the Mount Vernon Hospital ; 
 Consulting Physician to theVidoria Hospital. Burnley 
 
 [third edition} 
 
 NEW YORK 
 
 PAUL B. HOEBER 
 
 I9I8 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 
 Open Knowledge Commons 
 
 
 \':D\'^ 
 
 http://www.archive.org/details/symptomstheirintOOmack 
 
PREFACE 
 TO THE THIRD EDITION. 
 
 TN this, the third edition of Symptoms and 
 -"^ their Interpretation, in addition to a number 
 of emendations in the text, I have added 
 two appendices. One of them, a summary of 
 Mr. Ligat's investigations, is intended to demon- 
 strate what a great field of research Hes ready to 
 the hand of the surgeon, and what an impetus 
 could be given to medical knowledge if the surgeon 
 would use his opportunities. 
 
 I am often asked for suggestions by willing 
 workers as to what field of medicine thej^ should 
 investigate. I give in the second appendix some 
 suggestions, which are the outcome of my experience, 
 and which some may find of use. 
 
 J. M. 
 
PREFACE 
 
 TO THE SECOND EDITION. 
 
 THE exhaustion of the first edition of this work 
 and its translation into other languages has 
 shown an appreciation which I did not anticipate. 
 It has been gratifying to find so much interest evoked 
 by the method of examination described in this book. 
 Numerous members of the profession have testified to 
 me the real help they have obtained in examining 
 patients on the lines here laid down. 
 
 Several writers have criticised the view of 
 visceral pain set forth in this book, but it is evident 
 that some of them have not grasped my meaning, 
 nor sought in individual instances for the pheno- 
 mena which are necessary for the determination of 
 the question. Some physiologists have imagined that 
 they have demonstrated the sensitivity of the viscera, 
 when evident distress has been caused in an animal 
 by injury to a viscus. In making such a claim, they 
 only prove that with an adequate stimulus suffering 
 may be caused, but, of necessity, they cannot from an 
 animal acquire the knowledge of the plienomena 
 which determine the mechanism by which the animal 
 became conscious of its suffering, for such phenomena, 
 as the spread of pain and hyperalgesia, are incapable 
 of recognition in the dumb animal. 
 
viii. Preface. 
 
 Other adverse critics who have studied the sub- 
 ject chnically have practically ignored the essential 
 phenomena associated with visceral pain. In many 
 cases it is not possible to prove or disprove this view 
 in the absence of these confirmatory evidences, but 
 by the careful and continuous observation of cases 
 with visceral pain, unquestionable e\'idence will be 
 forthcoming. 
 
 In preparing this edition, I gratefully acknow- 
 ledge the help and criticism given me by Professor 
 
 David Waterston. 
 
 J. M. 
 
 133, Harley Street, 
 
 London, W. 
 
PREFACE. 
 
 IN the following pages I draw attention to the 
 valuable aid to diagnosis afforded by the 
 careful study of pain, and the nervous phe- 
 nomena which accompany it. The recognition of 
 these nervous phenomena provides the means for 
 ascertaining how many of the symptoms of disease 
 are produced. Although much has been done to elicit 
 the more obscure symptoms that arise from dis- 
 ordered functions of diseased viscera, comparatively 
 little attention has been paid to the more obvious 
 symptoms. While I am far from decrying the 
 importance of the advances that have been made 
 in what may be called the laboratory methods of 
 clinical diagnosis, yet the practical value of these 
 methods to the general practitioner is very small 
 compared to the information to be gained by the 
 recognition of the symptoms arising from reflex 
 stimulation of the nervous sj^stem. It is only in a 
 small proportion of the cases which the general prac- 
 titioner sees that the more intricate methods of 
 examination are of use, or are available, while in the 
 great majority of cases the reflex symptoms lie ready 
 to his liand, and it is on these alone he has often to 
 rely for diagnosis and treatment. It must be borne in 
 mind that the general practitioner sees a vast 
 number of cases wliicli are never met witli in hospital 
 
X. Preface. 
 
 wards. Text-books are too often written from 
 the standpoint of an experience gained in the 
 hospital or consulting room ; their authors necessarily 
 see the more advanced cases, and do not realise 
 sufficiently the class of patient which the general 
 practitioner has daily to treat. The earty stages of 
 disease are, therefore, not fully appreciated, and 
 can never be fully appreciated till the general 
 practitioner takes his position as an investigator. 
 I hope to show in the following pages that there 
 is not onl}^ a wide field open to him for exploration 
 that can be accomplished b}^ simple practical 
 methods, but that the results that await his 
 investigation are equal in importance to those 
 acquired by the more recondite methods used in 
 well-equipped hospital wards or laboratories. No 
 one has such opportunities for the observance of 
 the earty symptoms in disease, and no one can 
 so readily follow the changes that occur in the 
 advance of disease. The nature of the early symp- 
 toms and the prognosis of disease are amongst the 
 least understood matters in medicine. 
 
 The views put forth here are the outcome of 
 an inquiry that has extended over twent}^ years. I 
 have endeavoured to utilise the opportunities of a 
 general practitioner to study the earliest symptoms 
 of disease and the bearing of the disease upon the 
 patient's future life in times of suffering and of 
 stress, as when affected by other illnesses, by 
 pregnancy, or by hard bodily labour. A great deal of 
 preparatory work had to be done to find out what 
 S}'mptoms were serviceable, and to understand the 
 meaning and mechanism of these symptoms. In 
 this work symptoms that had been overlooked or 
 
Preface. xi. 
 
 ignored have received special attention, and the 
 study of some of them has given a clearer conception 
 of the nature of many phenomena. 
 
 In dealing with the reflex phenomena of disease, 
 as a basis on which to found a rational principle of 
 diagnosis, I have limited niA^self chiefly to explaining 
 the nature of these reflex phenomena, passing over 
 more cursorily the symptoms that arise from changes 
 in function or in the structure of organs as revealed 
 by physical signs, since these are dealt with more or 
 less fully in every book on diagnosis. I mention 
 this lest it might be inferred from the scant reference 
 to these symptoms that I held them of small 
 importance. 
 
 After setting forth the principles on which diag- 
 nosis should be based, I give illustrative exam.ples 
 in the application of this doctrine to diseases of 
 certain viscera. The description of the symptoms 
 present in the affection of any organ does not 
 profess to be complete — it would have led me 
 too far afield to have attempted a complete 
 description — and an outline only is given of 
 the manner in which the symptoms arise, and the 
 nature of these symptoms. I have been able to work 
 out the symptoms in detail in only a few organs, as 
 the heart and stomach, and even all the symptoms 
 in these are not fully comprehended. The symptoms 
 in heart affections afford good opportunities for 
 detecting the real nature of the reflex phenoniena, on 
 account of the peculiar fiekl in whicli the symptoms 
 appear, and the ease with which the heart's action 
 can be studied. As the production of the reflex 
 ])henomena are fundamentally the same in all viscera, 
 1 have frequently used tlie symptoms in heart 
 
xii. Preface. 
 
 affections to illustrate the principles underlying the 
 S3'mptoms in disease of other organs. 
 
 It is hoped that not only the general practi- 
 tioner, but also the surgeon and physician, will find 
 the methods here described of use. Our present 
 diagnostic powers, in regard to abdominal affections 
 for instance, stand sadly in need of strengthening. 
 It is a matter of common experience to find skilled 
 surgeons, who are daily operating on abdominal 
 organs, giving widely divergent opinions as to the 
 nature of the complaint in some single individual. 
 In a measure the ease and supposed safety with 
 which an abdominal exploration can be performed 
 has thrown back the need of a careful and pains- 
 taking examination into the nature of the symptoms, 
 so that much confusion exists in regard to the nature 
 and origin of many easily recognised phenomena. 
 This confusion is, in a great measure, due to the fact 
 that the reflex phenomena of visceral disease have 
 not been sufficiently appreciated. The description 
 given in this book is not a solution, but an attempt 
 to bring forward the means of arriving at a solution. 
 
 It may be said that I have not sufficiently 
 recognised the work done hj other observers in this 
 field. While I have in the main followed my own 
 line of observation, I acknowledge the many valuable 
 suggestions I have obtained from the writings of 
 Hilton, Ross, Head, Maylard, Moynihan, Keaj^ 
 Lennander, Ramstrom, and others. I have also to 
 express my indebtedness for advice and help from 
 my friends Sir Clifford Allbutt, Professor Cushny, 
 
 Dr. Purves Stewart, and Dr. John Muir. 
 
 J. M. 
 
 ■ 133, Harley Street, 
 
 London, W. 
 
( xiii. ) 
 
 CONTENTS. 
 
 Chapter I. Pages 1 — 16. 
 
 Introduction. 
 
 1. Medicine a science. 2. Accuracy of observation. 
 3. Method of observation. 4. The vahie of a hypothesis. 5. The 
 parsimony of hypotheses. 6. Nomenclature. 
 
 Chapter II. Pages 17 — 23. 
 
 Classification of the Symptoms of Disease. 
 
 7. Reflex symptoms. 8. Purpose of reflex symptoms. 
 9. Functional symptoms. 10. Structural symptoms revealed by 
 physical signs. 11. The relative importance of symptoms. 
 
 Chapter III. Pages 24—31. 
 
 Pain. 
 
 12. Definition of pain. 13. Constitution of the nervous 
 
 system. 14. The sensitiveness of tissues to painful stimuli. 
 
 15. Mechanism by which pain is produced. 16. Radiation of 
 
 pain. 
 
 Chapter IV. Pages 32 — 53. 
 
 Visceral Pain. 
 
 17. The function of afferent sympathetic nerve fibres. 
 18. Insensitiveness of the viscera to stimulation. 19. Sensitive 
 tissues of the external body wall. 20. Testicular pain. 
 21. Artificial production of visceral pain. 22. Relationship of 
 the site of pain to the site of the lesion, 23. Mechanism by which 
 paui is produced in visceral disease. 24. Referred pain. 
 25. Radiation of visceral pain. 26. Pain the only sensory reflex 
 in visceral disease. 27. Lennander's observations. 
 
xiv. Contents. 
 
 Chapter V. Pages 54 — 62. 
 Visceral Pain {continued). 
 
 28. Objections to the referred nature of visceral pain. 
 
 Chapter VI. Pages 63—70. 
 Increased sensibility of the external body wall. 
 
 29. Hyperalgesia. 30. Cutaneous hyperalgesia. 31. Mus- 
 cular hyperalgesia. 32. Hyperalgesia of other structures. 
 33. Effect of exercise on hyperalgesic muscles. 34. The areas of 
 cutaneous hyperalgesia. 35. The areas of muscular hyperalgesia. 
 36. Tender vertebrae. 
 
 Chapter VII. Pages 71 — 77. 
 
 The Viscero-motor Reflex. 
 
 37. Definition. 38. Effects of stimulation of motor nerves 
 on limb muscles and on flat abdominal muscles. 39. Character 
 of the viscero-motor contraction. 40. Conditions causing the 
 viscero-motor reflex. 41. Experimental production of the 
 viscero-motor reflex. 
 
 Chapter VIII. Pages 78—83. 
 
 Organic Reflexes. 
 
 42. Vomiting. 43. Dyspnoea. 44. Secretory reflexes. 
 
 45. Cardiac reflexes. 46. Vaso-motor and pilo-motor reflexes. 
 
 Chapter IX. Pages 84—98. 
 
 Laws determining the nature of the Reflex Symptoms. 
 
 47. Mechanism of the production of " direct pain " and 
 
 " referred pain." 48. The viscero-motor reflex. 49. The 
 
 organic reflexes. 50. Irritable foci in the spinal cord. 
 
 51. Exaggerated reflexes due to irritable foci in the cord. 
 
 52. Relation of visceral lesion to site of reflex. 
 
Contents. xv. 
 
 Chapter X. Pages 99—108. 
 
 Preliminary Examination of the Patient. 
 
 53. The patient's appearance. 54. The patient's sensations. 
 55. Facial aspect. 56. The general condition. 57. A review 
 of all the organs. 
 
 Chapter XI. Pages 109—114. 
 
 Symptoms of Affections in the region of Distribution of 
 Cerebrospinal Nerves. 
 
 58. Headache. 59. Sensory and motor symptoms. 60. Dif- 
 ferential diagnosis. 
 
 Chapter XII. Pages 115—130. 
 
 Affections of the Digestive Organs. 
 
 61. The nerve supply of the digestive tract. 62. Distri- 
 bution of sensory symptoms in affections of the digestive tract. 
 63. Appetite. 64. Hunger. 65. Nausea. 66. Mouth and 
 fauces. 67. Tongue. 68. Swallowing. 69. (Esophagus. 
 
 Chapter XIII. Pages 131—155. 
 
 Affections of the Digestive Organs {continued). 
 The Stomach. 
 
 70. The nature of the symptoms. 71. Nerve supply of 
 the stomach. 72. The site of pain in affections of the stomach. 
 73. The character of the pain and its relation to the ingestion of 
 food. 74. Hyperalgesia. 75. Superficial reflexes. 76. Viscero- 
 motor reflexes. 77. Vomiting. 78. Pyrosis and heart-burn. 
 79. Air suction. 80. Functional symptoms. 81. Structural 
 symptoms. 82. The diagnosis of stomach affections. 83. Pain 
 in gastric ulcer. 
 
xvi. Contents. 
 
 Chapter XIV. Pages 156—166. 
 
 The Liver, Gall-bladder, and Ducts. 
 
 84. Nerve supply. 85. Keflex symptoms iu gall-stone 
 disease. 86. Gastric symptoms in gall-stone disease. 87. The 
 result of reflex symptoms. 88. Functional symptoms in gall- 
 stone disease. 89. Structural symptoms in gall-stone disease. 
 90. Fever in gall-stone disease. 91. Nature of reflex symptoms 
 in affections of the liver. 92. Functional symptoms in affections 
 of the liver. 93. Structural symptoms in affections of the liver. 
 
 Chapter XV. Pages 167—177. 
 
 The Great and Small Intestine. 
 
 94. Difficulties in diagnosis. 95. Pain. 96. Appendicitis. 
 97. Affections about the anus and perineum. 98. Perineal reflex. 
 99. Functional symptoms. 100. Structural symptoms. 
 
 Chapter XVI. Pages 178 — 192. 
 
 Affections of the Urinary System. 
 
 101. Symptoms of affections of the kidney. 102. Symptoms 
 of affections of the pelvis of the kidney and ureter. 
 103. Symptoms of affections of the bladder. 
 
 Chapter XVII. Pages 193—197. 
 
 Affections of Female Pelvic Organs. 
 104. The uterus. 105. The ovaries. 106. The vagina. 
 
 Chapter XVIII. Pages 198—203. 
 
 Peritonitis and Peritoneal Adhesions. 
 
 107. Insensitiveness of the peritoneum. 108. Symptoms 
 in peritonitis. 109. Symptoms in peritoneal adhesions (parietal). 
 110. Symptoms in peritoneal adhesions (visceral). 
 
Contents. xvii. 
 
 Chapter XIX. Pages 204—218. 
 
 Affections of the Lungs and Pleura. 
 
 111. Nature of the subjective sensations. 112. The respira- 
 tion. 113. Reflex symptoms. 114. Functional symptoms. 
 115. Structural symptoms. 116. Affections of the pleura, 
 117. Nature of the pain in pleurisy. 
 
 Chapter XX. Pages 219—250. 
 
 Affections of the Circulatory System. 
 
 118. Heart failure. 119. The nature of the symptoms in 
 heart failure. 120. Consciousness of the heart's action. 
 121. Breathlessness. 122. Viscero-sensory and viscero-motor 
 reflexes. 123. The viscero-sensory reflexes in dilatation of the 
 heart and liver. 124. The pain of angina pectoris is a 
 viscero-sensory reflex. 125. Evidences of the viscero-motor 
 reflex. 126. Organic reflexes. 127. Summation of stimuli 
 the cause of angina pectoris. 
 
 Chapter XXI. Pages 251—268. 
 
 Estimation of the Value of Symptoms. 
 
 128. The relation of the symptoms to the general state. 
 129. Remote effects of the lesion. 130. Relation of symptoms 
 arising from different causes. 131. The bearing of symptoms 
 on prognosis. 132. The bearing of symptoms on treatment. 
 
 APPENDICES. 
 
 Appendix I. Page 269. 
 Mr. Ligat on Hyperalgesia in Abdominal Muscles. 
 
 Appendix II. Page 273. 
 Clinical Investigation. 
 
( xix. 
 
 LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. L Diagram of the origin and distribution of the efferent 
 
 autonomic nervo fibres ..... 27 
 
 Fig. 2. Shows the vertebrae that may become tender in 
 
 affections of the heart, stomach, liver, &c. - 69 
 
 Fig. 3. Diagram showing the mechanism by which pain and 
 
 the superficial reflexes are produced - - ' - 86 
 
 Fig. 4. Diagram showing the mechanism by which pain, the 
 viscero-sensory reflexes, the viscero-motor reflexes, 
 and the organic reflexes are produced in visceral 
 disease .... ... 87 
 
 Fig. 5. Diagram "of a primitive vertebrate - - - - 94 
 
 Fig. C. Shows the areas of i)ain and hyi)eralgesia in angina 
 
 pectoris ........ <jo 
 
 Fig. 7. Shows the area of eruption in a case of herpes zoster 
 
 affecting the upjier thoracic nerves ■ - - 97 
 
 Fig. 8. Shows the areas in which pain is folt in affections of the 
 
 digestive tube - • - - - - -117 
 
 l'"i(i. 9. Shows the seat oi pain, and the position of the gastric 
 
 ulcer causing the pain - - - - - -].")(» 
 
 Fig. 10. Shows the seat of pain, and the position of the gastric 
 
 ulcer causing the pain - - • - • !r)2 
 
 Fig. 11. Shows the seat of pain, and tlin position of the gastric 
 
 ulcer causing the pain .... 154 
 
XX. List of Illustrations. 
 
 PAGE. 
 
 Fig. 12. Shows the region of cutaneous hyperalgesia after an 
 
 attack of gall-stone colic - - - - 158 
 
 Fig. 13. Shows the region of cutaneous hyperalgesia after an 
 
 attack of renal colic - - - - - - 183 
 
 Fig. 14. Shows the region of cutaneous hyperalgesia after an 
 
 attack of renal colic - - - - - - 187 
 
 Fig. 15. Shows areas of pain and hyperalgesia in diaphragm- 
 atic pleurisy - - - - - - - - 216 
 
 Fig. 16. Shows areas of cutaneous hyperalgesia in acute dilata- 
 tion of the heart and liver ..... 234 
 
 Fig. 17. Shows the area of cutaneous hyperalgesia after the 
 
 first attack of angina pectoris .... 238 
 
 Fig. 18. Shows the areas of cutaneous hyperalgesia after a 
 
 number of attacks of angina pectoris - - - 238 
 
 Fig 19. Diagrammatic illustration of the hyperalgesia points, with 
 
 typical spread - - - - - - - 271 
 
Chapter I. 
 
 INTRODUCTION. 
 
 1. Medicine a Science. 
 
 2. Accuracy of Observation. 
 
 3. Method of Observation. 
 
 4. The Value of a Hypothesis. 
 
 5. The Parsimony of Hypotheses. 
 
 6. Nomenclature. 
 
 1. Medicine a Science. — Medicine has not 
 attained that position in science which ought of right 
 to belong to lier. Instead of leading in scientific 
 development, and giving guides and indications to 
 allied branches, she is too often content languidly to 
 follow in their wake, or to pursue some erratic course 
 of her own. The observations made in her name are 
 frequently made more to support some vague specu- 
 lation or far-fetched theory than to realise the actual 
 condition of the observed phenomena. The sister 
 sciences in place of seeking for assistance from 
 medicine look askance at the wild speculations put 
 forth in the name of medical science, and at the loose 
 tliiiiking and play of the imagination which many 
 medical writers deem legitimate in deahng with tlio 
 phenomena of disease. To emancipate medicine from 
 this position of inferiority, and to secure for it that 
 
 B 
 
2 Chapter I. 
 
 status which it ought to possess, an effort must be 
 made, as far as possible, to free it from the habih- 
 ments that have hampered it in the past, and if this 
 appears an unattainable goal at present, its votaries 
 may at least aim at greater precision in thought and 
 in observation. Although this doctrine m.a.y seem the 
 commonest of platitudes, and teachers and writers of 
 text-books are unwearied in inculcating it, neverthe- 
 less precision in thinking and in observation are 
 among the rarest qualities. 
 
 2. Accuracy of Observation. — The power of 
 accurate observation and precise thinking is seldom 
 acquired, because methods have become so stereo- 
 typed that many observers do not realise that they 
 are fettered in the bonds of tradition. Even in the 
 writings of those who claim to be exponents of exact 
 observation and logical reasoning, loose methods of 
 thinking and observing too often appear, even when 
 the scientist imagines himself supreme, for tradi- 
 tional teaching influences their minds and gives a 
 bias to their deductions. What are called observa- 
 tions are often but a mixture of imperfect 
 observation and unwarranted assumption. While a 
 fact is supposed to be recorded, an opinion is at the 
 same time expressed. As an illustration let us 
 observe how the sj^mptoms of a patient with an 
 enlarged liver are often investigated. The position 
 of the liver having been ascertained, pressure over it 
 is found to elicit pain. The surgeon or physician 
 proceeds to record the " fact " that the " liver is 
 painful on pressure," and such a description is 
 universally accepted as truthful. Yet, if the matter 
 be carefully analysed, the statement will appear not 
 to be a fact at all. Had the statement been that the 
 
Introduction. 3 
 
 patient felt pain when pressure was made over the 
 Hver, then a plain fact might have been recorded, if 
 the patient's testimony was reliable. But to say that 
 the " liver was painful " is to make an assertion that 
 may or may not be true, but which is not warranted 
 by the evidence, seeing that pressure was being 
 exerted on the sensitive structures of the external 
 body wall, and no attempt was made to eliminate the 
 possibility of the painful sensation being produced 
 by their stimulation. This tendency to embody war- 
 ranted or unwarranted assertions in the record of a 
 fact is a fault common among medical investigators, 
 and impedes the progress of medicine. An inquirer 
 should keep his mind free from bias and ready to 
 review his most cherished beliefs. What is to-day 
 accepted as axiomatic, may be shown to-morrow to be 
 but a part of the truth. The tendency to be led by 
 tradition is very powerful, and it is difficult to free 
 the mind from beliefs that have been inculcated with 
 the acquiring of knowledge. In consequence of this 
 many observations are fundamentally untrue, and 
 only covered by a veneer of science. I shall have 
 occasion to enter into some detail concerning the 
 relation of pain to the viscera, and this inquiiy will 
 reveal that the conception universally prevalent with 
 regard to the S3^mptom is based on tradition and 
 imperfect observation. So much lias been taken for 
 granted that the very first step in the examination is 
 often a wrong one. " What do you complain of ? " 
 asks the physician. " Pain in my stomach," replies 
 the patient, and the physician too often accepts the 
 statement and records that the patient's pain is in 
 the stomach. The patient having some notion of the 
 situation of the stomach, and finding the pain is in 
 
4 Chapter I. 
 
 this neighbourhood, assumes the stomach to be the 
 seat of the pain, and thus, at the very beginning, an 
 erroneous notion is obtained which may pervert the 
 further steps of the examination. The unproved 
 assumption that the mechanism by which visceral 
 pain is produced is similar to that producing pain in 
 the external body wall has led astray physiologists 
 as well as clinical observers. It is assumed that 
 stimuli which produce pain when applied to the 
 external body wall, will likewise produce pain when 
 applied to the viscera. It is recognised that certain 
 nerves running from the skin to the central nervous 
 system convey sensation, and are therefore called 
 " sensor}^" From this it has been assumed that nerves 
 proceeding from the viscera to the spinal cord have 
 the same function. They are, therefore, also called 
 " sensory," whereas, as a matter of fact, there is not 
 a single observation or experiment justifying such 
 an assumption. Though this is the interpretation 
 usually attached to the term " sensory," physiologists 
 do not now consider that a " sensory " nerve neces- 
 sarily evokes sensation when stimulated, but use the 
 term to imply an " afferent " nerve whatever its 
 function may be. 
 
 When making an observation upon any symptom 
 care should be taken to record nothing beyond what, 
 strictly speaking, the facts warrant. If our know- 
 ledge tells us that an organ is situated in the neigh- 
 bourhood of the area in which a pain is felt, we 
 should not assert the connection between the pain 
 and the organ until we have sufficient evidence of the 
 nature of such connection. The search for such 
 relations Avill reveal things unsuspected. I may here 
 cite an experience which occurred to me many years 
 
Introduction. 5 
 
 ago. A colleague was denaonstrating to me the symp- 
 toms ill a case of gastric ulcer. The pain was located 
 in a small area in the epigastrium, which, the patient 
 said, could be covered with the point of a finger. 
 M}^ friend, commenting on this exact reference to a 
 limited area, asserted that the pain was felt in the 
 ulcer, and were he to push a long pin through this 
 painful site it would inevitably penetrate the ulcer. 
 I demurred to this, remarking that the evidence did 
 not warrant such a conclusion, that though the pain 
 might be due to the ulcer, the assumption that the 
 pain was felt in the ulcer, and that it could be so 
 definitely localised, was not justified. To demon- 
 strate this I asked the patient to expire deeply, then 
 to draw a deep inspiration. By this procedure 
 the stomach and its ulcer executed an excursion of a 
 considerable extent. But, though the stomach and 
 ulcer moved, the site of the pain remained stationary. 
 From this observation it could be concluded that the 
 relation between the ulcer and the pain was not of 
 the kind usually assumed. The inquiry into the 
 nature of their relations has revealed some very 
 instructive features, which will be dealt with in 
 speaking of the mechanism of pain and the symptoms 
 evoked by gastric ulcer. The necessity for this warn- 
 ing is illustrated by the remarks of observers who 
 iiave been testing the sensibility of the alimen- 
 tary canal. Where they have succeeded in provoking 
 a sensation by stimulating some portion of the 
 digestive tract, they have neglected some essential 
 features, such as the exact situation of the region in 
 which the sensation was felt, or the manner in wliicli 
 it has spread, and have liastily assumed tliat the part 
 stimulated possesses the sensation whicli has been 
 
6 Chapter I. 
 
 evoked. How this assumption misleads will be 
 sliOAvn when I deal with the mechanism by which 
 sensations are produced. 
 
 3. Method of Observation. — If the nature of 
 any symptom is not apparent, all the attendant cir- 
 cumstances and accompanjdng phenomena should be 
 the more carefully considered. The nature of many 
 a striking phenomenon may remain inexplicable 
 until its association with some remote, or trivial, or 
 transient, but better understood sjanptom reveals its 
 true nature. This method is in frequent use, as for 
 instance, when a severe headache or retinal haemor- 
 rhage directs our attention to the state of the kidneys 
 or a pain at the knee leads us to inquire into the 
 condition of the hip joint. The recognition of the 
 relations of symptoms so widely separated has been 
 acquired by the observation of a sufhciently large 
 number of instances of this continual association. 
 The occurrence of one symptom of a group now 
 leads to the inquiry for the other symptoms that may 
 be associated with it, and from the experience thus 
 acquired a better view is obtained of the diagnostic 
 significance of particular symptoms. When I come 
 to deal with the reflex symptoms of visceral disease 
 it will be shown that, in many cases, phenomena 
 appearing at a distance from the causative lesion 
 give the best clue to the seat of the disease ; while 
 the inquiry into the nature of the symptoms throws 
 a flood of light upon the physiological relation of 
 different organs. 
 
 4. The Value of a Hypothesis. — An inquirer 
 into the symptoms of disease will in course of time 
 accumulate a large number of more or less isolated 
 facts. Though these may be provisionally employed 
 
Introduction. 7 
 
 in the diagnosis of disease, the observer may have no 
 clear idea of their significance, nor of the process by 
 which they are produced. Accordingly, we often find 
 the symptoms of some given disease presented in the 
 form of more or less detached pieces of evidence. 
 The value of such indicative symptoms will be greatly 
 enhanced if in all cases an attempt be made to detect 
 the mechanism of their production, and to correlate 
 them with the diseased process and with one another. 
 To this end it is necessary to construct a provisional 
 hypothesis. 
 
 Symptoms, in respect of concepts, are like the 
 materials used in the construction of an edifice. We 
 may know that detached they can be used to build a 
 house, but their relative values and uses are realised 
 only as we find we can work them into the edifice. 
 It is when the symptoms are logically included in a 
 hypothesis that we clearly ascertain their origin and 
 relative values. But the construction of a h^^pothesis 
 serves a useful purpose in many ways beyond giving 
 an approximate conception of the disease. It stimu- 
 lates the search for proofs, and gives a line to follow 
 in the search. The progress of clinical medicine is 
 comparatively slow, in great measure because no 
 attempt is made to give a clear conception of the 
 mechanism of disease. This has largely come about 
 because the observer does not trouble himself to 
 reason out the relations of the symptoms to one 
 another, and to the morbid process as a whole, 
 relations which can alone be ascertained by forming a 
 liypothesis in regard to their association. In the 
 attempt to substantiate the hypothesis definite lines 
 for investigation will arise. The vakie of a working 
 hypothesis is that it affords a guide and a line of 
 
8 Chapter I. 
 
 observation. Defective, or false, or useless, as 
 eventual^ it may prove to be, yet it is of advantage 
 in, as a step, directing our attention to the relation 
 of sjmiptoms, and the need for a better interpretation 
 of them. The facts that belie a hypothesis have 
 been appropriateh' used in building a better one. 
 The atomic theory is now found insufficient to 
 explain the newer revelations of science, but 
 its adoption has proved of immense service 
 in giving a definite line for the prosecution 
 of investigations and in the discovery of those 
 new facts that have led to its modification. 
 In matters more closely concerning the subject in 
 hand we have plenty of illustrations. When Ross 
 drew attention to the nature of sensory disorders 
 in visceral disease he propounded the hypothesis 
 that visceral pain was of two kinds, one he called 
 " splanchnic," because he assumed that it was 
 referred by the brain to the site of the lesion in the 
 organ, the other he called somatic, because it was 
 referred to definite areas in the external body wall. 
 This hypothesis is the one held to-day by practically 
 all those who have given attention to the matter ; and 
 it has been of no little use in diagnosis. In my own 
 work it influenced me very considerably. At the time 
 Ross propounded this opinion I was inquiring into 
 the sensor}^ phenomena of visceral disease, but was 
 like a ship at sea without compass, I had no definite 
 guide to follow. Then, with this hypothesis before 
 me, I proceeded to inquire into the facts concerning 
 a " splanchnic " pain. The question of the sensitive- 
 ness of the viscera arose, of the function of the nerves 
 supplying them, and of the relation of the site of the 
 pain to the lesion. This inquiry brought to light 
 
Introduction. 9 
 
 mam' other important symptoms, which either had 
 not been recognised, or whose significance had not 
 been appreciated, such as the accompanjdng hyperal- 
 gesia of the tissues of the external body wall, and the 
 contractions of muscles, all having a definite relation- 
 ship to the viscera affected by means of their nervous 
 connection. These results, though demonstrating 
 that Ross' hypothesis was no longer tenable, were 
 brought to light by means of his hypothesis. Thus, 
 by suggesting a line of inquiry a hypothesis may 
 bring many obscure S3'mptoms to light. In investi- 
 gating the manner in which sensation is produced by 
 the viscera, I found that to a great extent they were 
 not susceptible to stimuli in the same manner as is 
 the skin. Thus, under certain circumstances, the 
 ingestion of cold water into the stomach is followed 
 by a sensation of cold felt in the abdomen, descending 
 as low as the umbilicus. We usually explain this by 
 saying that the stomach is sensitive to a cold 
 stimulus. RiBcognising that it was strange that cold 
 should be a sensation of which the stomach was 
 capable, I made a series of observations that showed 
 the cold sensation was in all probability due to a 
 contraction of the cutaneous blood vessels, and was 
 associated with the goose-skin eruption. Further, 
 the evidence pointed to the fact that the so-called 
 goose-skin sensation was coincident with a constric- 
 tion of the cutaneous blood vessels, and this constric- 
 tion might possibly be the cause of this sensation. 1 
 do not quote this observation as if it settled the 
 question of the sensibility of the stomach to cold, but 
 rather to show the complexity of results from a single 
 e xperiineiit. Hertz, in liis Goulstonian Lectures on 
 the sensibilitv of the alimentarv canal, contests this 
 
10 Chapter I. 
 
 observation, and reckons to disprove it, but while I 
 am far from believing that m}^ explanation is beyond 
 question, I do not accept Hertz's contradiction, for the 
 reason that he has not considered the peculiar nature 
 of the " cold " sensation, and has ignored the very 
 instructive manner in which the sensation spreads. 
 
 Whether this explanation be the correct one or 
 not, the attempt to prove the hypothesis led to the 
 discovery of other facts hitherto unsuspected, which, 
 trivial as they may appear, point nevertheless to 
 some fundamental relation between the viscera and 
 the external bod}^ wall whose significance cannot yet 
 be fully understood. 
 
 A hypothesis based on clinical evidence may 
 serve as a guide to physiological inquiry. The hard 
 contracted muscles present in certain abdominal 
 affections have never received the attention they 
 merit. This contraction, as will be shown later, is of 
 a peculiar kind, and may occur in a small portion 
 of the muscle. I had called this contraction the 
 " viscero-motor reflex " on the hypothesis that the 
 nerve supply to certain portions of the muscles bore 
 a definite relation to the nerve supply of certain 
 viscera, so that the stimulation from a viscus would 
 produce contraction of a definite portion of the 
 abdominal musculature. To test this hypothesis 
 Professor Sherrington cut and stimulated the central 
 ends of certain nerves passing to the viscera, and^ 
 in response to such stimulation, found the abdominal 
 muscles contract in a definite manner. The import- 
 ance of this observation will be appreciated later 
 when we deal with the viscero-motor reflex. This 
 was, moreover, the first physiological demonstration 
 of the function of afferent sympathetic nerves. 
 
Introduction. 1 1 
 
 The hypothesis formed by chnical observation 
 may anticipate the result of physiological experi- 
 ment. In 1891, as the result of the stuch^ of certain 
 common irregularities of the heart, I formed the 
 hypothesis that the ventricle contracted at times 
 before, and independently of, the auricular contrac- 
 tion. Subsequently this was demonstrated experi- 
 mentally by Engelmann in the frog's heart, and later 
 by Cushny in the mammalian heart. A hypothesis 
 drawn from clinical experience, though ultimately 
 proved wrong, may stimulate a search which may 
 lead to very important results. Thus in the research 
 just alluded to I found a large and important 
 group of patients in whom all evidences of the auri- 
 cular systole had disappeared, and I speculated for 
 years as to the cause of this disappearance, and built 
 up one hypothesis after another to explain it. When 
 I found for instance at the post-mortem examination 
 that the auricle in these cases was greath^ distended 
 and thin-walled, I put forth the view that the auricle 
 was paralysed. Further investigations to prove this 
 sliowed that the auricles in some cases were hyper- 
 trophied, and I was forced to change my view, for it 
 was evident that if the auricles were hypertrophied, 
 they must have contracted. The cause of the dis- 
 appearance of the auricular activity was the object 
 of research by several investigators, and Lewis finally 
 showed it to be due to fibrillation of the auricle, a 
 condition in which the individual fibres of the 
 auricular wall no longer contract together at regular 
 intervals, but are in incessant movement, so that tlie 
 auricle stands still. The recognition of this clinical 
 condition and its cause is one of the most important 
 discoveries in the clinical pathology of the heart. 
 
12 Chapter I. 
 
 5. The Parsimony of Hypotheses. — In seeking 
 in any given case for the causation of a group of 
 sjauptoms, however far apart they may be in 
 situation, and however diverse in character, it is far 
 more probable that the nexus will be found, not in 
 a diversity of causes producing the symptoms sever- 
 ally, but in some condition capable of producing the 
 group. The application of this method, called by 
 logicians " the law of the parsimony of hypotheses," 
 should be rigidty applied in all cases ; and, although 
 it may not always be successful, the search for a 
 connection between the several phenomena will reveal 
 many facts previously overlooked or neglected, and 
 give a guide to further evidence. A good illustration 
 of the application of this law is seen in the examina- 
 tion of cases with a focal lesion in the brain or spinal 
 cord. Certain lesions of small extent may produce 
 symptoms widely separated, such as paralysis in 
 one part of the body, and sensory disturbances in 
 another, while disturbed functions may be detected 
 in certain viscera. When the nerve supply of these 
 different parts is considered, it will be found that at 
 some point the different tracts lie close together, so 
 that it becomes fairly certain the lesion will be found 
 at this place. The value of this method will be appre- 
 ciated in dealing with visceral disease, where it 
 is shown that a diseased viscus, besides affording 
 evidences of im'paired function and change in form, 
 may also produce an irritation of the spinal cord, 
 resembling in many respects a focal lesion, and 
 inducing widespread symptoms of great diversity. 
 The application of this law becomes a matter of 
 considerable difficulty when the more prominent 
 symptoms are due immediately to one or more organs. 
 
Introduction. 13 
 
 while the remoter causes He hidden in the depraved 
 function of some other less obvious part. Thus, head- 
 ache and convulsions may be the symptoms to arrest 
 attention, but diseased kidneys may be the cause of 
 offence. Though, in this instance, it is not possible 
 for us to trace directly the connection between the 
 symptoms and the organ primarily at fault, never- 
 theless, by the frequent association of these pheno- 
 mena with kidney disease we have discovered at least 
 the nexus. In the same way hypertrophy of the 
 heart, high blood pressure, arterial degeneration, 
 have been found so frequently associated with kidney 
 disease that the primary cause of these affections may 
 be attributable to the reaction of the depraved kidney 
 function, or, again, to some remoter cause lying 
 behind them all. Thus it will be seen that in many 
 instances while the direct relationship of the remoter 
 cause to the symptoms may not be capable of 
 demonstration, the frequent association of symptoms 
 in certain parts with a pre-existing primary 
 lesion in some other part, affords sufficient 
 ground foi' the hypothesis that this pre-existing 
 lesion is an antecedent of the distant con- 
 sequences, 
 
 6. Nomenclature. — In the employment of 
 medical terms there is no system or m.ethod. In 
 dealing with the nomenclature of disease, names are 
 devised anyhow. In certain instances, as peritonitis, 
 endocarditis, gall-stones disease, disease of the mitral 
 valves, the seat of the disease is indicated. In other 
 instances a particular symptom or a group of 
 symptoms is used, such as tachycardia, exophthalmic 
 goitre, angina pectoris ; while in otlier instances 
 again a name derived from an observer wlio described 
 
14 Chapter I. 
 
 the symptoms, such as Bright' s disease, Cheyne- 
 Stokes respiration, Brown-Sequard's paralysis. 
 While such names as these do, perhaps, convey a 
 more or less definite idea of a particular disease, 
 other names are used which may, indeed, designate 
 some fairlj^ definite lesion, but more often cover large 
 numbers of cases supposed to be akin, but of whose 
 nature we are ignorant, such as neurasthenia, 
 rheumatism, neuralgia, gout. On the face of it the 
 ambiguity of these terms is unsatisfactory, but it is 
 difficult to see how it can be altered ; partly because 
 some names by long usage have become fixed ; partly 
 because provisional names must be adopted for 
 groups of symptoms of whose nature we are mean- 
 while imperfectly informed. Even when precision is 
 supposed to be attained, and a name given to the 
 lesion, as endocarditis, peritonitis, neuritis, it may 
 yet happen that the symptoms are not really the 
 outcome of the lesion whose name is employed. Such 
 sj^mptoms as dilatation of the heart, rapid or 
 irregular action, so often attributed to an endocar- 
 ditis, are not evidences of an endocarditis, but of a 
 myocardial affection. In the same way lesions of the 
 myocardium are often ignored if there is a murmur 
 produced at some orifice of the heart. Almost 
 invariably the diagnosis is then based on the noise the 
 heart happens to make, so that we find cases recorded 
 as " mitral disease " when in reality the accom- 
 panying heart failure is due to other conditions. A 
 painful and hard abdominal wall is often taken 
 as evidence of a peritonitis, when no peritonitis 
 exists ; or, again, a persistent pain along the sup- 
 posed course of a nerve with tenderness on pressure, 
 often attributed to neuritis, is not infrequently not 
 
lnt7'oduction. 15 
 
 due to neuritis, but is the reflex phenomenon arising 
 from some diseased viscus. 
 
 The employment of symptomatic names for 
 diseases may find justification in some instances, but 
 may cause confusion in those larval cases which do 
 not happen to present the characteristic symptoms, 
 as, for instance, in the early stage of exophthalmic 
 goitre. But, if justifiable in a few cases, the employ- 
 ment of a symptomatic name, unless very vague, as 
 epilepsy, is very misleading. Although a name 
 ought to be restricted to the one particular ailment, it 
 is too often used loosely to cover the outcome of 
 several widely distinct causes, as gastralgia, tachy- 
 cardia, embryocardia, neuralgia, albuminuria. The 
 results of these incoherent methods of nomenclature 
 are detrimental in several ways. Diseases of. very 
 diverse nature are included under one name. On 
 account of the frailty of the human mind, a certain 
 satisfaction is given when the name of some sonorous- 
 ness is applied to a malady. Mental effort is 
 hard work, and painstaking inquiry into the natiire 
 of symptoms may be shirked by the use of some fine 
 name that seems to embrace the case under considera- 
 tion. Hence it is that the symptoms present in 
 affections like angina pectoris are not generally 
 analysed, while an all-embracing name like neuras- 
 thenia, being turned from a specific to any convenient 
 meaning, serves for the designation of many hetero- 
 geneous and undefined cases. 
 
 There seems to be no logical way of revising 
 our names until the science of diagnosis is farther 
 developed, so that we must fain be content with such 
 names as are at hand. We should, however, recognise 
 and duly appreciate our limits in respect of this 
 
16 Chapter I. 
 
 imperfect and disorderly nomenclature, and con- 
 tinually endeavour to explain the meaning we attach 
 to doubtful names so as to make the use of names 
 as precise as possible, in order that like diseases 
 may be brought together from those unhke, and our 
 classification be based no longer on superficial and 
 accidental resemblances but on deep affinities. 
 
( 17 ) 
 
 Chapter II. 
 
 CLASSIFICATION OF THE SYMPTOMS OF 
 
 DISEASE. 
 
 7. Reflex Symptoms. 
 
 8. Purpose of Reflex Symptoms. 
 
 9. Functional Symptoms. 
 
 10. Structural Symptoms revealed by Physical Signs. 
 
 11. The Relative Importance of Sy7nptoms. 
 
 Disease is manifested by the presence of 
 symptoms, and these can be classified, according to 
 the mechanism of their production, into three 
 groups : — 
 
 Reflex Symptoms. 
 Functional Symptoms. 
 Structural S3'mptoms as revealed by 
 physical signs. 
 
 7. Reflex Symptoms. — In the development of 
 the body, organs are adapted for special purposes, 
 some for the nourishment and maintenance of the 
 economy, others for its protection. Tlie functions of 
 separate organs are pecuUar to them, and one organ 
 cannot take on the function of anotlier. It is neces- 
 sary to keep this distinction in mind in order to 
 appreciate the meaning and mechanism of symptoms. 
 What is called health is tlie harmonious action of 
 all the organs. Ill-health, or disease, is the dis- 
 cordant action of one or more organs. There is a 
 certain sense of " well-being " present in every 
 
 c 
 
18 Chapter II. 
 
 healthy individual. Until the health is impaired one 
 is barely conscious of having possessed it, and its im- 
 pairment is tlie first sign conveyed to the individual 
 that all is not well with him. This first sign is some 
 disagreeable sensation arising from no apparent 
 cause, or brought on by some event that hitherto had 
 caused no discomfort. The disagreeable sensation 
 may var}^ from pain of a severe type to a slight im- 
 pakment of the sense of well-being. It may vary 
 also in character, as pain in its various forms 
 and degrees, breathlessness, vomiting, exhaustion, 
 mental depression and muscular contraction. It will 
 be seen that the production of these symptoms is due 
 to the implication of the nervous sj^stem, and 
 although the possession of consciousness is necessary 
 for the perception of subjective sensa^tions, yet the 
 occurrence of these phenomena imphes the partici- 
 pation of the nervous system in a particular manner. 
 The sensation of pain implies the consciousness to 
 perceive pain as well as the involvement of the 
 special nervous mechanism b}^ which it is produced. 
 This involvement of the nervous system in the pro- 
 duction of symptoms requires special consideration 
 if we desire to understand the true significance and 
 diagnostic importance of symptoms. It is compara- 
 tively rare that the changes in the function of an 
 organ, or in its size, shape and position, lead to the 
 detection of disease in the first instance, whereas the 
 presence of sj^mptoms due to involvement of the 
 nervous S3^stem are the earliest evidences and are 
 nearly always present. As a matter of fact the lay- 
 man knows so little of his anatomy that even a 
 serious anatomical change would often not suggest 
 a consultation with a physician, unless it was 
 
Classification of the Symptoms of Disease. 19 
 
 accompanied by nerve symptoms. While the func- 
 tional disturbance of an organ may interfere with the 
 nutrition of the nervous system and produce nervous 
 symptoms directly, in the vast majority of cases the 
 S}'mptoms are produced by reflex stimulation. 
 Organs that are not themselves sensitive to painful 
 stimuli liave provided in them a mechanism b}^ 
 which they can call into play the parts of the 
 economy that subserve the function of pain, and, 
 therefore, of protection. Thus the bowels themselves 
 are insensitive to pain, but the}^ can cause pain by 
 stimulating the nerves that are distributed to sensi- 
 tive structures. This is brought about by the reflex 
 stimulation in the central nervous system of nerves 
 supplying other tissues. Other reflexes, as muscular 
 contraction and vomiting, have also a protective 
 purpose. 
 
 8. Purpose of Reflex Symptoms. — To gain a 
 clear idea of the mechanism of these reflexes, their 
 purpose and meaning should be understood. To do 
 this I put forward the following hypothesis, which 
 seems to account adequately for their manner of 
 origin, and has much to recommend it from a 
 developmental standpoint. In the early development 
 of animal life a digestive cavity is first evolved, then, 
 later, a rudimentary circulatory system appears. To 
 this is added a rudimentary respiratory system. To 
 co-ordinate these different systems a nervous com- 
 munication is developed. The various organs are 
 protected first by an insensitive and, it niay be, 
 a somewhat unyielding outer covering. As develop- 
 ment proceeds this outer covering becomes modified 
 in such a manner as to provide for both protection 
 and movement, hence arises the sensori-muscular 
 
20 Chapter II. 
 
 s} stem. Protection is secured in a twofold manner, 
 first, by rendering the outer covering sensitive and 
 uniting it with muscles by means of a reflex nervous 
 system. Painful stimuli excite consciousness and the 
 muscles are stimulated to contract, so that the 
 organism, is removed from the offending neighbour- 
 hood, or there is interposed between the viscera and 
 the offending agent a hard resistant muscle. Second, 
 by uniting the nerves from the viscera with sensory 
 and motor nerves of the cerebro-spinal system., so 
 that the m.uscles of the external body wall react to 
 a stimulus from the viscera. From this point of view 
 the primitive nervous system corresponds with the 
 sympathetic, while the more recently developed sen- 
 sori-motor corresponds with the cerebro-spinal ner- 
 vous system.. This finds support in view of the fact 
 that pain is elicited only by stim.ulation of structures 
 supplied by the cerebro-spinal nervous system, while 
 such stimuli as produce pain and other sensations in 
 the skin and structures of the external body wall are 
 inadequate to produce these sensations when applied 
 to tissues supplied by the sympathetic nerves {see 
 page 28). When pain does arise from the viscera it 
 does so by calling into play the cerebro-spinal 
 system, of sensory nerves, and the pain is then 
 referred to regions supplied by the cerebro-spinal 
 system of nerves. 
 
 From this point of view it will be found that 
 the m.ost striking symptoms in disease are produced 
 by reflexes, sensory, m.otor and organic. 
 
 9. Functional Symptoms. — The economy is so 
 arranged that the function of each organ is neces- 
 sary to the due action of the whole. When, there- 
 fore, an organ is not acting efficiently the work of 
 
Classification of the Symptoms of Disease. 21 
 
 all is impaired. As disease modifies the functions 
 of individual organs these modifications become 
 signs or symptoms of disease, hence it is necessary 
 to understand the function of each organ, and the 
 manner in which derangement of function affects the 
 economy as a whole, or its indi\ddual parts. It hap- 
 pens not infrequently that the S3anptoms which direct 
 attention to disease are caused not directly by the 
 organ at fault, but by the effects of its impaired 
 function on parts remote from the offending organ. 
 From this it will be seen that a series of phenomena 
 may arise from disordered functions of an organ, 
 hence the class of " functional symptoms." 
 
 10. Structural Symptoms revealed by Physical 
 Signs. — All the separate organs of the body have 
 a size and situation which experience tells us are 
 normal, and any departure therefrom is presumed 
 to be an evidence of disease ; hence a class of 
 symptoms may arise due to alteration in the size, 
 shape, consistency, or position of an organ. 
 
 Structural symptoms do not arise until the 
 disease has advanced so far as to have modified the 
 organ, either by causing destruction of tissue, 
 or by rephicing its tissue by new formation, or by 
 altering its shape for some cause. These symptoms 
 then are the signs of advanced disease, and often 
 indicate that the disease has advanced to an 
 irremediable si aire. 
 
 11. The Relative Importance of Symptoms.— 
 Disease is seldom revealed by the direi't evidence 
 of modified function, but rather by the effect of 
 depraved or deficient functions in other organs and 
 especially in the central nervous system. W'e are 
 yet very ignorant of the evidence of the functions 
 
22 Chapter II. 
 
 of man}^ organs, particularly those glands which 
 have no specialised outlet. Organs that are special- 
 ised for a particular purpose, as the organs of 
 generation, have other functions which influence 
 growth and nutrition. 
 
 Even when we detect the presence of abnormal 
 functions, it is but rarely that this evidence of 
 derangement is the actual cause of the symptoms. 
 In kidney disease it is not the presence of albumen 
 or the escape of albumen into the urine that is really 
 the serious fault of the function. Albuminuria is 
 merely an abnormal condition which is often asso- 
 ciated with functional changes of such obscurity 
 that we know little about them, but of such potency 
 that we are justified in attributing widespread effects 
 to their presence. In functional derangement of the 
 stomach, though we may detect certain abnormalities 
 in the secretion as an increase in the hydrochloric 
 acid, it is not the acid itself that is the chief symptom, 
 but the pain associated with its presence. It is very 
 doubtful if the secretion of an excess of hydrochloric 
 acid is the real functional derangement, for it may be, 
 like the albumen, only one result of a complicated 
 process. In disease of the digestive apparatus it is 
 not always the disease itself which produces the 
 symptoms, nor the functional disturbance, but the 
 absorption of toxic products. 
 
 From this standpoint the most important class 
 of symptoms arise from the involvement of the 
 nervous system, where a stimulus arising in some 
 viscus passes to the central nervous system, and 
 there acts on the nerves supplying other organs, 
 exciting the function peculiar to them. Thus it is 
 that we find pain, muscular contraction and vomiting 
 
Classification of the Symptoms of Disease. 23 
 
 excited by an organ remote from these evidences of 
 nervous stimulation. These reactions are not the 
 outcome of accidental purposeless stimulation, but 
 are'reflexes arisino; in a very definite manner and with 
 a definite purpose. It is necessary to recognise the 
 purpose of these reflexes as their intelligent appre- 
 ciation leads to the recognition of their cause, 
 whereas to look upon them merely as purposeless 
 evils, and as an indication for something to 
 relieve suffering and discomfort, tends to hamper 
 an opportunity of diagnosis and rational treatment. 
 
 The predominance of the reflex S3"mptoms has 
 never been properly realised, with the result that in 
 the description of physical signs of disease little 
 attention has been paid to these manifestations, and 
 no clear conception has been made of the nature of 
 the symptoms. The small part played by functional 
 and structural signs or symptoms compared with 
 those of a reflex origin will be appreciated if, as an 
 instance, the phenomena of gastric affections be 
 considered. Long before any change can be detected 
 in the function or structure of the organ, the reflex 
 symptoms have been in evidence. It is these 
 symptoms that really call attention to the fact that 
 the stomach is diseased, and the patient may go on 
 for years and ultimateh' die of the stomach com- 
 plaint, and none but the reflex symptoms have been 
 capable of recognition. To a great extent it is 
 towards the relief of the reflex symptoms that every 
 endeavour at treatment is directed. 
 
 In rare cases a physical sign of grave signifi- 
 cance may be detected in the absence of distinctive 
 reflex symptoms. 
 
( 24 ) 
 
 Chapter III. 
 
 PAIN. 
 
 12. Definition of Pain. 
 
 13. Constitution of the Nervous System. 
 
 14. The Sensitiveness of Tissues to Painful Stimuli. 
 
 15. Mechanistn hy which Pain is produced. 
 
 16. Radiation of Pain. 
 
 12. Definition of Pain. — The due recognition 
 of the factors concerned in the production of pain is 
 of the first importance in the study of disease. Not 
 only is pain the most important of complaints, but 
 it is the most instructive diagnostic sign, for the 
 study of its mechanism gives often the key to the 
 best means for attaining rehef. The term " pain " 
 used here is easy to understand though difficult to 
 define. It is beside my purpose to enter into abstruse 
 metaphysical considerations regarding the conscious- 
 ness of pain and its mental affinities. Nor do I 
 include other disagreeable sensations, which are 
 sometimes spoken of as pain, as when a brilliant 
 light or a piercing noise unpleasantly affects the 
 sense of sight or hearing. The term is limited to 
 that very definite form of disagreeable sensation 
 which everyone has experienced, and we all recognise. 
 The meaning attached to the term pain in this book 
 may be summarised shortly as follows : — 
 
Pain. 25 
 
 Pain is a disagreeable sensation due to stimulation 
 of some portion of the cerebro-spinal nervous system 
 and referred to the peripheral distribution of cerebro- 
 spinal sensory nerves in the external body wall. 
 
 13. Constitution of the Nervous System. — The 
 nervous system consists of two great divisions, which 
 are distinctly separated in their functions, viz., the 
 cerebro-spinal and the sympathetic or autonomic. 
 The former of these divisions consists of the brain 
 and spinal cord, and the peripheral nerves which are 
 distributed to the external body wall and subserve 
 the functions of sensation and muscular contraction. 
 Incorporated within the cerebro-spinal system is the 
 other division, the s^'mpathetic or autonomic nervous 
 system, which includes the origin of such nerves as 
 the vagus and the sympathetic. The position and 
 distribution of the efferent fibres of the autonomic 
 s^'stem is shown in Langley's diagram (Fig. 1, page 
 27). It will be seen that this system presides over 
 the functions peculiar to the different organs. While 
 much experimental work has been done to establish 
 the distribution and functions of the nerves that pass 
 from the centres to the periphery (efferent nerves), 
 httle has been done to examine the nerves that pass 
 from tlie viscera to the central nervous system 
 (afferent nerves). The reason for this is that the 
 TUTves passino; from the organs to the nerve centres 
 afford httle direct evidence of their function, and 
 it has not yet been understood in what way these 
 afferent nerves react. In the scheme ]nit fortli 
 liere for tlie production of visceral pain it is 
 suggested that under certain circumstances these 
 afferent nerves of the autonomic system convey 
 a stinuilus to the cerebro-spinal nerves, and 
 
26 Chapter III. 
 
 stimulate them, so that certain phenomena as pain, 
 hyperalgesia, and muscular contraction in the ex- 
 ternal body wall are the evidences of stimulation 
 by the afferent autonomic nerves. 
 
 It is a justifiable inference from clinical 
 evidence that the centres of these sympathetic and 
 cerebro-spinal nerves are in close association. From 
 this association it has been possible to show that the 
 afferent autonomic nerves have a close resemblance 
 in their distribution to the efferent fibres represented 
 in Fig. 1. 
 
 14. The Sensitiveness of Tissues to Painful 
 Stimuli. — To appreciate the distinction between 
 these two divisions of the nervous system, and to 
 understand the mechanism by which pain arises in 
 areas supplied by the cerebro-spinal nerves, and by 
 the autonomic system (visceral pain), it will be 
 advisable to consider the sensibility of the tissues of 
 the human body. 
 
 A great difference will be found in the suscepti- 
 bility of different structures. The sensibility to pain 
 varies widely in different parts of the cutaneous 
 surface. The deeper tissues of the external body 
 wall are also sensitive to pain, and generally in a less 
 degree than that of the skin, but the relative sensi- 
 tiveness of parts is not well understood. When we 
 consider the viscera we meet a totally different state 
 of affairs, for in them the tissues are insensitive ta 
 stimuli that produce pain in the external body 
 wall. To bring this clearly forward, let the reaction 
 of the tissues to some definite form of stimulation, 
 as pinching or pricking with a pin, be considered. 
 There will be found, on a systematic examination, 
 tissues where there is a sense of pain evoked by 
 
Pain, 
 
 27 
 
 Sphincter of iris \ 
 Ciliarv muscle. ) 
 
 Dilator of iris. Orbital muscle 
 Heart. Blood-vessels of mucous 
 
 membrane of head. 
 Walls of gut from mouth to de- 
 scending colon. 
 
 Outgrowths from this region of the 
 gut (muscle of trachea and 
 lungs ; gastric glands, liver, 
 pancreas). 
 
 The skin (arteries, muscles, glands). 
 
 Blood-vessels of gut betwean 
 mouth and rectum, of lungs 
 and of abdominal viscera. 
 
 Arteries of skeletal muscle. 
 
 Muscle of spleen, ureter, and of 
 internal generative organs. 
 
 Walls of stomach, intestine, gall 
 bladder and ducts, urinary 
 bladder. 
 
 .Mid-brain autonomic. 
 
 Bulbar autonomic. 
 
 Sympathetic. 
 (I. Th. to il. or III. L. in man.) 
 
 Arteries of rectum, anus and' 
 external generative organs. 
 
 Walls of descending colon to end 
 of gut. 
 
 Walls of bladder and urethra. 
 
 Muscle of external generative 
 organs. 
 
 Sacra' autonomic. 
 (II. to IV. S. about in man.) 
 
 Fig. 1. 
 Diagram to show the general origin and tli.strilmtionof efferent autonomic 
 fibres. By "muscle" is, of course, meant vmstriatod muscle only. By 
 the •' walls " of a structure are meant all the unstriated muscle in it. 
 The innervation in some cases is still a matter of controversy (gastric 
 glands, liver, and i)rtncreas ; vos.sels of lungs ; small arterites of skeletal 
 muscles, and arteries of the central n(>rvous system). (Langley.) 
 
28 Chapter III. 
 
 pinching or pricking, and tissues where no sensation 
 is felt. Wlien these tissues are placed in two 
 separate groups, it will be found that in the group 
 where the tissues are sensitive to pain the nerve 
 supply comes from, the cerebro-spinal nervous system, 
 while the group where there is no sensation of pain 
 is supplied solely by the autonomic system of 
 nerves. 
 
 Seeing that the viscera are insensitive to stimuli 
 that produce pain in tissues supplied by cerebro- 
 spinal nerves, and seeing that pain can arise from 
 visceral, stimulation, it follows that the mechanism 
 by which pain is produced must be different in these 
 two systems. 
 
 15. The Mechanism by which Pain is pro- 
 duced on stimulation of Cerebro-spinal Nerves. 
 — There is good ground for assuming that there are 
 special nerves for the conduction of pain, with 
 special organs at the periphery capable of receiving 
 the special stimulation. The conduction of such 
 pain stimulus is by the afferent nerves passing into 
 the central nervous system by the posterior nerve 
 roots. 
 
 When a stimulus is applied to the peripheral 
 organ in the skin, the nerve not only conveys to the 
 centre of consciousness the sensation of pain, but 
 also indicates the locality in which the stimulus is 
 produced. This power of localisation varies in its 
 exactitude, but pain is always referred to a point 
 somewhere in the neighbourhood of the stimulation. 
 
 In the course of its passage from the skin to 
 the brain the nerve may be subjected to stimulation, 
 and if the stimulation be suflficient to provoke a 
 response, pain will be felt, and it will be localised not at 
 
Pain. 29 
 
 the place stimulated but in the field of the peripheral 
 distribution of the nerve. The pressure of a growth on 
 the trunk of a nerve, or disease affecting the posterior 
 root ganglia, as occurs in herpes zoster, or lesions in 
 the spinal cord, as in locomotor ataxia, or irritation in 
 the brain itself, all give rise to pain when a pain 
 nerve is stimulated, and the pain is referred to the 
 peripheral distribution of the nerve in each case. 
 
 The reason for this pain being referred to a 
 part remote from the seat of the irritation is due to 
 the fact that when stimulated to activity every 
 nerve gives rise to its peculiar function. If it be the 
 optic nerve then it gives rise to a sensation of light ; 
 if it be the auditory nerve then to the sensation of 
 sound ; if it be a pain nerve then to the sensation of 
 pain referred to the peripheral distribution of the 
 nerve. 
 
 16. Radiation of Pain. — The consideration of 
 the localisation of pain and the manner in which it 
 spreads throws a great deal of light upon the 
 mechanism, of pain. It often happens that when 
 there is severe pain due to an}^ cause, such as from a 
 whitlow, or a sm.all abscess by the side of a finger 
 nail, that the pain is felt to spread up the finger to 
 the hand, and, it may be, to the arm. Not 
 only so, but the skin and deeper tissues in 
 the neighbourhood of the disease are often 
 very tender on pressure. It might seem, and it 
 is usually accepted, that this is due to the irritation 
 of the nerve ends in the neiglibourliood of the 
 lesion by some obscure process. But this is not the ex- 
 planation. The real nature of the disturbance can be 
 inferred when the nerves stimulated by the disease 
 ])rocess are in close association in the brain or s]iinal 
 
30 Chapter III. 
 
 cord with nerve fibres supplying structures at some 
 distance. To take the most common instance, the 
 fifth cranial nerve supplies the teeth and also the 
 skin of the cheek. In toothache there may not only 
 be the pain referred to, and great sensitiveness of, 
 one tooth, but the pain may be felt along the jaw and 
 in the cheek. Not only may the pain be felt in the 
 cheek, but the skin of the cheek may become ex- 
 tremely tender to touch, so that to gently brush the 
 hair causes a definite sensation of pain. A still 
 more striking instance is recorded by Professor 
 Sherrington. He states that " by applying a mus- 
 tard leaf over the front of the upper part of the 
 sternum, I can produce in myself the sensation of a 
 patch of unpleasantly tingling character referred to 
 the inner side of each upper arm, just above the 
 inner condyle." 
 
 Neither in this case nor in that of the toothache 
 could continuity of the peripheral structures be the 
 cause. The same stimulation produced the pain in 
 widely separated parts. If we inquire into the nerve 
 supply the matter becomes clear. The second 
 thoracic nerve supplies the skin of the upper part 
 of the chest and of the inner side of the upper arm. 
 While the peripheral ends of the nerves supplying 
 the upper part of the chest and the inner side of the 
 upper arm are widely apart, their centres in the 
 spinal cord are intimatety associated, so that when 
 a violent stimulus from the periphery reaches the 
 spinal cord it affects the nerve cells in its neighbour- 
 hood, which in this case happen to be those supplying 
 the upper arm., and thej^ react accordmg to their 
 nature, and give rise to pain referred to their peri- 
 pheral distribution. In the same manner the nerves 
 
Pain. 31 
 
 supplying the teeth and the skin of the cheek meet 
 in the centre of origin of the fifth cranial nerve, and 
 the stimulation of the fibres from the teeth affect 
 the fibres supplying the cheek. 
 
 In the diagnosis of symptoms it is of the highest 
 importance to appreciate both the nerve suppty of 
 the part in which the pain is felt, and the relation of 
 these nerves to others in the central nervous system. 
 The manner in which the pain spreads and the 
 appearance of other phenomena due to central 
 stimulation provide the clue. 
 
( 32 ) 
 
 Chapter IV. 
 
 VISCERAL PAIN. 
 
 17. The Function of Afferent Sympathetic Nerve 
 
 Fibres. 
 
 18. Insensitiveness of the Viscera to stimulation. 
 
 19. Sensitive Tissues of the External Body Wall. 
 
 20. Testicular Pain. 
 
 21. Artificial Production of Visceral Pain. 
 
 22. Relationship of the Site of Pain to the Site of the 
 
 Lesion. 
 
 23. Mechanism by which Pain is produced in 
 
 Visceral Disease. 
 
 24. Referred Pain. 
 
 25. Radiation of Visceral Pain. 
 
 26. Pain the only Sensory Reflex in Visceral Disease. 
 
 27. Lennander^s Observations. 
 
 17. The Function of Afferent Sympathetic Nerve 
 Fibres. — Bearing in mind the view that the effective 
 stinaulation of any part ot a nerve fibre from the 
 periphery to the brain will result in the evidence of 
 its peculiar function, the cause of pain in visceral 
 disease becomes easy to understand. In the normal 
 processes of life a succession of stimuli is continually 
 passing from the viscera by the afferent nerves to 
 the spinal cord, and reacting upon the nerves 
 supplying muscles, blood vessels and other struc- 
 tures. These processes are so conducted that they 
 normally give rise to no appreciable sensation. 
 
Visceral Pain. 33 
 
 If, however, on account of a morbid j)rocess in 
 any viscus an increased stimulus passes b}^ the 
 afferent nerves to the spinal cord this stimulus may 
 be of a kind that affects neighbom'ing nerve cells, and 
 these nerve cells react according to their functions — 
 a sensory cell by producing pain, a motor cell by 
 contraction of certain muscles, a secretory nerve by 
 increased flow of its peculiar secretion, and so forth. 
 When such stimulation affects a sensor}' nerve, pain 
 arises, which is referred to the peripheral distribu- 
 tion of the nerve so stimulated. 
 
 18. Insensitiveness of the Viscera to ordinary 
 stimulation. — I have already pointed out that 
 the viscera are insensitive to those methods of 
 stimulation that produce pain in the external body 
 wall. Haller demonstrated that in animals the 
 viscera could be cut and burnt while the animal 
 unconcernedly ate its food. Harve}^ described the 
 insensitiveness of the heart, and a great number of 
 observers have testified to the fact that other 
 viscera are totally insensitive to stimulation. Per- 
 sonally I have stimulated nearly every organ of the 
 body, and have failed to elicit pain by procedures 
 which elicited pain when applied to the external 
 body wall. It is only in rare instances that the 
 opportunity is afforded of demonstrating the insen- 
 sitiveness of the viscera by their direct stimulation 
 in the conscious subject. As, however, it is often 
 attempted to demonstrate the tenderness of organs 
 by stimulating them through the external body wall, 
 it is necessary to comprehend the sensitiveness of 
 the structures so stimulated, for it often happens 
 that the pain produced by stimulation of one 
 structure is referred to another. 
 
34 Chapter I V. 
 
 19. Sensitive Tissues of the External Body 
 Wall. — If we take the abdominal wall we find three 
 great laj^ers endowed with exquisite sensibility to 
 pain. The first of these, the skin, I need not dwell 
 upon, save to point out how its sensibility frequently 
 becomes increased in visceral disease, and how this 
 increased sensitiveness is united to an exalted 
 muscular reflex. The second of these sensitive layers 
 is the voluntary muscular system best observed in the 
 flat muscles of the abdomen. It is the sensitiveness 
 of this muscular layer which is most commonly 
 exalted in visceral disease, its sensibility being very 
 readily increased. Muscular hj^peralgesia is such a 
 striking phenomenon, is so frequently present and 
 plaj^s such an important part in the protective 
 mechanism, that it is astonishing to find it almost 
 universally overlooked. One can read elaborate 
 treatises devoted to special organs, in which this 
 symptom is the most striking and the most instruc- 
 tive feature, but its presence is nevertheless over- 
 looked or misinterpreted. In an ordinarj^ case of 
 stomach ulcer, appendicitis, gall-stone, renal colic, 
 or enlarged liver, if one notes the tenderness of the 
 abdominal wall, and observes how this deep tender- 
 ness extends far beyond the site of the organ affected, 
 one can appreciate the nature and significance of this 
 sensitive layer. With a little care one will be able to 
 distinguish this muscular hyperalgesia from cutaneous 
 hyperalgesia and from hyperalgesia of the deeper 
 tissues. The third sensitive la3^er is one of which 
 anatomists and physiologists were quite ignorant till 
 recently, though it has long been suspected from 
 clinical observations. It is the laj^er of loose 
 connective tissue lying immediately outside the 
 
Visceral Pain. 35 
 
 peritoneum. I suspected its presence for a long time as 
 I could frequently get exquisite tenderness in pushing 
 my fingers between the recti muscles, for instance in 
 cases of gastric ulcer, the stomach not being affected 
 by the pressure. Its existence can be shown in an 
 operation for the radical cure of hernia under cocaine 
 anaesthesia. The skin and muscles can be cut 
 through, and the patient experiences no pain. When 
 the loose connective tissue outside the peritoneum is 
 gently torn through the patient may experience most 
 exquisite pain. After the peritoneum is exposed it 
 can be incised, its visceral layer scratched and after- 
 wards stitched, and the patient feels no pain. I have 
 verified this observation on several occasions. 
 Ramstrom has made a careful histological exam- 
 ination of the abdominal wall of man and other 
 mammals, and showed that this region is richly 
 endowed with nerves and nerve endings, the nerves 
 being derived from those which supply the muscles of 
 the abdoniinal wall. This observation may probably 
 afford a clue to the confused statements that exist in 
 regard to the sensitiveness of the peritoneum. I can 
 only say this, that I have on numerous occasions in 
 the course of operations scratched and cut the serous 
 surface of the peritoneum on conscious subjects with- 
 out any analgesic, local or general, and have never 
 known the slightest sensation elicited. One can 
 understand, however, that the inflamed peritoneum 
 and adhesions might readily affect this remarkable 
 nervous layer. Peritonitis, however, so readily 
 produces muscular hyperalgesia and tonic muscular 
 contractions (viscero-motor reflex), that the pain and 
 tenderness are demonstrably, in tlie niajority of cases, 
 of spinal origin {see Chapter XVIII.). 
 
36 Chapter I V. 
 
 With the recognition of these sensitive struc- 
 tures — frequentty rendered exquisitely sensitive to 
 painful stimuli in visceral disease — it will be under- 
 stood how impossible it is to judge of the sensitiveness 
 of the viscera from external exploration. When, 
 therefore, we find the surgeon or physician demon- 
 strating the sensitiveness of any viscus, it will be 
 realised that he is in reality stimulating, in his 
 examination, those extremely sensitive structures of 
 the external abdominal wall, and referring the pain 
 he elicits to an organ that is totally insensitive to 
 any such stimulation. 
 
 20. Testicular Pain. — On the other hand, one 
 cannot always be sure of the source of pain, as 
 when pressure is applied over a movable kidney or 
 readily palpated abdominal tumour. That pain 
 arises on pressure on a viscus is undoubted, but the 
 pain does not seem to arise from the direct stimula- 
 tion but by reflex stimulation of a sensory cerebro- 
 spinal nerve. This can be demonstrated in the case 
 of the testicle. In ordinary cases when the cord is 
 short the pains felt on applying pressure to the 
 testicle are not readily differentiated. If, however, 
 an individual with a long cord, where the testicle 
 hangs down a long way from the groin, be examined, 
 the pains resulting from pressure on the testicle can 
 be separately recognised. In such an instance a pain 
 is felt at once readily localised over the point of 
 pressure. A few seconds later another pain is felt 
 gradually increasing in intensity, and gradually 
 passing away and referred to the groin. Accom- 
 panying the pain there is sometimes a sensation of 
 faintness, very slight with light pressure, but 
 evidently of the same nature as the intense 
 
Visceral Pain. 37 
 
 depression following on a blow on the testicle. 
 This depression and pain are similar to those which 
 are evoked by pressure on the kidney and ovary. 
 Concerning the first of these pains when it is felt 
 at once and referred to the place of stimulation, a 
 curious question arises bearing on the sensibility of 
 serous membranes. As I have already pointed out, 
 I have scratched the serous surfaces of both visceral 
 and parietal peritoneum and pleura, and elicited no 
 sensation of pain, but exquisite pain may be elicited 
 by scratching the tunica vaginalis. In certain cases 
 in tapping a hydrocele, if the testicle be gentty held 
 with one hand and the visceral layer of the tunica 
 vaginalis lightly scratched with the canula, the 
 patient at once experiences pain and refers the pain 
 unerringly fco the region scratched. However lightly 
 the stimulus is made no sensation is experienced 
 beyond that of pain, resembling in this respect the 
 sensibility of the cornea. As demonstrating the 
 difference between the sensibility of the tunica 
 vaginalis and the peritoneum, I cite the following 
 experience. A patient consulted me with his 
 scrotum greatly enlarged and full of fluid, which I 
 took to be a hydrocele. I tapped him and tested the 
 sensibihty of the testicle. I found the patient did 
 not feel pain when I scratched what I took to be 
 liis tunica vaginalis. I scratched rather roughly, yet 
 no painful sensation was experienced. Finding I 
 coukl not reduce the whole of the swelling I 
 coiu'hided that the case was not one of hydrocele, 
 and on operating I found the case was one of 
 omental liernia with the sac distended by peritoneal 
 fluid. What I had been scratching was the 
 peritoneum. 
 
38 Chapter I V. 
 
 As the tunica vaginalis and the peritoneum 
 have the same origin it appeared strange that there 
 should be this difference in sensation, until on 
 inquiry I found that a cerebro-spinal nerve is 
 distributed to the tunica vaginalis, viz., a twig of the 
 genital branch of the genito-crural nerve. The tunica 
 vaginalis is the only sensitive serous membrane 
 covering an organ that I have detected, and it is the 
 only one to which a branch of a cerebro-spinal nerve 
 has been traced. 
 
 In certain cases the tunica vaginalis becomes 
 hyperalgesic [see page 183). Professor Waterston 
 tells me that the visceral layer of the tunica 
 vaginalis is not of the same origin as the parietal, 
 but is looked on as a persistence of the germinal 
 epithelium. This may have some bearing on the 
 sensibility of the testicle, and ray suggestion as to 
 the nature of the testicular sensitiveness is therefore 
 provisional. 
 
 21. Artificial Production of Visceral Pain. — 
 It is a curious fact that although the belief is so 
 universally held that the viscera are endowed with 
 " sensory " nerves, and that physiologists refer to 
 afferent sympathetic nerves as " sensory " in func- 
 tion, not a single authentic observation has been 
 rendered to show that the viscera have a direct 
 sensibility of their own, i.e., a sensibility derived 
 from the possession of nerves which when stimulated 
 produce a sensation. Of course, a great deal 
 depends on what is considered evidence, many people 
 being perfectly satisfied if they elicit pain b}^ pressing 
 over an organ. Phj^siologists have interpreted 
 certain movements as an expression of pain after 
 stimulating afferent sympathetic nerves. But this 
 
Visceral Pain. 39 
 
 does not prove that pain was evoked nor does it prove 
 that the pain was a direct pain, nor does it show in 
 what situation the pain was felt, for the location of 
 the pain is the key to the problem. It is therefore 
 necessary in investigating this matter to be sure of 
 the tissue stimulated, and the region in which the 
 resultant pain is felt. It is because of the absence 
 of the specification of the locus of the pain that many 
 otherwise important observations are rendered of 
 little value in respect to this investigation. 
 
 That pain can be produced bj^ visceral stimula- 
 tion is easily demonstrated if one employs an 
 adequate stimulus. It is now many years since I 
 pointed out that the most violent pains of which we 
 are conscious are associated with hollow muscular 
 organs, and that by producing violent contraction 
 of a hollow viscus pain can be elicited. The easiest 
 way to do this is to give a distending enema of warm 
 water, and to retain the enema until painful peri- 
 stalsis results. That the pain is really due to the 
 contraction of the muscle wall of the bowel is evident 
 from the fact that with the relaxation of the 
 sphincter during the pain the contents of the bowel 
 are expelled with considerable force, and the pain at 
 the same time subsides. Here it is evident that a 
 considerable portion of the descending colon and 
 rectum must have contracted, but the pain is not felt 
 along the position occupied by these structures, but, 
 in the majority of people, it is referred across the 
 middle line immediately above the pubis. 
 
 The following observation demonstrates an 
 exactly similar series of facts : — 
 
 T liad occasion to resect a small portion of the 
 small intestine in a conscious subject, for umbilical 
 
40 Cha'pter IV. 
 
 fistula, whose abdominal cavity I laid open. He 
 refused to take an anaesthetic, and no analgesic, local 
 or general, Avas administered. There were numerous 
 peritoneal adhesions, and while I cut and tore these 
 the patient was unconscious of any sensation. I cut 
 and stitched the serous surfaces of parietal and vis- 
 ceral peritoneum, I tore adhesions from the hver, I 
 cut and sutured the bowel and mesentery, and no 
 sensation was felt. After preparing tlie\ipper part 
 of the bowel it was A\Tapped in a warm cloth and 
 laid on one side. During the subsequent steps the 
 patient frequently moaned. I asked him if he felt 
 pain, and he replied that he did. I asked him where 
 he felt the pain, and he indicated with his hand 
 that it was across the middle line at the level of the 
 umbihcus. I at first felt that it might be due to the 
 part that I was manipulating, but the pain was 
 intermittent. Chancing to look at the prepared 
 upper part of the bowel that lay on the left side of 
 the abdomen, I observed that every few minutes a 
 peristaltic wave passed over the lower portion of it, 
 and when this occurred the patient moaned in pain. 
 I made certain that the pain was connected with 
 the peristaltic wave, and I produced the peristalsis 
 several times by lighth" pinching the bowel. I also 
 made sure the patient had no doubt as to the place 
 in which it was felt, with the result that here before 
 my eyes was the cause of the pain which the patient 
 felt, and yet the patient referred the site of the pain 
 Avith precision to an area ten inches or twelve inches 
 away from the contracting bowel. 
 
 An objection has been taken by Hirst to the 
 explanation of this observation. He contends that 
 the reference of the pain to the middle line was due 
 
Visceral Pain. 41 
 
 to the brain referring the sensation of its " average 
 position." The average locahsation theory is but an 
 attempt to explain obscure symptoms without 
 taking the trouble to inquire into all the 
 evidence. 
 
 22. The Relationship of the Site of the Pain 
 to the Site of the Lesion. — For mam- years I have 
 kept notes of the position in which pain was felt in 
 a great variety of diseases, and in course of time I 
 have been able to identify the exact site of the lesion 
 in cases that come to operation, or to post-mortem 
 examination. The conclusion arrived at from the 
 consideration of these cases was that the situation 
 of the pain did not as a rule directly afford any clue 
 to the situation of the lesion, but when the situation 
 of the pain was immediately over the lesion, other 
 evidences showed that the pain was not felt in the 
 organ, but referred to the sensory nerves in the 
 external body wall. I shall quote the proofs of this 
 conclusion presently, but here I will describe the 
 theory which explains the peculiar nature of visceral 
 pain. 
 
 23. The Mechanism by which Pain is produced 
 in Visceral Disease. — Wlien a nerve that ter- 
 minates in a sense organ is stimulated in any part of 
 its course from the periphery to the brain, a stimu- 
 lation is given to the brain of a kind similar to what 
 would liave happened if the peripheral end-organ 
 had been stimulated. Thus the stimulation of any 
 part of the optic nerve or auditory nerve gives rise 
 to the sensation of light or of sound. In the same 
 manner if a sensory nerve be stimulated in any part 
 of its course through the brain, spinal cord, or trunk 
 of the nerve, the resultant sensation is referred to 
 
42 Chapter IV. 
 
 the peripheral distribution of the nerve in the exter-^ 
 nal body wall. As already remarked, in the normal 
 processes of life, a succession of stimuli is con- 
 tinually passing by the afferent nerves to the spinal 
 cord, and continuously plajdng upon the efferent 
 nerves that run to muscles, blood vessels, and so 
 forth, maintaining what we call " tone " in muscles 
 and blood vessels. These processes are conducted so 
 that they give rise to no appreciable sensation. If, 
 however, a morbid process in a viscus gives rise to an 
 increased stimulus of the nerves passing from the 
 viscus to the spinal cord, this increased stimulation 
 affects neighbouring centres, and so stimulates sen- 
 sory, motor, and other nerves that issue from this 
 part of the cord. Such stimulation of a sensory 
 nerve will result in the production of pain referred 
 to the peripheral distribution of the nerve, whose 
 spinal centre is stimulated, so that the visceral pain is. 
 really a viscero-sensory reflex. If the increased 
 stimulus affects a motor centre, then a contraction of 
 the skeletal muscle results, and thus is produced the 
 viscero-motor reflex (see diagram. Fig. 4, page 87). 
 
 The two following cases illustrate these points : 
 A female, aged 36. For a couple of years the patient 
 had suffered from violent attacks of abdominal pain, 
 I never saw her during an attack, but the following 
 was the condition found after a severe attack. The 
 abdominal wall over the right iliac fossa was hard 
 and rigid, due to the contraction of the muscles^ 
 When the skin was lightly pinched there was no 
 increased tenderness but pressure on the rigid 
 muscle was very painful. The right thigh was 
 slightly bent upon the abdomen, and could be 
 extended only with difficulty, owing to a tonic 
 
Visceral Pain. 43 
 
 contraction of the psoas muscle. On walking a short 
 distance the patient developed a stoop, due to the 
 increased contraction of this muscle. When the 
 erector spinae muscles on both sides were lightly 
 grasped in the lumbar region those of the right side 
 were found very painful. There were frequent calls 
 to micturition, the quantity passed at each time 
 being small, and containing no abnormal constituents. 
 
 This description of the sj'mptoms was confirmed 
 by ]\Ir. Caird, who operated on the patient. The 
 following conditions were found at the operation : — 
 When the abdominal cavity was opened nothing 
 abnormal could be detected. The parietal peri- 
 toneum was perfectly healthy, and only healthy coils 
 of intestine were exposed to view. On separating 
 these coils the appendix was found red and inflamed, 
 adherent by soft red bands to the caecum, and 
 separated from the bladder by coils of uninflamed 
 intestine. The appendix was removed, and the patient 
 made a good recovery, though it was a couple of 
 months before all the symptoms quite disappeared — 
 the last symptom to go being the slight contraction 
 of the psoas muscle, which became more contracted 
 on walking a short distance. 
 
 Grouping the reflex phenomena in this case we 
 recognise (1) A viscero-motor reflex in the muscular 
 contraction of the transversalis abdominis, the 
 oblique and psoas muscles ; (2) a viscero-sensory 
 reflex in the increased sensitiveness of the sensory 
 nerves supplying the muscles over the right iliac 
 fossa and the erector spinse ; and (3) an irritability 
 of the bladder resulting in frequent micturition. 
 
 It is manifest from the condition found at the 
 operation tliat these very definite symptoms could not 
 
44 Chapter I V. 
 
 have been caused by the impHcation of the structures 
 m the inflammation which affected the appendix. If, 
 on the other hand, we look into the origin of the 
 nerves, motor and sensory, that supply these muscles 
 and the sj^mpathetic supplying the bladder, we find 
 that they all arise from a limited area in or near the 
 twelfth thoracic and first or second lumbar spinal 
 segments. It becomes, then, a justifiable inference 
 that the stimulus that produced these symptoms 
 arose in the appendix, and that this stimulus was 
 conveyed from the appendix by its sympathetic nerve 
 supph" to the spinal cord, and therefore that the 
 appendix is supplied by a sympathetic nerve that 
 joins the cord at the segments mentioned. In Fig. 1, 
 page 27, it is shown that the nerve to the bladder 
 leaves the cord at two places — with the sympathetic 
 nerves from the upper lumbar region, and with the 
 visceral sacral nerves. In the case just cited the 
 frequent micturition showed an increased sensitive- 
 ness of the bladder and so we can infer that the 
 afferent fibres of the bladder reach the spinal cord 
 at the upper lumbar region. 
 
 In the following observation a description is 
 given of the effects produced by a stimulation of the 
 cord as definite as Siuy plwsiological experiment. 
 
 Renal Colic. — A man, aged 30, had suffered for 
 a year from occasional attacks of renal colic, and one 
 attack had been followed by haematuria. He was a 
 very intelligent man, and I told him to note every 
 particular during an attack. The following is a 
 summary of his statement — the original statement 
 being illustrated by the patient placing his hand 
 over the regions mentioned : The pain suddenly 
 seizes him with great severity in the right lumbar 
 
Visceral Pain. 45 
 
 region, then after a few minutes it strikes into the 
 front of the abdomen over the ihac fossa. Then tlie 
 belly becomes hard and rigid. The pain then strikes 
 down into the internal part of the groin, the testicle 
 is felt to be drawn up, and the pain then shoots 
 into the testicle. The facts here described were 
 corroborated by him in a few subsequent attacks, 
 each attack invariably pursuing the same sequence. 
 My notes made after an attack describe an indefinite 
 area of cutaneous hyperalgesia over the iliac fossa, 
 hardness and rigidity of the abdominal muscles over 
 the right iliac fossa, with great tenderness on 
 pressing over the muscles and on pressing the right 
 testicle and the right erector spinae muscles in the 
 lumbar region. Here the symptoms pointed to a 
 localised stimulation of the spinal cord at the origin 
 of the sensory nerves supplying the skin over the 
 right iliac region, the testicle and the abdominal and 
 erector spinae muscles, and at the origin of the motor 
 nerves supplying these abdominal muscles and the 
 cremaster muscle. These nerves issue from the spinal 
 cord by the twelfth thoracic and first lumbar roots. 
 The area stimulated in the cord, it will be observed, 
 is not confined to one segment, but passes along a 
 path which affects only a limited portion of several 
 segments — a curious feature to which I shall revert 
 in dealing with the radiation of pain. 
 
 In regard to the immediate cause of the symp- 
 toms, 1 reasoned that there was a calculus lodged 
 somewhere about the pelvis of the kidney, and that 
 its presence acted like a foreign bod}-, sending a 
 wave of strong peristalsis down the ureter, the 
 gradual passage of the peristalsis sending strong 
 stimuli to a descending region of the spinal cord. 
 
46 Chapter I V. 
 
 The fact that the pain always started at the same 
 place indicated that the stone remained fixed in its 
 position, a view confirmed by the fact that there was 
 never ?iny evidence of the calculus having reached the 
 bladder. The reasons I had for the assumption that 
 the stone remained in the pelvis will be gathered as 
 I develop my argument. An X-ray photograph 
 failed to reveal the stone. Such being my opinion I 
 sent the patient to Mr. Wright, who, agreeing with 
 my diagnosis, operated in 1903, and found a small 
 calculus about the size of a pin's head adherent to 
 the apex of a calyx, opposite the junction of the 
 middle and lower third of the kidney. This was 
 removed, and the patient made a good recovery, and 
 has remained quite free from all symptoms. 
 
 24. Referred Pain.— The reason why the pain 
 is referred to portions of the body so far apart is 
 because in the course of development the tissues that 
 in a low scale of life immediately covered the organ 
 had been displaced. Thus, the pain felt in the 
 testicle in renal colic is due to the fact that in its 
 journey down to the scrotum the coverings of the 
 testicle receive a twig from the first lumbar nerve, 
 and when the centre of this nerve in the spinal cord 
 is stimulated, as in renal colic, the pain radiates to 
 the testicle. In renal colic one never finds the skin 
 of the scrotum hyper algesic, but always the deep 
 covering of the testicle, because the scrotum is sup- 
 plied by the sacral nerves, while the ureter and 
 testicle are supplied by lumbar nerves. 
 
 This view is the one adopted by practically all 
 to account for what is called " referred pain." Ross 
 described visceral pains as of two sorts, " splanchnic " 
 pain in the organ, and " somatic " pain referred to 
 
Visceral Pain. 47 
 
 some part of the body wall remote from the organ. 
 But when the so-called " splanchnic " pains are 
 critically examined they will be found to be of the 
 same nature as somatic pain. 
 
 25. Radiation of Visceral Pain. — Perhaps the 
 best evidence as to the true nature of ^^sceral pain 
 is found in the manner in which pain spreads. No 
 attempt has been made by writers to appreciate the 
 meaning and significance of the spreading of pain. 
 It is usually assumed that the pain is in the affected 
 viscus, so that we find such statements as a "hyper- 
 sensitive " gall-bladder and a " tender liver," while 
 the pain of an inflamed gall-bladder is " diffused over 
 a large area along and below the margin of the liver." 
 In what tissues was this widely diffused pain felt ? 
 If the pain were in the gall-bladder, how comes it 
 that it was felt in a region more extensive than that 
 occupied by the gall-bladder ? 
 
 The diffusion of pain over a wider area than 
 that occupied b}' the organ in which the stimulus 
 producing the pain originates can be proved in 
 many ways to be due to an extension of the irritation 
 affecting the central ends of sensor}^ nerves in the 
 spinal cord as has been described. Thus the exten- 
 sion of the painful area is frequently associated with 
 hyperalgesia of the tissues of the external body wall. 
 The pain is often found to radiate along pecidiar 
 areas, inexplicable unless we recognise the relation- 
 ship in the spinal cord of the nerves supplying these 
 areas, as, for instance, when the pain of angina 
 pectoris passes from the front of the chest into the 
 axilla and down the arm — that is to say, into areas 
 supplied by contiguous nerve roots (third, second, 
 and first thoracic nerves) ; or the pain may appear 
 
48 Chapter I V. 
 
 at a distance from the affected organ and gradualljr 
 approach it till it is felt in the tissues covering the 
 organ, as when in angina pectoris the pain may at 
 first be confined to the arm, but with increasing^ 
 severity radiates to the front of the chest. 
 
 An excellent illustration of the referred pain is 
 seen in cases where the lesion is in the tissues 
 supplied by the phrenic nerve. The phrenic nerve 
 passes out of the spinal cord with the fourth cervical 
 nerve, receiving sometimes small branches from the 
 third and fifth cervical nerves. It is distributed to 
 the diaphragm, the liver, and the gall ducts. The 
 sensory nerves from the fourth and fifth cervical 
 nerves are distributed to the skin, over the top of the 
 shoulder and down the outside of the arm. In a few 
 cases of diaphragmatic pleurisy (sometimes with 
 basal pneumonia) the patient has felt severe pain 
 over the top of the shoulder on the affected side. On 
 rare occasions I have found a patch of cutaneous 
 hyperalgesia on the shoulder {see Fig. 15, page 216). 
 In gall-stone disease, shoulder pain is a not infre- 
 quent complaint, and the pain may extend from the 
 top of the shoulder, and down the outside of the 
 upper arm. It may persist here with such severity 
 that the casual condition may be overlooked, and the 
 case looked upon as one of " neuritis." The expulsion 
 of a gall-stone may be followed by instant and per- 
 manent relief. In many instances pain of real severity 
 may be experienced and the pain may be in some 
 part near the organ causing the pain, and no hyperal- 
 gesia may be detected. Such instances cannot claim 
 to settle the question whether the pain is direct or re- 
 ferred. If, however, a careful search is made in all cases,, 
 some will be found which exhibit this hyperalgesia. 
 
Visceral Pain. 49 
 
 26. Pain the only Sensory Reflex in Visceral 
 Disease.— There is one pecuHar and puzzling 
 feature about the reflex stimulation set up by a 
 visceral affection, namely, that pain is practically 
 the only sensation evoked. I shall show later that 
 the stimulus from the organ on reaching the spinal 
 cord, if of an adequate strength, will pass on to 
 neighbouring nerve cells, and stimulate motor and 
 secretor}' nerves, as well as the pain nerves. But it 
 is not clear why the stimulation should not affect 
 the nerves that subserve otlier forms of sensation as 
 touch, heat, and cold. The ingestion of cold into the 
 stomach does, under certain circumstances, give rise 
 to a sensation of cold, and I have tried to explain 
 that by another hypothesis, but apart from this the 
 stimulus from any viscus does not produce cold or 
 any sensation but that of pain. The only explana- 
 tion I can suggest is that for other sensations, apart 
 from pain, a special receptor organ is necessary, for 
 we know that in the skin there are special spots 
 which are alone susceptible to heat or cold, and unless 
 the stimulation reached the central nervous S3'stem 
 by the special organ at the periphery for receiving 
 these sensations, the stimulation of these nerves at 
 higher levels gives no response. On the other hand, in 
 disease of the central nervous system other sensations 
 may arise, such as formication, which are supposed 
 to be due to stimulation of particular nerve fibres. 
 
 27. Lennander's Observations. — The observations 
 of Lennander are in agreement with those I have 
 made, and I quote here a typical illustration from 
 Barker's translation of Lennander's book. Jt will be 
 seen that pain is sometimes produced from stimulation 
 of the viscera, as in pulling on the gall-bladder, but 
 
 E 
 
50 Chapter IV. 
 
 such methods of stimulation do not give a clear idea 
 of the tissues that gave rise to the pain, whether, for 
 instance, the pulling affected the sensitive outer layer 
 of the peritoneum ; nor is there any indication of the 
 locality to which the pain was referred. 
 
 Hast and Meltzer object to the conclusions 
 drawn by Lennander from his observations, because 
 Lennander had used injections of cocaine, which, 
 they say, induced a certain degree of anaesthesia, 
 and diminished the sensibility of the viscera. I 
 do not think this objection valid, for m\^ results 
 agree with Lennander' s, and most of my patients 
 had no anaesthetic of any kind. 
 
 ' Parietal Peritoneum ; Gall-bladder ; Adhesions 
 between Abdominal Viscera. — We learn, from the 
 following case and others, that the parietal peri- 
 toneum derives its sensibility from the intercostal 
 nerves in the subserosa. If such a nerve be divided, 
 the parietal peritoneum on the distal side becomes 
 insensitive over an area corresponding to the 
 distribution of its twigs, which is not, however, 
 large. This depends upon the fact that the areas of 
 distribution of different twigs are common to both. 
 In case ... it will be seen that a gall-bladder which 
 was adherent to the omentum and transverse colon 
 and whose mucous membrane showed marked 
 catarrh — it contained a gall-stone as large as a plum 
 — was entirely without sensation. The patient 
 had no feeling either of pain or touch during all 
 the manipulations of the operation necessary for 
 a cholecystotomy with so-called " water-tight 
 drainage." 
 
 ' As it seemed desirable to produce adhesions 
 between the anterior surface of the liver and the 
 
Visceral Pain. 51 
 
 abdominal wall in the neighbourhood of the gall- 
 bladder, the serosa of the former was destroyed over 
 a considerable area by various means, such as silver 
 nitrate, thermo-cautery, scratches mth a needle, etc. 
 The surface of the liver proved to be destitute of all 
 sensation either of pain or touch. It was the same 
 when the anterior border of the liver was pinched 
 between the finger and thumb. The adhesions also 
 between the gall-bladder, the omentum and meso- 
 colon were insensitive, as also were the two last 
 structures. 
 
 ' F., aged 64, admitted December 3rd, 1900. 
 Biliary colic, with tedious fever for fifteen months. 
 Great weakness and diffuse bronchitis in both lungs. 
 In the urine both albumen and granular casts. 
 General anaesthesia contra-indicated. December 3rd, 
 J cgr. morphia and Schleich's infiltration. Notes : 
 " The gall-bladder was adherent to the transverse 
 mesocolon, and moderately full of dark green bile. 
 The mucous membrane was red and swollen, but 
 without ulcers ; one calculus, the size of a plum, 
 lying in the entrance of the c^^stic duct." 
 
 ' Microscopically and bacteriologically the bile 
 showed B. coli C07n., and another rod-like organism 
 which reacted to Gram's stain, but could not be 
 further differentiated. 
 
 ' During the whole operation the patient re- 
 mained perfectl}^ quiet, and to each question in 
 regard to pain gave a clear and intelligent answer. 
 
 ' Notes specially directed to the question of pain 
 during cholecystotomy with " water-tight drainage " 
 of the gall-bladder. The omentum was stitched to 
 the latter. Iodoform gauze packing between liver 
 and abdominal wall. The first incision was parallel 
 
52 Chapter IV. 
 
 to the right rectus, and at its outer border. Division 
 of the aponeuroses of the obhque produced pain. 
 How far the pain was present at ever}^ point or 
 only where small nerve-twigs were divided is uncer- 
 tain. Nevertheless the pain which follows division 
 of the aponeurosis maj^ clearly be severe. After 
 infiltration between the aponeurosis of the external 
 oblique and between the internus and transversalis 
 muscles, these structures can be divided without any 
 expression of pain on the part of the patient, but 
 on\.j those parts involved in the artificial oedema. 
 The same holds for the transversalis muscle both 
 before and after the infiltration after Schleich. 
 
 ' On division of a nerve in the abdominal Avail a 
 momentarj^ pain was felt. 
 
 ' In the area supplied by the divided nerve no 
 pain was felt in the parietal serosa, either when 
 incised or pinched with arter}" forceps, etc., but 
 outside of this area severe pain was produced by the 
 same stimuli. After infiltration of the extraperi- 
 toneal areolar tissue the p. parietale became insensi- 
 tive over the rather limited area efficiently charged 
 b}' the fluid. In the other parts not reached by the 
 ansesthetic the pain on manipulation of the p. 
 parietale was alwaj's severe. 
 
 ' Stretching of the abdominal wound with 
 rounded hooks produced severe pain. 
 
 ' When the peritoneum had been opened the 
 mesial part of the same was found to be insensitive 
 (the nerves supplying it had been gradual^ divided), 
 but the outer part of the peritoneum was still very 
 sensitive to pain.' 
 
Visceral Pain. 
 
 53 
 
 Palpation within the belly — of the gall-bladder and its 
 
 neighbourhood . . . . . . . . . . . . Pain. 
 
 Gall-bladder — gentle palpation of the fundus so that the 
 
 walls of the sac were pressed together without 
 
 stretching or contact with the abdominal wall . . Xo sensation. 
 Drawing forward of the gall-bladder . . . . Pain, 
 
 Three artery forceps were applied to the serosa of the 
 
 organ . . . . . . . . . . . . . . Xo sensation. 
 
 Silver nitrate to the serosa of the organ . . . . . . Xo sensation. 
 
 Drying of the serosa with gauze . . . . . . . . Xo sensation. 
 
 Burning of the serosa of gall-bladder with the thermo- 
 cautery . . . . . . . . . . . . . . Xo sensation. 
 
 Powerful compression of the gall-bl«idder between the 
 
 fingers . . . . . . . . . . . . . . Xo sensation. 
 
 Drying of the surface of the liver with gauze . . Xo sensation. 
 
 Cauterisation of the surface of the liver with silver nit. 
 
 thermocautery, and scratching with needles . . Xo sensation. 
 
 Drawing forward of gaU-bladder and division of adhesions 
 
 with thermo -cautery . . . . . . . . . . Pain. 
 
 Division of adhesions between the gall-bladder and 
 
 omentum with thermocautery . . . . . . Xo sensation. 
 
 Division or cauterisation of adhesions between the trans. 
 
 m. colon and gall-bladder behind . . . . . . Xo sensation. 
 
 P. Peritoneum drawn with hooks on midline of the wound Xo sensation. 
 On outer side of the same . . . . . . . . . . Severe pain. 
 
 Introduction and removal of gauze between p. parietale 
 
 and omentum . . . . . . . . . . . . Pain. 
 
 Opening the abdominal wound in order to introduce 
 
 gauze packing . . . . . . . . . . . . Severe pain. 
 
 Grasj)ing the whole thickness of the gall-bladder with 
 
 Pean's forceps . . . . . . . . . . . . Xo sensation. 
 
 Puncture and aspiration of the gall-bladder . . . . Xo sensation. 
 
 Incision of gall-bladder with thermo-cautery . . . . Xo sensation. 
 
 Palpation of its interior with the finger . . . . . . Xo sensation. 
 
 Compression of gall-bladder upon the large calculus 
 
 behind . . . . . . . . . . . . . . Pain. 
 
 Extraction of the .stone with a large spoon introduced 
 
 with the finger . . . . . . . . . . . . Xo sensation. 
 
 Plugging of the gall-bladder with iodoform gauze as far 
 
 as cystic duct . . . . . . . . . . . . Xo sensation. 
 
 '■ Tobacco-pouch " suture round the opening in the viscus 
 
 with a large needle for "" water-tight ' drainage . . Xo sensation. 
 Introduction of a drain tube and closure of the above 
 
 suture, lasting a minute . . . . . . . . Xo sensation. 
 
 Removal of tampons between omentum and transverse 
 
 colon .... . . . . . . . . . . . . No sensation. 
 
 Introduction and removal of gauze tampons between 
 
 liver and i)arietal peritoneinn . . . . . . . . Severe jjain. 
 
 Suture of omentum round gall-bladder . . . . . . Xo sensation. 
 
 Ligature of vessel in wall of gaU-bladder . . . . Xo sensation. 
 
 Comjiression of tran.sversi colon between fingers . . Xo sensation. 
 
 A|>plication and knotting of sutures between the gall- Little if any 
 
 bladder and j). ])arietale of the niedivun side of wound pain. 
 
 On the outer side . . . . . . . . . . . . Severe pain. 
 
 I'lugging on the inner side of the wound . . . . Slight pain. 
 
 On the outer side . . . . . . . . . . . . Severe pain. 
 
 A|)plicati()n of Pean's forceps on either side of the wound 
 
 showed the same results. 
 
( 54 ) 
 
 Chapter V. 
 
 VISCERAL VAm— continued. 
 
 28. Objections to the Referred Nature of Visceral 
 Pain. 
 
 28. Objections to the Referred Nature of 
 Visceral Pain. — In putting forward the view that 
 the pains arising from the viscera are not felt in the 
 organ, but are referred to the peripheral distribution 
 of cerebro-spinal nerves in the external body wall, I 
 had opposed to me the opinion of practically aU 
 people, whether they had studied the subject or not. 
 It is, therefore, necessary to consider the reasons why 
 such unanimous opinion should have been held, and 
 to show the grounds on which I based a contrary 
 view. 
 
 It is now recognised that pains arising from an 
 organ may be referred, but it is even now held that 
 there are pains felt in the organ itself, and that the 
 organ can become sensitive, i.e., the organs give 
 rise to a " somatic " or referred pain, and to a 
 " splanchnic " or pain felt in the organ. 
 
 The evidence for this splanchnic pain is sup- 
 posed to be found in the fact that the organ, though 
 insensitive in its normal state, may, under certain 
 circumstances, become sensitive. The evidence for 
 this is supposed to be found in the fact that pressure 
 over the organ causes pain. Thus, the stomach is 
 
Visceral Pain — continued. 55 
 
 said to be tender in gastric ulcer, because pressure 
 applied over the epigastrium is very painful. In 
 the same wa}^ pressure over an enlarged liver or 
 inflamed pleura causes pain. As this method of 
 investigation ignores the heightened sensibility 
 (hyperalgesia) of the tissues covering the external 
 body wall (as the skin and muscles), it is no argu- 
 ment in favour of the sensibility of the organ. 
 This matter is dealt with more fully in Chapter VI., 
 where I describe in detail the hyperalgesia of the 
 skin and of the muscles. While in the vast majority 
 of cases the pain arising from pressure applied to an 
 organ through the external body wall will be found 
 to be due to stimulation of the structures of the ex- 
 ternal body wall, there are exceptional cases where 
 the pain cannot be attributed to such structures. It 
 has been shown in the case of the testicle, that the 
 pain is felt not in the organ but in the groin, i.e., it 
 is a referred pain, the pressure being an adequate 
 stimulus to produce this form of pain. In rare and 
 exceptional cases, as in a movable kidney, or an 
 abdominal tumour, I have not been able to satisfy 
 myself as to the real nature of the pain elicited by 
 pressure, and this matter requires further investiga- 
 tion, if possible, when the organ or tumour is 
 exposed. 
 
 Another reason for assuming that the pain is 
 in the organ is the fact that a pain is felt in the 
 position where our knowledge tells us the organ is 
 situated, and other evidences abundantly justify the 
 view that the pain did arise from this organ. This 
 seems to most people to be conclusive evidence of 
 the sensibility of tlie organ, but there has to be 
 exercised a very cautious discretion before accepting 
 
56 Chapter V. 
 
 such a view. The assurance in all cases is not forth- 
 coming that the organ, though diseased, and though 
 causing the pain, is situated exactly where the pain 
 is felt. I have already referred to the fact that if 
 the organ be moved the pain does not shift, as in 
 gastric ulcer, for though the stomach may be made 
 to move up and down by deep respiratory move- 
 ments, the pain remains stationary. Another reason 
 against assuming the pain to be in the organ is 
 that the pain may extend to regions beyond the limit 
 of the organ. This fact, though observed, has 
 never received the consideration it merits in connec- 
 tion with the locating of the pain. Thus, a pain may 
 be described as being felt in an organ and extending 
 in various directions beyond the limits of the organ. 
 I have endeavoured to explain why it does this by 
 pointing out how it is caused by an extension of 
 the stimulus in the spinal cord to the nerve supply of 
 regions adjacent to the nerves supplying the offend- 
 ing viscus (page 47). In certain cases this extension 
 to regions beyond the site of the organ has been 
 recognised. Thus in angina pectoris the pain may 
 start in the chest and radiate to the left arm. This 
 is spoken of as a pain starting in the heart and 
 shooting into the arm — the pain in the heart being 
 of the nature of a localised pain in the organ, while 
 the pain in the arm is a referred pain. To such an 
 argument as this one cannot alwa^^s bring direct and 
 demonstrable objections, but if all the evidence 
 present in certain cases be considered it will be 
 found that the reasonable conclusion to draw is that 
 the pain in the chest and the pain in the arm arise in 
 the same manner. On page 96 I show that the nerves 
 supplying the chest-wall are in close association in 
 
Visceral Pain — contiyiued. 57 
 
 the spinal cord with those supplying the arm, and 
 that both sets of nerves are thus closely associated 
 Avith the origin of the sympathetic nerves supplying 
 the heart. The question naturally arises, is the pain 
 in the arm not merely an extension of that felt in the 
 chest, and due to an extension of the stimulation in 
 the spinal cord ? When all the facts in certain cases 
 are considered, then an affirmative answer to such a 
 question can be reasonably given. Thus the pain 
 may be felt with greater intensity in the arm than 
 in the chest. I have witnessed attacks of angina 
 pectoris where the pain Avas felt in one case in the 
 left upper arm, and in the other in the left lower 
 arm. In both cases the pain started in the chest and 
 radiated to the arm, and the patients nursed the arm 
 across the chest, rocking backwards and forwards in 
 agony. In other cases the pain has been equally 
 severe in arm and in chest, and on careful inquiry 
 the patients could find no difference either in the 
 character or severit}^ of the pain in the two places. 
 Finally, after an attack, or after a series of attacks, 
 of angina pectoris the skin and subcutaneous tissues 
 in the region of the chest and arm where the pain 
 was felt became hyperalgesic, and it is reasonable to 
 conclude that there is a direct relation between the 
 pain and the hyperalgesia, and that these phenomena 
 were due to the stimulation of the same nerves. As 
 these nerves are the cerebro-spinal nerves supplying 
 the chest wall and the arm, the pain in the chest has 
 the same kind of origin as the pain in the arms, i.e., 
 the pain in angina pectoris is a referred pain. 
 
 A similar series of phenomena can be 
 seen in affections of other organs, where the 
 contiguous nerve centres in tlic spinal cord 
 
58 Chapter V. 
 
 supply parts widely separated. Thus, in renal colic 
 the pain is described as being felt in the ureter, then 
 shooting into the testicle. On page 46 I point out the 
 meaning of this distribution of the pain, and that 
 observation clearly shows the mechanism by which 
 the pain and other reflex phenomena are produced. 
 
 Another argument employed to indicate that 
 pain may be felt in the organ is that the pain is felt 
 not only in the situation where it is known that the 
 organ is situated, but that it is felt deeper than 
 the skin. Thus, the pain in angina pectoris is 
 variously described as being under the breast-bone, 
 and some physicians describe it as being in the aorta, 
 and as actually travelling along the arch of the 
 aorta. This idea also seems to receive support when, 
 in addition, some agency directly affecting the organ 
 seems to give rise to the pain, as in gastric ulcer on 
 taking food ; or in the case of pain arising from the 
 oesophagus on drinking hot fluids. 
 
 Before determining the nature of the pain in 
 such cases it is necessary to realise certain peculiari- 
 ties in the character of visceral pain. It is not 
 possible to describe visceral pain by any features 
 peculiar to it, for, although many varieties might 
 be described, there is nothing in any of them to dis- 
 tinguish them from the pain resulting from stimu- 
 lation of a cerebro-spinal nerve itself, either in its 
 peripheral distribution, or in some part of its course 
 in the trunk of the nerve or in the central nervous 
 S3 stem. It is for this reason that one frequently 
 finds patients suffering from pain due to a visceral 
 lesion treated for neuritis, neuralgia, rheumatism, or 
 some affection peculiar to a cerebro-spinal nerve. In 
 many cases of visceral pain, though the suffering 
 
Visceral Pain — continued. 59 
 
 may be very great, the pain itself is of so vague and 
 ill-defined a character that its exact situation is not 
 easily ascertained unless attention is paid to this 
 point while the pain is actually present. Because of 
 this vagueness in locality it is sometimes assumed 
 that this vagueness is an evidence of its presence in 
 an organ, as it is notorious that the viscera are defi- 
 cient in the nervous mechanism subserving the func- 
 tion of localisation. This interpretation of the seat of 
 pain would seem to be strengthened by the fact that 
 patients will often say that the pain is felt deeper 
 than the skin, as if it were in their insides. If, 
 however, we examine those patients in whom the 
 pain is found to radiate some distance away from 
 the offending organ, it will be found that the same 
 kind of sensations — the vagueness, and the depth of 
 the pain, are also present in what is undoubtedly 
 referred pain. It is in cases of heart pain that 
 this can also best be studied. It frequently happens 
 that the patient will describe the region in which the 
 pain is felt in such general terms that no clear con- 
 ception can be acquired of the situation of his pain. 
 He may say he feels it in his arm, but be uncertain 
 in which arm he feels it. Or, if he describes it as 
 appearing in the left arm, he can give no clear idea 
 of the particular part of the arm. If, however, he be 
 interrogated while he is actually suffering from the 
 pain, he will describe with accuracy the parts in 
 wliicli the pain is felt. It is my custom in these cases 
 to ask the patient to note accurately the situation in 
 which the pain is felt, and the manner in which it 
 spreads, in the next examination the patient, if he 
 has suffered in the meantime from a recurrence of the 
 pain, can usually give a very clear account of the 
 
60 Chapter V. 
 
 pain and its radiation, and will indicate with pre- 
 cision the distribution of contiguous nerves in the 
 chest and arm, as shown in such figures as Fig. 6, 
 p. 95, and Fig. 18, p. 238, whereas in the first 
 account no such definite description could be 
 obtained. 
 
 The situation of the pain in regard to its depth 
 is the same in referred pain in the arm as in the 
 chest. In angina pectoris the patient will describe 
 his pain as deep in the arm ; "in the flesh " is a 
 description not infrequent. If in such cases it be 
 asked if the pain here differs from that felt in the 
 chest — differs, that is to say, from the pain supposed 
 to be felt "in the heart " — the answer Avill be that 
 they are identical in character, the only difference 
 being that sometimes the chest pain is the more 
 severe, and in other cases that the arm pain is the 
 more severe. This peculiarity in the sensation of 
 depth of pain, or, when it is on the trunk, the 
 attributing of pain to some internal organ, is seen 
 also in such a characteristic affection of the cerebro- 
 spinal nerves as herpes zoster. It has been estab- 
 lished b}^ Head and Campbell that this complaint is 
 due to an inflammation of the ganglia of the root of 
 the posterior spinal nerves. In places where no 
 eruption appears, or long after the eruption has 
 healed, pains of a most excruciating character may 
 be experienced. In their description of these pains 
 the patients will state that they feel deep in the 
 belly, and not infrequently the patient attributes 
 these to his bowels and consults his doctor lest a 
 cancer or some other painful disease has affected his 
 bowels. These pains of herpes zoster are also often 
 somewhat vague and difficult to localise with 
 
Visceral Pain — continued. 61 
 
 precision, though they are always felt within an area 
 of definite hmits. The same features are present 
 when the pain due to herpes is in the arm, and in 
 one case the pain occurred in paroxysms so hke an 
 attack of angina pectoris that at first I felt inclined 
 to attribute the pain to an attack of that affection. 
 The appearance of a herpetic eruption on the chest 
 and arm revealed the true cause (compare the 
 shaded areas in Fig. 6, p. 95, and Fig. 7, p. 97). This 
 feeling of pain deep in the body is, therefore, no 
 reason for assuming the pain to be in the organ. 
 The pain resulting from drinking hot fluids, due in 
 all likelihood to stimulation of the oesophagus, 
 cannot be felt in the oesophagus. The pain itself is 
 felt so distinctly in the middle line of the front of 
 the chest, while the oesophagus does not lie alto- 
 gether in the middle line. Furthermore, the 
 oesophagus is situated actually nearer the skin of the 
 back, yet the pain is never, or rarely, felt in this 
 position. It seems more reasonable that the 
 oesophageal pain follows the laws that regulate the 
 mechanism of pain in the other portions of the 
 digestive tube as described in Chapter XII. {see also 
 Fig. 8., p. 117). 
 
 Another explanation for the pain being felt at 
 a distance from the offending organ is sometimes 
 put forward when it is said that the individual 
 refers the pain to the place usually occupied by the 
 viscera, according to a law of " average localisation." 
 This so-called law is a pure assumption and neglects 
 or ignores the essential facts, and is indeed merely 
 a means to avoid a difficulty. When cases of 
 "average localisation" are carefully examined, other 
 phenomena may be found, which shed light upon the 
 
62 Chapter V. 
 
 distribution of the pain. When no evidence can be 
 found to explain satisfactorily the region in which 
 pain is felt, it is far better to acknowledge our 
 ignorance and strive to remedy it, than to stultify 
 one's position by giving some plausible explanation 
 incapable of proof. 
 
( 63 ) 
 
 Chapter Vl. 
 
 INCREASED SENSIBILITY OF THE 
 EXTERNAL BODY WALL. 
 
 "29. Hyperalgesia. 
 
 30. Cutaneous Hyperalgesia. 
 
 31. Muscular Hyperalgesia. 
 
 32. Hyperalgesia of Other Structures. 
 
 33. Effect of Exercise on Hyperalgesic Muscles. 
 34 The Areas of Cutaneous Hyperalgesia. 
 
 35. The Areas of Muscular Hyperalgesia. 
 
 36. Tender Vertebrce. 
 
 29. Hyperalgesia. — In the older writings ten- 
 ■derness of the tissues in visceral disease sometimes 
 receives a passing reference. Morgagni mentions 
 it, and John Hunter, after an attack of angina pec- 
 toris, speaks of his left arm being very sore, so that 
 he could not bear it to be touched. In 1891, a 
 patient I had been attending for an attack of gall- 
 stone colic called upon me, and as he entered my 
 room I observed he was holding his right arm stiffly 
 away from his side. On inquiring why he did this, 
 he told me that the skin was so tender he could not 
 bear the slightest pressure. On stripping him, I 
 found a large field of skin extremely tender to touch, 
 covering the upper part of the abdomen and lower 
 part of the chest wall on the right side. This caused 
 me to look for cutaneous tenderness in other cases, 
 and I found it fairly frequentty, and I published an 
 account of these observations in 1892, when I called 
 
64 Chapter VI. 
 
 attention to the fact that there was a distinct 
 relationship between the viscera and certain defined 
 areas of skin. This method of examination was also 
 taken up by Head, who had previously been making 
 researches on the origin of pain in visceral disease, 
 and he mapped out the areas of cutaneous hyperal- 
 gesia in visceral disease that corresponded to the 
 areas of eruption in herpes zoster. I pursued the 
 subject further, and found that not only did the 
 surface of the skin become occasionally hyperalgesic, 
 but the deeper layers and the muscles also, while 
 glands, like the mammae and testicles, become also 
 very tender. This tenderness of the muscles wa& 
 invariably coupled with an extremely sensitive and 
 powerful reflex contraction, so that on the lightest 
 palpation they often became violently contracted. 
 In addition, the muscles sometimes became con- 
 tinuously contracted for long periods. As these 
 muscular phenomena are of considerable importance, 
 I shall deal with them in the next chapter. 
 
 30. Cutaneous Hyperalgesia. — Cutaneous 
 hyperalgesia due to visceral disease exists in two 
 forms, superficial and deep. The former is recog- 
 nised by an extreme sensitiveness of the skin when 
 lightly stroked by a pin head, or by moving hairs, 
 and the latter when pressure between finger and 
 thumb is made to the whole thickness of the skin. 
 The superficial form is comparatively rare, and the 
 deeper form is always present with it. The area in 
 which the superficial occurs is less than, and included 
 within, the deeper. The borders are in both cases 
 ill-defined and inconstant ; at one moment the 
 patient will say the skin is tender, and on returning 
 to this part a few minutes after, the patient may 
 
Increased Sensibility of the External Body Wall. 65 
 
 not feel it tender. The result is that the liyperal- 
 gesic area is ill-defined, and I have been unable to 
 verify any exact limitation of fields such as Head 
 describes. 
 
 31. Muscular Hyperalgesia. — Hyperalgesia of 
 the muscles is far more common than hyperalgesia 
 of the skin, but can only be recognised with cer- 
 tainty when the skin sensibility is unaltered, as 
 hyperalgesia cannot be accurate^ recognised in 
 deeper structures if the skin covering them is 
 tender. Before testing for deeper hyperalgesia the 
 condition of the cutaneous sensibility should first be 
 ascertained. 
 
 The same method — grasping between the finger 
 and thumb— is the best also for eliciting the 
 hyperalgesia of such structures as the muscles. Many 
 of the muscles, as the sterno-mastoid, upper border 
 of the trapezius, pectoralis major, erector spinse, can 
 be grasped, and the sensibility compared with the 
 corresponding muscles of the opposite side. It is 
 not easy to do this always with the flat muscles of 
 the abdominal wall, particularly when they are con- 
 tracted. By such devices as pushing the finger into 
 the umbilicus the recti can be hooked up and com- 
 pressed. By light pressure on the contracted muscles 
 one can feel fairly certain of the hyperalgesic struc- 
 tures. Sometimes, to decide the matter, pressure has 
 to be applied to the origin of the muscles at the ribs, 
 when, with a little dexterity, the pressure can be 
 exercised on the muscle against the ribs. These 
 devices have to be resorted to when the muscles over- 
 lying a diseased organ are tender, as otherwise the 
 pain is often referred to the organ. As a rule the 
 tissues that are painful can be differentiated by 
 
66 Chapter VI. 
 
 observing that the hyperalgesic area extends beyond 
 the organ. Thus, in enlargement of the hver ten- 
 derness over the organ may be fomid, but it may be 
 difficult to tell whether the pain is in the organ or 
 external body wall. On mapping out the size of the 
 organ and the area of hyperalgesia, it will be found 
 that they do not correspond. 
 
 32. Hyperalgesia of Other Structures (extra 
 peritoneal tissue, mammae, testicle). — I have referred 
 to the layer of tissue outside the peritoneum in which 
 numerous fine nerve fibrils ramify. I am inclined to 
 think that this part can become very tender, as I have 
 found pain complained of when pressure was made 
 between the recti. It is very difficult, however, to 
 distinguish the tenderness of this tissue from that 
 of the skin and muscles. Glands, such as the 
 mammae and the testicles, may be very tender on 
 pressure. This can be shown by gentle pressure, first 
 making sure that there is no cutaneous hyperalgesia. 
 The reason for the pain on pressing the testicle is 
 explained on p. 36. 
 
 33. Effect of Exercise on Hyperalgesic 
 Muscles. — The exercise of muscles affected with 
 this hyperalgesia usually results in increasing the 
 hyperalgesia, inducing pain and contraction of the 
 muscles. The hard, tender belly, and " dragging " 
 pains found in various visceral affections, as gall- 
 stones, renal calculus, appendicitis, are always asso- 
 ciated with, if not due to, this muscular hyperalgesia. 
 In such cases walking induces pain, and the contrac- 
 tion of the muscles may compel the patient to stoop. 
 
 After exercising the muscle, or after the testing 
 for muscular hj^peralgesia, the patient may suffer 
 from aching in the muscles which may last for hours. 
 
Increased Sensibility of the External Body Wall. 67 
 
 34. The Areas of Cutaneous Hyperalgesia. — 
 
 Sherrington has demonstrated that the spinal nerves, 
 after they leave the spinal cord, are distributed to 
 the skin in fairly definite areas around the body. 
 Somewhat similar areas are found in herpes zoster, 
 which Head and Campbell have shown to be due to 
 destructive inflammation of the ganglia of the pos- 
 terior nerve roots. These areas are spoken of as 
 " segments," and the spinal cord is supposed to be 
 " segmentally " arranged. The question arises, is 
 the hyperalgesia of \4sceral disease segmental in its 
 distribution ? If by this is meant that when hyperal- 
 gesia appears it first extends to the whole of one 
 segment before affecting the next, the answer is in 
 the negative. When hyperalgesia appears it extends 
 very definitely along portions of neighbouring nerve 
 areas, and from my observation is never limited to 
 the full extent of one " segment." The spread is from 
 one definite portion of a nerve area to another, with- 
 out completely affecting the whole of one " segmen- 
 tal " area. In widespread hyperalgesia the whole of 
 a series of nerve areas may be affected, as when one 
 half of the trunk is hA^peralgesic. The manner of 
 spread is well seen in certain cases of angina pec- 
 toris, when it may begin in a patch affecting portions 
 of the distribution of the third and fourth thoracic 
 nerves, and extend into the arms affecting portions 
 of the second and first thoracic nerve areas. 
 Although appearing in tlie region of distribution of 
 four nerves the hyperalgesia does not affect the 
 whole of the distribution of any one. Cutaneous 
 hyperalgesia will usually be found in an ill-defined 
 patch occupying portions of the fiekl of distribution 
 of one or more spinal nerve roots. The centres of 
 
68 Chapter VI. 
 
 these nerves in the cord will be found to be in close 
 association with the sympathetic nerves from the 
 offending viscus. 
 
 35. The Areas of Muscular Hyperalgesia. — 
 There is great difficult^' in delimiting the areas of 
 muscular hyperalgesia, as frequently only portions of 
 the muscle are demonstrably hyper algesic. In such 
 muscles certain spots may be more tender than the 
 rest. Here a small nerve- trunk may be pressed upon, 
 and this nerve may be distributed to other tissues 
 than the muscle (as in McBurney's point). I am 
 disposed to consider that the sensory nerve supply 
 of a muscle is from the same region of the cord as 
 the motor. As the motor supply is more accurately 
 known than the sensory, we may by this means more 
 accurately ascertain the centre of stimulation in the 
 cord. 
 
 It has been long known that the muscles have 
 an afferent nerve supply reaching the cord by the 
 anterior nerve roots with the motor nerves. Head 
 describes a form of pain elicited by compressing 
 muscles which is conveyed by these nerves. 
 Whether these are the nerves that show tenderness 
 in muscular hyperalgesia I cannot say, but, if so, 
 their centres in the spinal cord must be in close 
 proximity to the nerve that conducts pain from the 
 skin. 
 
 36. Tender Vertebrae. — In many cases of vis- 
 ceral disease pressure over the spines of certain 
 vertebrae elicits pain, sometimes of a very acute 
 character. I have not been able to account satis- 
 factorily for the manner in which this arises. These 
 ■ tender vertebrae are usually associated with areas of 
 hyperalgesia in the skin and muscles of certain 
 
Increased Sensibility of the External Body Wall. 69 
 
 Fig. 2. 
 
 Areas in which pain is sometimea felt in affections of heart (a) ; of 
 tho stomach (b) ; of the liver (c) ; of the rectum and uterus (n). The 
 numbers refer to the dorsal vertebrae, and those included in each area are 
 sometimes tender in diseases of the organ to whic^h the letters refer. 
 
70 Chapter VI. 
 
 definite areas, at some distance from the spinal 
 column. Such hyperalgesic areas are supplied by 
 the nerves that issue from the cord at the level of 
 the tender vertebrae. The skin over the vertebrae 
 may not be hyperalgesic, so that the pain is elicited 
 from deeper structures. The pain is referred to the 
 region of the vertebrae that are tender. These tender 
 vertebrae must not be confused with the spinal ten- 
 derness so common in certain neurotic cases. In 
 these latter the tenderness is not limited to a few 
 vertebrae, but the whole spine is tender on pressure. 
 In 1892 I gave a figure showing the vertebrae that I 
 found tender in association with lesions of certain 
 organs, and continued observation has confirmed the 
 opinion there expressed. The vertebrae that are 
 tender in association with the different organs are 
 shown in Fig. 2. 
 
 If the visceral origin of the tenderness of these 
 vertebrae be not kept in view, an error in diagnosis 
 may result from the fact that the tender vertebrae 
 may be looked upon as evidence of disease of the 
 spinal colum.n. This is all the m,ore likely to be the 
 case if there is well-marked evidence of cutaneous 
 hyperalgesia. I have seen a patient encased in a 
 plaster of Paris jacket on the recommendation of 
 a distinguished neurologist, because of an extreme 
 tenderness of the sixth and seventh dorsal vertebrae, 
 and a band of marked hyperalgesia of the skin 
 around the left half of the upper part of the 
 abdomen. At the post-mortem examination no 
 disease of the spinal column could be detected, but 
 there was a cancer at the cardiac end of the stomach. 
 
( 71 ) 
 
 Chapter yil 
 
 THE VISCERO-MOTOR REFLEX. 
 
 37. Definition. 
 
 38. Effects of Stimulation of Motor Nerves on Limb 
 
 Muscles and on Flat Abdominal Muscles. 
 
 39. Character of the V iscero-motor Contraction. 
 
 40. Conditions Causing the V iscero-motor Reflex. 
 
 41. Experimental Production of the V iscero-motor. 
 
 Reflex. 
 
 37. Definition. — By the term viscero-motor 
 reflex I mean the contraction of voluntary muscles in 
 the external body wall in response to a stimulus 
 arisin^^ from a viscus, as distinct from the normal 
 superficial reflex where the muscle gives a brief con- 
 traction in response to a stimulus from the skin (as 
 the plantar reflex). Everyone is familiar with the 
 viscero-motor reflex, wliicli is best seen in the board- 
 like hardness of the abdominal wall in certain vis- 
 ceral diseases. A similar reflex is found in the 
 muscles of a hmb when an adequate stinxulus arises 
 from an inflamed joint. A shoulder joint may be 
 absolutely immobile on account of the stronij; tonic 
 contractions of the surrounding muscles. if tlu' 
 
72 Chapter VII. 
 
 patient is put deeply under chloroform the muscles 
 relax, and the joint can be freely moved, and while 
 being moved a grating may be detected. As the 
 patient recovers from the general anaesthetic, the 
 muscles again become firmly contracted and fix the 
 joint. 
 
 38. Effects of the Stimulation of Motor 
 Nerves on Limb Muscles and on Abdominal 
 Muscles. — It is in the muscles forming the abdo- 
 minal wall that this reflex can best be studied. Some 
 years ago I pointed out that these muscles could be 
 demonstrated to possess the power of contracting in 
 small sections in response to visceral stimulation. 
 Later I found that Sherrington had described a 
 difference in the reaction to nerve stimulation 
 between these flat muscles and the muscles of the 
 limbs. The fibres that constitute the nerve supply 
 of any given muscle leave the spinal cord in separate 
 bundles. If one of these bundles be stimulated the 
 whole length of a limb muscle like the sartorius will 
 contract. On the other hand, if one of the bundles 
 that constitute the nerve supply of one of the 
 abdominal muscles be stimulated, only a portion of 
 the fibres of the muscle will contract. 
 
 The contraction of a small portion of the 
 abdominal muscle, in response to a visceral stimulus, 
 may remain for an indefinite period. The limited 
 hardness thus arising gives to the palpating hand 
 the impression of an underlying tumour, and not 
 only does it give the impression, but it is often 
 mistaken for a tumour. I have, on several occasions, 
 seen experienced surgeons and physicians make this 
 mistake, and at the subsequent operation no tumour 
 was found. This hard contracted portion of a muscle 
 
The Viscero-motor Reflex. 73 
 
 is often h\'peralgesic, and its tenderness is readily 
 mistaken for an evidence of tlie sensitiveness of the 
 supposed " abdominal tumour." 
 
 The extent of this contraction of the abdominal 
 muscle is variable. In appendicitis it may be limited 
 to a few strands of muscle, which may be mistaken 
 for the appendix itself. It may be more extensive 
 and resemble a rounded tumour, and this, in appen- 
 dicitis, is often mistaken for swelling in and around 
 an appendix (the perityphlitis of olden days). On 
 the other hand, the whole of the right side of the 
 abdomen, and even a portion of the left, may be 
 found hard and board-like. 
 
 39. The Character of the Viscero-motor Con- 
 traction. — There are features in these contracted 
 muscles that have not been appreciated, and which 
 open up some new points in the physiology of con- 
 tracted muscle. As a rule the contraction is long 
 continued, lasting, it may be, for daj^s or weeks — or it 
 may be months — as long as the visceral lesion keeps 
 up an adequate stimulus. As a rule it begins as a 
 slight increase in the tonicity of the muscles, and 
 is detected through one side of the abdomen or one 
 portion of a muscle being a little more resistant than 
 other parts. At this stage it is readily provoked to a 
 strong and firm contraction by palpation. If, as 
 often happens, the skin or the muscle itself is 
 hj'peralgesic its reflex contraction is very readily 
 induced, but after the contraction it remains for a 
 time strongly contracted. Thus, in palpating the 
 epigastrium in cases of gastric ulcer, if the part is 
 not explored with gentleness the muscles imme- 
 diately become contracted, and remain strongly 
 •contracted. On the other hand, if very gently 
 
74 Chapter VII. 
 
 palpated, all that can be detected is a resistance 
 slightly greater than normal, and with the slightest 
 increase of pressure an increase in the hardness of 
 the muscle is produced. 
 
 When this contracted muscle is examined under 
 chloroform certain characteristic features are found. 
 It is, as a rule, the last portion of the muscular 
 system to yield to the influence of the anaesthetic, 
 remaining hard and contracted when all the other 
 muscles are limp and flaccid. The chloroform has 
 often to be pushed, and even in deep anaesthesia no 
 relaxation may take place. I have sometimes 
 observed that the muscles yield after an attack of 
 sickness. In many cases the contraction persists, 
 however deep the anaesthesia, and however long it 
 may be pushed. In such instances, when the muscle 
 is cut during an operation the fibres remain stiff and 
 unyielding, and one is much hampered in forcing an 
 opening through the cut muscle. Thus, in one case 
 of appendicitis the muscle was rigid and hard, and 
 gave the impression of an underh' ing tumour. When 
 cut the fibres would not yield, and I had much 
 difficulty in getting my finger in to explore the 
 abdomen. There was no underlying tumour, and 
 the peritoneum and bowel in the neighbourhood 
 were perfectly healthy. Deep down an inflamed and 
 suppurating appendix was found. 
 
 The contraction may come on suddenly with the 
 sudden onset of some visceral trouble. Thus, in a 
 case of renal calculus, cited on page 44, the onset of 
 pain was immediately succeeded by the contraction 
 of the abdominal muscles, and the patient was also 
 conscious of the contraction of the cremaster muscle 
 by the pulling up of the testicle. In angina pectoris 
 
The Viscero- motor Reflex. 75 
 
 the sudden onset of the powerful contraction of the 
 intercostal muscles is recognised by the feeling of 
 compression of the chest, which is so great at times 
 that the patient states that he feels as if his breast- 
 bone would break. 
 
 40. Conditions Causing the Viscero -motor 
 Reflex. — There are many conditions which produce 
 this reflex. Peritonitis causes it, and as the muscle 
 is usually also tender, these symptoms of hardness 
 and tenderness of the abdominal wall have come to 
 be looked upon as undoubted evidence of peritonitis. 
 But these symptoms ma}^ be, and often are, present 
 with absolutely no peritonitis. Thus, I have found 
 tenderness with firm contraction of the lower part of 
 the left rectus abdominis muscle in a case of stone 
 in the bladder without peritonitis. Hardness and 
 tenderness of the recti over the epigastrium is com- 
 mon in gastric ulcer, and I have found these symp- 
 toms without any peritonitis. I have also found 
 hardness over a limited area in the left lumbar 
 region due to a tuberculous ulcer in the posterior 
 wall of the descending colon, and there was no peri- 
 tonitis underlying the hard and tender muscle. In 
 like manner widespread tenderness of the abdominal 
 wall witli hard contraction of the whole abdominal 
 muscles may occur without any peritonitis. As 
 illustrating the extensive muscular contraction due 
 to visceral stimulation I cite the following case : I 
 was summoned to operate upon a fellow practitioner 
 for obstruction of the bowels. The symptoms were, 
 no movement of the bowels for two days, nor had 
 any flatus been passed ; some vomiting, but not 
 faecal ; considerable abdominal distension, with gi*eat 
 hardness of the whole abdominal wall, and pain on 
 
76 Chapter VII. 
 
 the slightest pressure. Some difficulty was experi- 
 enced in passing the finger into the bowel on account 
 of the strong contraction of the sphincters. The 
 patient had severe attacks of pain every few 
 moments. The pain began in the left lumbar region, 
 passing forwards and downwards towards the pubes. 
 Pain was felt on light pressure on the left testicle. 
 From the situation of the pain, and the tenderness 
 on pressing the left testicle, I had no hesitation in 
 recognising the condition as one of renal calculus. 
 In my experience the pain in obstruction of the 
 bowel is never so distinctly one-sided. The inability 
 to have the bowels moved was simply due to the 
 violent contraction of the sphincters, such contrac- 
 tion, with the contraction of the abdominal muscles, 
 being due to the renal calculus. The diagnosis was 
 confirmed by the passage of a calculus next day with 
 immediate disappearance of all the symptoms. This 
 patient had two subsequent attacks with a repe- 
 tition of all the foregoing symptoms. The contraction 
 of the muscles was undoubtedly due to a violent 
 stimulation passing from the affected organ to the 
 spinal cord. There the irritation spread, affecting 
 not only the centres of the sensory nerves, but also 
 the centres of the motor nerves. These stimulated 
 gave rise to violent muscular contractions — the 
 viscero-motor reflex. 
 
 41. Experimental Production of the Viscero- 
 motor Reflex. — Professor Sherrington has recently 
 been making an investigation into the effects pro- 
 duced in the abdominal muscles by stimulating the 
 sympathetic nerves. He dissects out and divides a 
 branch of the solar plexus going to the bowel, and 
 stimulates the central end. There is an immediate 
 
The Viscero-motor Reflex. 77 
 
 response in the broad muscles of the abdomen, which 
 contract over an extensive area. By dividing one 
 after another the anterior roots of those spinal 
 nerves that supph^ this extensive area, the extent of 
 the contraction becomes greatly limited until when 
 there is but one posterior root left intact the contrac- 
 tion becomes limited to a few fibres of the muscle. 
 
 This investigation is not yet completed. 
 Professor Sherrington having given me this verbal 
 description ; but it is not necessary here to insist 
 further upon the matter than to point out that 
 the recognition of the visceral nerve that is capable 
 of producing a given contraction of a limited portion 
 of the muscle will prove an invaluable aid in 
 diagnosis. 
 
( 78 ) 
 
 CHAPTER VJII. 
 ORGANIC REFLEXES. 
 
 42. Vomiting. 
 
 43. Dyspnoea. 
 
 44. Secretory Reflexes. 
 
 45. Cardiac Reflexes. 
 
 46. Vaso-motor and Pilo-motor Reflexes. 
 
 There are a number of reflex acts, apart from 
 the viscero-sensory and viscero-motor reflexes, pro- 
 duced by the stimulation of centres in the spinal 
 cord and medulla from a viscus. These acts may be 
 very complicated, bringing into play a large number 
 of subsidiary centres as in the reflex act of vomiting, 
 or they may result in the stimulation of some gland 
 as the salivary glands or the kidney. JMan}^ of these 
 reflex acts are obscure, as the vaso-motor, and there 
 are probably others we have not 3'et attained tlie 
 means of detecting. 
 
 42. Vomiting. — Vomiting is due to the stimula- 
 tion of a centre in the medulla, and this may be 
 plaj^ed upon from a great many sources, as from 
 irritation of the stomach, from disturbances in the 
 brain, impressions made on the senses of smell and 
 sight. It is frequently set up reflexly from stimula- 
 tion of the viscera of the abdominal cavity as in 
 affections of the liver or bile ducts, kidnej^, ureter. 
 
Organic Reflexes. 79 
 
 uterus, ovaries, testicles. Its occurrence with con- 
 traction of non-striped muscle is a curious feature. 
 In labour an attack of vomiting may be induced at 
 the same time as a uterine contraction. Colic due to 
 renal calculus and gall-stone — the pain arising from 
 contraction of the ureter or gall duct — is often 
 accompanied with vomiting. This association of 
 vomiting with the contraction of hollow muscles, so 
 common in abdominal organs, never occurs in affec- 
 tions of the heart or lungs, nor in affections liniited 
 to the bladder or rectum. I do not remember ever 
 seeing vomiting arise as a reflex in heart affections, 
 nor for that matter from a lung affection. One may 
 get vomiting from the stress of coughing, as in 
 phthisis or whooping cough, but it is doubtful if it 
 arises as a reflex from stimulation of the lungs or 
 pleura. In acute febrile conditions vomiting may 
 arise, as in kidney disease, from some general 
 poisoning effect. 
 
 43. Dyspnoea. — The centre for respiration is 
 also in the medulla, quite close to the vomiting 
 centre. Dyspnoea may arise directly from the pre- 
 vention of the entrance of air into the lungs, or 
 because the blood does not take up a sufficient amount 
 of oxygen. It may be excited reflexly also, as seen 
 on the application of a peripheral stimulus (immer- 
 sion in cold water causing a deep inspiration). In 
 affections of the lung, as pneumonia, pulmonary 
 apoplexy or infarcts, intense dyspnoea may arise, far 
 greater than the mere occlusion of the air cells 
 would account for, and it is generally assumed that 
 this breath lessness is due to a reflex stimulation of 
 the respiratory centre. Thus I have seen a patient 
 seized with an attack of pulmonary apoplexy of 
 
80 Chapter VIII. 
 
 small extent, and breathlessness of great severity 
 supervene. After lasting a few hours the dyspnoea 
 would suddenly cease, and the patient breathe com- 
 fortably. Some forms of asthma are undoubtedly 
 reflex. Dyspnoea may arise in heart affections as a 
 pure reflex, altogether apart from the amount of 
 blood that is supplied to the lungs. This is best seen 
 in cardiac asthma, and can be demonstrated in some 
 cases where there is enlargement of the liver. Gentle 
 pressure on the liver with both hands will fill the 
 right heart and distend the veins in the neck, and 
 the patient will at once experience a feeling of 
 dyspnoea. The sense of breathlessness is of great 
 importance in the examination of cases of heart 
 failure. 
 
 The possibility of a reflex spasm of the bronchial 
 muscles should be kept in mind, in view of the fact 
 that all non-striped muscles are liable to be played 
 upon, and a prolonged contraction produced. 
 
 44. Secretory Reflexes. — When the stimulus 
 from a viscus reaches a part of the spinal cord where 
 arise nerves supplying glands, increased flow of 
 secretion occurs. This is best seen in the kidney and 
 salivary glands. In a number of cases of angina 
 pectoris the pain may extend to the jaws, and the 
 saliva may dribble from the mouth. A similar reflex 
 affects the kidney. Some individuals, after an attack 
 of severe pain, as angina pectoris or headache, or 
 after some stimulation of an organ, such as paroxys- 
 mal tachycardia or mental excitement, have a desire 
 to micturate and pass a large quantity of pale urine 
 of low specific gravity. These two reflexes are due 
 to stimulation of centres in the medulla. Wherever 
 the nerve centres supplying separate organs are in 
 
Organic Reflexes. 81 
 
 close approximation, the stimulation of one viscus 
 may affect another. In many cases of sub-acute 
 appendicitis, for instance, there is frequent micturi- 
 tion though the appendix may be situated at some 
 distance from the bladder. 
 
 From the consideration of these organic reflexes 
 it is clear that there must be some special connection 
 from such remote organs as the testicle and ureter 
 (severe vomiting ma}^ occur in orchitis and in renal 
 colic) and the niedullary centres, probably b}^ some 
 special path in the spinal cord. In certain cases the 
 stimulus m.ay reach the medulla by the afferent fibres 
 of the vagus. 
 
 45. Cardiac Reflexes. -Of all viscera the heart 
 is the most sensitive to stimulation, and the result of 
 stimulation is most readily recognised. This readi- 
 ness to respond to stimulation is necessary to the 
 demands of the economy, for it is on this account 
 that effort can be undertaken with ease and comfort, 
 the heart rate increasing with the demand made by 
 effort. The heart is so readily susceptible to so 
 many influences that it is often impossible to deter- 
 mine the mechanism by which its changes in action 
 are brought about. Mental impressions have so 
 powerful an effect that reactions playing first upon 
 the mind may secondarily affect the heart, and it is 
 difficult in many cases to tell whether the heart's 
 stimulation is direct or secondary to the mental 
 stimulation. Temperature has also a very marked 
 influence on the heart apart from the toxins which 
 cause the rise of temperature. Toxins may at the 
 same time have an influence on the heart, so that it 
 is im.possible in many cases to tell how much of the 
 heart's reaction is due to the rise in temperature, 
 
82 Chapter VIII. 
 
 and how much to the infection. Experimentally it is 
 known that by such means as pinching the stomach 
 wall, reflex stimulation of the heart takes place 
 through vagus excitation, and even the act of 
 swallowing in man can sometimes be shown to affect 
 the heart. Hence it is often assumed that many ab- 
 normalities in rate and rhythm of the heart are of 
 visceral origin, and this may be so, as one sometimes 
 finds certain irregularities increased by stomach 
 disorders. Nevertheless one has to be very careful 
 before accepting such conclusions, as a very great 
 many abnormalities in the heart's action are attri- 
 buted to reflex stimulation when the real cause is in 
 the heart itself. 
 
 46. Vaso-motor and Pilo-motor Reflexes. — 
 The peripheral circulation is also susceptible to 
 reflex stimulation through the influence of the vaso- 
 motor nerves. Except in such cases as flushing and 
 the redness or heat of the ears or of the cheek in 
 pulmonary affections, vaso-dilator reflexes are not 
 often recognised. Vaso-constrictor effects are more 
 common though they have not been sufficiently in- 
 vestigated. As they are often accompanied by the 
 pilo-motor reflexes they are often assumed to be due 
 to the pilo-motor reflex. Thus the sensation accom- 
 panying the appearance of " goose-skin " is usually 
 put down as a goose-skin sensation. Goose-skin is 
 due to the contraction of the muscles attached to the 
 hair roots, and, doubtless, their contraction does give 
 rise to a sensation as when one feels the hair rise 
 on the scalp. But the curious chilly sensation is due 
 to a vaso-constrictor effect, for it can be felt in 
 regions where there are no pilar m.uscles, as on the 
 ulnar border of the hand. The explanation I suggest 
 
Organic Reflexes. 83 
 
 is that the stimulation which causes the pilar 
 contraction causes also a vaso-constriction, for the 
 pilar and vaso-constrictor nerves both belong to the 
 autonomic system, and are associated in their origin 
 and distribution. This association is well brought 
 out in the following experiment. If in a suitable 
 case the skin under the nipple be given a smart rub 
 with a piece of flannel, the goose-skin will be seen 
 to arise over the part rubbed, then to spread up the 
 chest to near the clavicle, and on to the inner side of 
 the upper arm and forearm. At the same time the 
 individual may feel the curious chilly sensation 
 passing from his chest into his arm and to the ulnar 
 border of the hand. The reason for this distribution 
 is that the stimulus produced by the rubbing has 
 reached in the spinal cord the centres of origin of 
 the pilo-motor and vaso-constrictor nerves, and 
 passed up this region for some little distance. That 
 this is so can be inferred from the fact that the 
 pupil will be seen to dilate at the same time. The 
 dilator pupillae nerve, according to Langley, leaves 
 the cord at the place where this stimulation has 
 taken place — that is to sa}^ by the upper thoracic 
 nerves. In one instance, a patient described always 
 a chilly sensation in his cheek when I tried this ex- 
 periment on him, and Sherrington saj^s that in 
 stimulating the sympathetic fibres issuing with, the 
 third thoracic nerve in the monkey, he produced 
 elevation of the hair of the cheek. 
 
Chapter TX. 
 
 LAWS DETERMINING THE NATURE OF 
 THE REFLEX SYMPTOMS. 
 
 47. Mechanism of the production of " direct fain " 
 
 and " referred j)ainJ^ 
 
 48. The Viscero-motor Reflex. 
 
 49. The Organic Reflexes. 
 
 50. Irritable Foci in the Spinal Cord. 
 
 5L Exaggerated Reflexes due to Irritable Foci in 
 the Cord. 
 
 52. Relation of Visceral Lesion to Site of Reflex. 
 
 In this chapter I give a resume of the fore- 
 going observations in order to bring clearly forward 
 the mechanism of the production of the reflex 
 symptoms. 
 
 47. Mechanism of the production of " direct 
 pain " and " referred pain." — From what has been 
 said in regard to the production and recognition of 
 pain it will be realised that from the practical and 
 clinical point of view pain can arise from peripheral 
 stimulation in two ways, what may be called " direct 
 pain " and " referred pain." Leaving out of con- 
 sideration the pain arising from direct implication 
 of the nervous system by disease (as affections in the 
 nerve-trunks and in the central nervous system), and 
 considering only the pains arising from stimulation 
 
Laws determining nature of Reflex Symptoms. 85 
 
 of the peripheral distribution of the cerebro- 
 spinal and of the sympathetic nerves, we recognise 
 that pain induced in either case is always accom- 
 panied by a judgment of locality, that is, the pain is 
 referred to some region more or less well defined. 
 There is, however, this difference— in the case of the 
 cerebro-spinal nervous system the region in which 
 the pain is felt is the region in which the painful 
 stimulation occurs, whereas in the sympathetic 
 system the region in which the pain is felt is not 
 the region in which the painful stimulus occurs. 
 
 The mechanism of the production of direct 
 pain (cerebro-spinal) and referred pain (sympa- 
 thetic) can be shown b}^ the two accompanying 
 diagrams. Fig. 3 represents the course of the sen- 
 sory and motor cerebro-spinal nerves from their 
 centres in the spinal cord to the periphery. If a 
 stimulus be applied to the skin (Sk), the sensation is 
 conveyed by the sensory nerve (SN) to the spinal 
 cord, and up to the brain. The brain becomes con- 
 scious of the stimulus, and recognises the place from 
 which the stimulus arose. In Fig. 4 there is added 
 to the diagram of Fig. 3 two organs (V and V) with 
 sympathetic nerves (SyN) passing from them to the 
 spinal cord, and these nerves terminate in cells near 
 to the motor and sensory cells connected with the 
 motor and sensory nerves (MN, SN). 
 
 A stimulus, adequate to produce pain, arising 
 in the organ V passes to the spinal cord, extends 
 beyond its own nerve cell and affects neighbouring 
 cells. These cells being thus stimulated respond 
 according to their function, so that when the sensory 
 cell is stimulated pain arises and the brain recog- 
 nising this pain forms, at the same time, a judgment 
 
86 
 
 Chapter IX. 
 
 Fig. 3. 
 
 Diagram to represent the mechanism of pain and the superficial or 
 skin reflex arising from stimulation of a sensory cerebro -spinal nerve (SN). 
 An adequate stimvilus applied to the skin (Sk) or to any part of the 
 sensorj' nerve (SN) in the external body wall, spinal cord or brain is per- 
 ceived by the brain (Br), and referred to the peripheral distribution of the 
 nerve in the external body wall (Sk, M). The stimulus from the skin may 
 in the spinal cord pass to the cell of a motor nerve (MN) and simulating 
 it cause a contraction of a muscle (M). 
 
Laws determining nature of Reflex Symptoms. 8' 
 
 Fig. 4. 
 Diagram to represent the mechanism of visceral pain, cutaneous and 
 muscular hyperalgesia (viscero-sensory reflex), the viscero-motor reflex, and 
 the organic reflex. An adequate stimulus proceeding from the organ, V, 
 by the sympathetic nerve, SyN, to the centre in the spinal cord extends to 
 the cells of nerves in its neighbourhood, and stimulates them to activity, 
 when the fimction peculiar to each nerve is exhibited. Thus the stimulus 
 affecting the cells of a pain norve, SN, results in the perception of pain 
 which is referred by the brain to the peripheral distribution of the nerve 
 in the external body wall (Sk,M) ; affecting the cell of a motor nerve, MN, 
 causes a contraction of the muscle, M, HU|)plied by the motor norve ; 
 affecting the colls su])plying other viscera (as V") stiniulates them to their 
 peculiar fvmction (contraction of a hollow muscular viscus, iiicroased 
 secretion of a secretory organ). If the stimulus be of sufficient strength 
 it may leave an irritable focus in the spinal cord (shaded area) as shown 
 l)y a persistent hyperalgesia of skin and muscle (Sk,M) and by a persistent 
 contraction of the muscle (M). 
 
88 Chapter IX. 
 
 of locality. That locality, however, is not the region 
 where the pain stimulus arose (organ V), but at Sk 
 in the peripheral distribution of the sensory nerve 
 whose centre in the spinal cord had been stimulated. 
 For this reason visceral pain is seen to be of the 
 nature of a viscero-sensory reflex, and is " referred " 
 to the peripheral distribution of the sensory cerebro- 
 spinal nerves whose centre in the spinal cord is in 
 close association with the sympathetic centre 
 supplying the offending viscus. 
 
 48. The Viscero-motor Reflex. — In diagram 
 Fig. 3, the stimulation of the skin may produce other 
 symptoms than that of pain ; it may, for instance, 
 produce a reflex contraction of the muscle (M), whose 
 nerve centre in the spinal cord is in close association 
 with that of the sensory nerve (the superficial or 
 skin reflex). In a like manner the stim.ulation 
 reaching the spinal cord from the organ V (Fig. 4) 
 may produce a reflex contraction of the same muscle 
 (the viscero-motor reflex). It is this reflex that 
 causes the hard contraction of the abdominal muscles, 
 or some portion of them, in disease of the abdominal 
 viscera and the mechanism of their production is 
 shown in Fig. 4. 
 
 49. The Organic Reflexes. — In Fig. 4 there is 
 also shown in the spinal cord the close association of 
 the nerve centres from the viscus V with that of the 
 viscus V^ It has already been pointed out that a 
 stim.ulus reaching the spinal cord may, if of adequate 
 strength, stimulate other nerve cells in its neighbour- 
 hood, and these respond according to the nature of 
 their functions, producing pain and muscular con- 
 traction as we have seen. If the nerve supply of 
 another organ be stimulated, then that organ will 
 
Laws determining nature of Reflex Symptoms. 89 
 
 respond according to its peculiar function, so that in 
 the affection of one viscus we may get reflex stimula- 
 tion of other viscera, as in the frequent micturition 
 from stimulation of the bladder centre in appendi- 
 citis, or increased flow of urine or saliva in angina 
 pectoris. Our knowledge of the exact relationship 
 of nerve centres does not permit of the real 
 mechanism being always ascertained, but the clinical 
 facts point to a relationship as in the production of 
 vomiting from organs so remote as the testicle and 
 uterus. 
 
 50. Irritable Foci in the Spinal Cord. — If the 
 symptoms arising in cases of visceral disease be 
 analysed after the manner in which a focal lesion in 
 the brain or spinal cord is analysed, then the true 
 nature of the sjmiptoms present will be appreciated. 
 This manner of looking at the subject will demor- 
 strate that in many cases of visceral disease nearly 
 the whole of the symptoms present are really due 
 to a stimulation of a limited portion of the central 
 nervous system. Thus, the shaded portion of the 
 spinal cord in Fig. 4 may be looked upon as being 
 rendered abnormally excitable in consequence of a 
 violent stimulation from the organ V. All the 
 centres in this region become abnormal^ sensitive to 
 stimulation, and this is recognised b}^ the exalted 
 functions of organs supplied from this region (hyper- 
 algesia, muscular contraction, and undue activity of 
 other organs). 
 
 The stimulus that has had so marked an effect 
 upon the spinal cord not only produced the charac- 
 teristic reflexes just described, but has rendered the 
 sensory centre abnormally sensitive so that the area 
 stimulated is left in a condition of excessive 
 
90 Chapter IX. 
 
 irritability. Thus, the hyperalgesia of skin and 
 muscle that is often so marked a feature in visceral 
 disease is due to the fact that a stimulus which would 
 normally produce no painful sensation on reaching 
 the spinal cord excites an abnormally sensitive 
 centre, with the result that the sensation of pain is 
 felt. That this is the explanation is shown by the 
 further fact that a stimulus reaching this excitable 
 area in the cord from other sources also produces pain 
 which is referred to the hyper algesic tissues (skin or 
 muscle). Thus, in a case of gall-stone colic, accom- 
 panied by jaundice, there is also extreme hyperal- 
 gesia of the skin of the upper part of the abdomen, 
 especially marked in the epigastrium. This per- 
 sisted for some days after the stone had passed and 
 had been found in the stool. During the time the 
 hyperalgesia persisted, food taken into the stomach 
 produced severe pain referred to the epigastrium. 
 With the disappearance of the hyperalgesia of the 
 skin the pain, on taking food, ceased. Here there 
 seem,s little doubt that the stimulation set up by the 
 ingestion of food, which normally passes to the 
 spinal cord unperceived by the brain, reached that 
 portion of the cord which had been abnormally 
 excited by the gall-stone colic. The irritable focus 
 thus produced in the cord had extended to the 
 centres of the cutaneous nerves for pain which 
 supply the epigastric region, so that the brain now 
 perceived the stimulation as pain and referred it to 
 the peripheral distribution of the nerves thus 
 stimulated. 
 
 I have lately been observing another remarkable 
 manner in which these abnormally sensitive foci in 
 the cord ma}^ be stimulated. My attention was 
 
Laws determining nature of Reflex Symptoms. 91 
 
 directed to this aspect of the question by the 
 foUowing experience : A lady who suffered from 
 endometritis experienced pain in her back across the 
 top of the sacrum, with tenderness and stiffness of 
 the muscles of the back in the lumbar region. She 
 told me that if she were startled, as by the banging 
 of a door, a pain would suddenly shoot into this 
 tender region of the back. 
 
 I have made inquiries of a number of other 
 patients, and have found abundant corroboration of 
 this experience ; so much so that many people in 
 whom there is a hj^peralgesic area (cutaneous or 
 deeper) experience a sudden pain in that region 
 when startled. Thus, one patient, who suffers from 
 a gastric ulcer, was frightened, on her way to con- 
 sult me, by being accosted by a drunken man, and 
 she felt a severe pain in the epigastrium at the same 
 time. In her case there was a great tenderness of the 
 skin and muscles of the epigastrium on light pres- 
 sure. Another patient, with a dilated heart and 
 great tenderness of the left side of the chest, de- 
 scribed how someone unexpectedly laid a hand upon 
 her shoukler, so that she started, and at the same 
 time a severe pain struck into her left breast. The 
 explanation I give for the occurrence of these pains 
 is that, Mlien startled, a stimulus passes down cer- 
 tain tracts of the spinal cord, affecting normally the 
 centres of the muscular nerve supply, as evidenced by 
 the sudden contraction of nearly all the muscles of 
 the body. The stimulus is not of sufficient strength 
 to affect the sensory nerves in a healthy cord, but 
 when there are abnormally irritable foci the stimu- 
 lus, passing through these, affects the excitable 
 sensory nerve centres, and the pain so arising is 
 
92 Chapter IX. 
 
 referred to the peripheral distribution of the nerve 
 stimulated. It may be that the pain is produced by 
 a stronger and painful contraction of the excitable 
 and hyperalgesic muscles. 
 
 A somewhat similar result follows on extra 
 stimulation of motor nerves whose centres are 
 excited by visceral stimulation. When there is an 
 exalted viscero-motor reflex, the muscles are in a 
 permanently more contracted condition than that 
 which the normal tonicity maintains, as evidenced 
 in the fiat muscles of the abdomen by the greater or 
 less hardness with which we are all familiar. This 
 is due to their being exercised in their function as 
 part of the protective mechanism. If now they be 
 exercised in their other functions by assisting in the 
 movements of the body, the combined result of these 
 two stimuli is to produce a continuous and increased 
 shortening of the muscle. This was remarked in the 
 case of appendicitis, cited on page 42, where the 
 psoas muscle caused the patient to stoop when she 
 walked a short distance. In another patient, who 
 suffered from renal colic, after an attack had passed 
 there always persisted for a few days a slight tender- 
 ness and rigidity of the lower part of the right rectus 
 muscle. When he went about the whole of the muscle 
 became so contracted after a few hours that he could 
 not straighten himself, but walked with his body 
 slightly bent. After a short rest the contracted 
 muscle would slightly relax. A similar condition is 
 found in those cases of " lumbago " where the pain 
 and stiffness of the muscles arise from some pelvic 
 trouble — endometritis, haemorrhoids, etc. 
 
 51. Exaggerated Reflexes due to Irritable 
 Foci in the Cord. — In all these hyperalgesic areas 
 
Laivs determining nature of Reflex Symptoms. 93 
 
 due to a focal irritation of the spinal cord the 
 ordinary cutaneous reflex is more easily excited and 
 the muscular response more vigorous and often more 
 prolonged than normal. I need not labour this point 
 as the fact is so readily demonstrated, and every one 
 is familiar with the hardening of the abdominal 
 wall when any tender part is palpated with even 
 very gentle pressure. This springing up of the 
 hardened muscle serves as an efficient protection of 
 the underlying viscera, and the purpose of the cuta- 
 neous and muscular hyperalgesia is manifestly to 
 render the reflex muscular contraction rapid and 
 powerful. In severe cases this muscular contraction 
 does not at once relax, but the muscle may remain 
 contracted for long periods, and even under deep 
 anaesthesia. 
 
 52. Relationship of Visceral Lesion to Site 
 of Reflex. — Recognising the fact that the pain and 
 other sensory phenomena are to be found in the 
 peripheral distribution of some cerebro-spinal sen- 
 sory nerve, it is necessary, for the detection of the 
 offending viscus, to know the relationship between 
 the distribution of the cerebro-spinal nerves in the 
 external body wall and the individual organs. In 
 the primitive vertebrate, before the development of 
 the limbs, each spinal nerve is distributed round the 
 body. The sympathetic nerves supplying the viscera 
 issue from the cord with the cerebro-spinal nerve 
 and supply the viscera at the same level, so that the 
 nerve supply of the organ and the nerve supply to 
 the covering external wall arise from the same region 
 of the spinal cord. 
 
 In Fig. 5 there is a diagi-am showing the posi- 
 tion of the heart in a primitive vertebrate. From the 
 
94 
 
 Chapter IX. 
 
 Fig. 5. 
 
 Diagrammatic representation of a primitive vertebrate animal — 
 the Amphioxus — divided for convenience into three segments for 
 the head, seven for the neck, twelve for the thorax, nine for the 
 lumbo-sacral region, and an indefinite number for the coccygeal region. 
 For clearness of comparison the heart (H) is represented as occupying 
 the same position as in man, so that an adequate stimulus from the heart 
 would cause pain in the distribution of the four upper thoracic nerves 
 covering and protecting the heart. Compare distribution of thoracic 
 nerves with Fig. 6. ( After Ross.) 
 
Laws determining nature of Reflex Symptoms. 95 
 
 Fig. 6. 
 
 The shaded area shows the distribution of the pain and cutaneous 
 hyperalgesia in a typical case of angina pectoris. The ronian numbers 
 refer to the nerves implicated, viz., I, II, III, and IV, thoracic nerves, 
 and VIII, cervical nerve. Compare the nerve distribution with Fig. 5, and 
 the shaded area with the position of the herpetic eruption in Fig. 7. 
 
96 Chapter IX. 
 
 spinal cord the nerves pass to be distributed around 
 the body wall. In addition to these, a branch is 
 given off which runs to the sympathetic ganglia to 
 be distributed to the heart (H). When a stimulus 
 of adequate strength passes from the heart through 
 the sjmipathetic to the spinal cord the result is 
 shown in the stimulation of the sensory and motor 
 nerves arising at that level, so that these reflex 
 phenomena are exhibited in the immediate neigh- 
 bourhood of the suffering viscus. 
 
 In the course of development, particularly with 
 the appearance of the limbs, this relationship of the 
 situation of the viscus to the distribution of the 
 allied cerebro-spinal nerves becomes modified, 
 although the relationship of the spinal and sympa- 
 thetic nerve remains. The viscera become displaced 
 backward, and the nerves that were wont to run 
 transversely round the body at the level of their exit 
 from the cord become distributed in an apparentl}^ 
 irregular fashion. Thus, the lower cervical and 
 upper thoracic nerves are distributed mainly in the 
 arm, so that the nerves supptying the skin over the 
 clavicle, and as low as the second rib, com,e from 
 the fourth cervical, while the adjacent skin lower 
 down on the chest is supplied from the second 
 thoracic nerve — the intervening nerves being distri- 
 buted in the arm. The sympathetic fibres supplying 
 the heart arise from the spinal cord at the level of 
 the upper thoracic nerves, so that the pain in affec- 
 tions of the heart is felt in the distribution of these 
 nerves. In the case of the primitive vertebrate 
 represented in Fig. 5, the pain would be over the 
 heart, whereas in man the pain is felt not only over 
 the heart, but in the arm, where the upper thoracic 
 
Laws determining nature of Reflex Symptoms. 97 
 
 Fig. 7. 
 
 The shaded areas show the distribution of the eruption in a case of 
 herpes zoster affecting the upper thoracic nerves. (Compare with the 
 area of hyperalgesia in Figs. 6 and 18) 
 
98 Chapter IX. 
 
 nerves are distributed, and tliis accounts for the 
 characteristic distribution of the pain in angina 
 pectoris (Fig. 6). 
 
 In herpes zoster there is an inflammation of the 
 gangha on the posterior roots of the spinal nerves, 
 and when the ganglia on the upper thoracic nerves 
 are affected, the eruption has a distribution closely 
 resembling the hypersesthetic area in angina pec- 
 toris (compare Fig. 7 with Fig. 6). 
 
 The same diversion of nerves takes place in the 
 lumbar region, where the lumbar plexus is distri- 
 buted to the inferior extremity, and, as a conse- 
 quence, the symptoms of visceral disease may appear 
 in the leg. 
 
 In addition to the disarrangement from the 
 primitive plan of the limb nerve-supply, the organs 
 themselves have shifted their position, such organs 
 as the heart and stomach being situated further 
 back, while the testicles migrate far away from their 
 embryonic position. 
 
 It is in consequence of this diversion of nerves 
 and displacement of organs that the symptoms 
 arising from a viscus may be exhibited at some 
 considerable distance from the situation of the 
 viscus. 
 
( 99 ) 
 
 Chapter X. 
 
 PRELIMINARY EXAMINATION OF THE 
 PATIENT. 
 
 53. The Patienfs Appearance. 
 
 54. The Patienfs Sensations. 
 
 55. Facial Aspect. 
 
 56. The General Condition. 
 
 57. A Review of all the Organs. 
 
 53. The Patient's Appearance. — Before enter- 
 ing upon the physical examination of the patient, the 
 physician ought to obtain a clear and comprehensive 
 appreciation, of the patient's own sensations. I 
 therefore wish to insist upon the importance of the 
 preliminary examination, which may be of more 
 value in arriving at a correct estimation of the 
 patient's condition than the most elaborate methods 
 of physical examination. The attempt to appreciate 
 the patient's condition should begin when first he 
 presents himself. On his appearance in the con- 
 sulting room, his bearing, his gait, the condition of 
 his respiration, the colour of his face, any nervous 
 peculiarity in his manner of speech and behaviour, 
 and so forth, should be noted. If he is in bed, note 
 the position he assumes, and any change in his colour 
 or respiration in response to such exertions as talk- 
 ing or turning over. By habit one unconscioush' 
 
100 Chapter X. 
 
 notices these things, and as the exanaination pro- 
 ceeds, first one trivial matter, then another, may 
 arise, which helps materially in guiding the exam- 
 ination, and in forming the final opinion. 
 
 54. The Patient's Sensations.— After ascertain- 
 ing the patient's name, age, and occupation, ask 
 him to describe briefly his chief symptoms.- After 
 this inquire into the history of any previous illnesses 
 or circumstances that may have a bearing on his 
 present condition, as the nature of his work, condi- 
 tion of worry, bygone adventures, and hereditar}^ 
 pre-disposition. The data thus elicited will serve as 
 a guide to a further inquiry into the symptoms 
 of which the patient complains. This should be 
 undertaken with the greatest minuteness, and the 
 answers should be precise and definite. When the 
 patient refers to his sensations, get him to indicate 
 the location by placing his hand over the region, and 
 on no account be content with his assertion that his 
 sensation has been felt in some viscus, as the 
 stomach, heart, bladder. When any disagreeable 
 sensation as pain is complained of, get a clear know- 
 ledge of the very earliest circumstances under which 
 it was produced, the situation in which it was first 
 felt, and the areas into which it spread. In 
 the same way, if it is breathlessness, the first sign of 
 its appearance and the circumstances that induced 
 it. In putting the questions the doctor should have 
 a definite purpose in view, based on the statements 
 made, but the questions must not be put in 
 such a manner that the patient will divine the drift. 
 It may be necessary, however, to ask leading ques- 
 tions, when it is suspected that other symptoms may 
 have been present which the patient has overlooked. 
 
Preliminary Examination of the Patient. 101 
 
 For instance, I have found patients dwell upon 
 symptoms referable to the epigastric region and 
 assumed to be gastric in origin ; further inquiry as 
 to whether there had been any pain in the shoulder 
 has frequently brought forth the answer that severe 
 pain had been felt on the top of the right shoulder, 
 but it was thought to be rheumatic or neuralgic. The 
 recognition of this pain then leads to the suggestion 
 that all the symptoms ma}^ be due to gall-stones. In 
 the same way, in obscure cases of pain in the lower 
 part of the abdomen, the question whether the 
 testicle was ever sore and tender has sometimes 
 brought out the answer that the breeches seemed at 
 times too tight, and were supposed to be the cause of 
 the testicular pain. The presence of this testicular 
 pain in such cases is often suggestive of renal 
 calculus. 
 
 It will be frequently found that the symptom, 
 such as pain even of the most severe type, is described 
 so vaguely that no definite idea can be obtained in 
 regard to its manner of onset, site, or radiation. In 
 such cases, if the patient be asked to note these par- 
 ticulars next time the suffering arises, he will often 
 be able to give a very clear and instructive account 
 of his symptoms. 
 
 I have said that a patient's answer that pain, or 
 any other sensation, was felt in an organ should 
 never be taken. I may add a warning to the doctor 
 not to make a note of the sensation by attributing 
 it to an}^ viscus ; thus, a pain should not be noted as 
 felt in the heart, stomach, liver, or lungs, but only 
 in the region indicated by the patient's hand, for 
 it \\ ill probably be found, on later examination, that 
 the disease was not in the supposed viscus. In oilier 
 
102 Chapter X. 
 
 words, he should make no notes that might prejudge 
 the nature of any symptom until he has all the evi- 
 dence before him. The results of this inquiry will be 
 a guide in the physical examination of the patient, 
 when corroborative evidence may be found in areas 
 of hyperalgesia of the skin and muscles, in con- 
 tracted muscles, or in functional or structural 
 symptoms in certain of the viscera. 
 
 55. Facial Aspect. — The first glance may at 
 once dispel the consideration of a large group of 
 complaints, as when a face is healthy-looking and 
 well-nourished there is no need to fear the presence 
 of any malignant or exhausting complaint. When 
 there is an absence of this healthy tinge the recogni- 
 tion of faint and subtle changes is useful. A 
 slight duskiness of the cheeks or lips indicates 
 imperfect aeration of the blood, and leads first to the 
 consideration of the pulmonary or circulatory con- 
 dition. A faint tinge of yellow in the duskiness 
 raises the suggestion of liver engorgement. This 
 faint yellow tinge is present in many conditions, as in 
 pernicious anaemia, malarial cachexia, and the 
 cachexia of malignant disease. A mere suspicion of 
 jaundice of the skin and conjunctiva, as in certain 
 cases of gall-stone disease, may give to the face the 
 suspicious look of a malignant cachexia, and so also 
 will certain forms of heart failure, particularly that 
 form which is often accompanied with wasting. In 
 the latter case the evident heart trouble gives a key 
 to the nature of the enlarged liver, which is usually 
 present. A dirty greyish aspect is sometimes seen 
 in aortic disease. 
 
 Pallor is a common feature, and while it may 
 indicate an anaemia (as chlorosis), yet it is natural 
 
Preliminary Examination of the Patient. 103 
 
 to many families, and one not infrequently sees such 
 people undergoing treatment for " anaemia." In 
 elderly people the pallor may indeed be associated 
 with various complaints, and it is often difficult to 
 tell what importance should be attached to the symp- 
 tom. I think on the whole the presence of a sallow 
 tinge is the most constant sign of malignancy- 
 bearing in mind what I have just said of the presence 
 of a slight jaundice in heart affections and gall-stone. 
 When people past the middle age suddenly develop 
 a pallor, the sign is one of grave significance, and 
 may be the first clue to the beginning of some 
 malignant affection (pernicious anaemia). Other 
 conditions should be recognised, as the flushed turgid 
 countenance of Graves' disease. Staring eyes, 
 while manifestly indicating the nature of the com- 
 plaint, may not be very distinctive, but a slight 
 prominence, which may momentarily increase while 
 the patient is being questioned, may be detected. 
 
 It is not possible here to detail the many other 
 instructive signs which the facial aspect pre- 
 sents, but I quote the foregoing as being the 
 most common, and would insist on the routine 
 study of the face all the time the patient is being 
 questioned. As a disease progresses the facial 
 aspect should be watched. In some, particularly in 
 cliildren, a sunken expression may appear in the 
 course of an attack of diarrhoea or pneumonia, due 
 to a shrinking of the contents of the orbit and of 
 the cheeks — often heralding a fatal issue. In the 
 course of a typhoid fever the dull look of indifference 
 may gradually be seen to creep over the face. A 
 gradual change in colour may be imperceptible to 
 tlie doctor wlio sees the patient day by day, but 
 
104 Chapter X. 
 
 is marked at once by one who sees the patient for the 
 first time, and this change — a shght pallor, or a 
 slight yellow tinge — may be the earliest sign of a 
 malignant disease (pernicious anaemia, cancer). 
 
 56. The General Condition.— It is undoubtedly 
 a misfortune that the study of what is called " tem- 
 peraments " has fallen into disuse. My own experi- 
 ence tells that the neglect of this basis of observation 
 is continually leading physicians and surgeons astray. 
 This is particularly the case with those who devote 
 themselves to some speciality. The possession of 
 certain temperaments, particularly the neurotic, 
 leads to exaggeration of the reflex symptoms, and a 
 trifling complaint is thus often mistaken for some- 
 thing more serious. We find such patients passing 
 from one specialist to another, each one attributing 
 the complaint to the fault of some organ which came 
 under his special purview. 
 
 Although it may not be possible to differentiate 
 exactly the six temperaments of Laycock (nervous, 
 sanguine, phlegmatic, bilious, lymphatic, and melan- 
 cholic), yet the consideration of each individual's 
 temperament should help us to estimate at its due 
 value the patient's symptoms and the account of his 
 or her sufferings. While we may not be' able to 
 classify temperaments with accuracy, yet in every 
 case the mental attitude of the patient to his com- 
 plaints should be borne in mind. Although, in a 
 general way, each individual is so constituted that 
 his temperament is a matter of inheritance, yet it 
 can be modified by circumstances. This is particu- 
 larly seen in people who become " neurotic " in 
 consequence of mental worry or long continuous 
 bodily suffering. 
 
Preliminary Examination of the Patient. 105 
 
 The characteristics of a patient's temperament 
 come out generally in the course of the preliminary 
 examination, in the manner, movements, and descrip- 
 tion of the complaints. 
 
 57. A Review of all the Organs. — In the 
 examination of patients the need for a thorough 
 inquiry may demand that all organs should be in- 
 quired into. It is, however, not feasible or even 
 necessary in the great majority of cases to make a 
 systematic examination into the condition of each 
 organ. 
 
 In an obscure case, and in cases where there is 
 some complication, and when there is time and 
 opportunity, no examination can be too careful or 
 too thorough. But the great majority of cases with 
 which the general practitioner has to deal do not 
 present such complicated features, and the pre- 
 liminary inquiry into the patient's symptoms gives 
 a clue to the organ chiefly at fault, so that it is 
 unnecessary that all the other organs should be 
 submitted to a detailed physical examination. It 
 is difficult to be certain when such thorough exami- 
 nation may be considered unnecessary, since, through 
 its neglect, many ailments may be overlooked. To 
 guard against this, many general practitioners have 
 devised for themselves methods which serve to guide 
 them in the detection of affections of organs other 
 than that of which complaint is made. 
 
 In the logical and thorough cross-examination 
 to which the patient is first submitted, a fair idea 
 can generally be obtained of the organ or region in 
 which there is trouble. Before examining more 
 specially that part, inquir}' should be made into the 
 functions of other organs. These may be at fault. 
 
106 Chapter X. 
 
 and ma}^ in reality be the real seat of the trouble, 
 and the patient, in describing the more prominent 
 features of his complaint, may have ignored some, 
 to him, trivial sign, which the systematic interroga- 
 tions may bring out. This inquiry need not be time- 
 robbing if the physician makes his questions clear 
 and distinct, and insists that the patient's replies 
 should be precise and to the point. In his inquiries 
 the physician should have some system in his own 
 mind, so that each question bears upon the symp- 
 toms of a single organ and has a definite significance. 
 Thus, after having exhausted the information of the 
 particular complaint, and having observed in the 
 course of his inquiry the general aspect of the 
 patient, as already described, he should then care- 
 fully inquire into the condition of other organs, 
 beginning as a rule with those related by position or 
 function to the complaint of the patient. Step by 
 step each organ is considered, and any that may 
 show evidence of derangement are reserved for fuller 
 investigation. To do this the essential symptoms of 
 derangement of any organ must be kept in view. 
 Thus, an inquiry is made into the condition of the 
 heart and circulation by asking if the breathing in 
 response to effort is good, or if he has palpitation or 
 breathlessness on running up stairs, beyond that, 
 which one would expect from his age and habits ; 
 into the lung condition by the presence of a cough, or 
 of trouble in the breathing ; into the digestive 
 system by the presence of discomfort at any time 
 before or after meals, and by the movement of the 
 bowel ; into the urinary system by the frequency of 
 micturition, and particularly as to whether the patient 
 has to get up in the night to pass urine. By following. 
 
Preliminary Examination of the Patient. 107 
 
 such lines as these, being often guided by some 
 incident in the patient's historj" or appearance, it will 
 usually be found that no essential sign is overlooked. 
 In all cases the patient's replies must be as direct and 
 to the point as the question asked. The tendency to 
 prolixity, which many patients show, must be firmly 
 repressed ; a clear reply should be obtained to each 
 question, and no question allowed to pass until the 
 answer is obtained. The patient may be so full of 
 his own view as to his condition that there may be 
 some difficulty in restricting him to the subject the 
 ph^^sician has in his mind, but if the phj^sician will 
 but be persistent in his method — having a clear 
 conception in his own mind as to what he requires — 
 the patient can usually be induced to give clear and 
 coherent replies. According to the tenor of the 
 replies the subsequent phj^sical examination will be 
 guided. In drawing conclusions from the results of 
 the examination it is necessary to consider the 
 bearing of any abnormality, or supposed abnor- 
 mality, on the sufferings of the patient. It often 
 happens that the complaint from which the patient 
 suffers is obscure, and the cause difficult or impos- 
 sible to determine. Should some other abnormality 
 be present, which is easily recognisable, then there 
 is a great tendency to attribute the symptoms to this 
 demonstrable abnormalit}'. 
 
 A patient of mine, suffering from some obscure 
 abdominal complaint, consulted a gynecologist, who, 
 finding an ovary which he considered too large, put 
 all the trouble and suffering down to this, and 
 removed it. Obtaining no relief, the patient sought 
 tlie opinion of a surgeon, who, finding a slight dila- 
 tation of the stomach, put all the symptoms down 
 
108 Chapter X. 
 
 to that, and performed a gastro-enterostomy, also 
 without reHef to the patient. In youth and in old 
 age certain forms of irregularity of the heart are 
 present in so many people that they may almost be 
 looked upon as normal, and have no important bear- 
 ing upon the patient's condition, yet when these 
 patients are found suffering from any obscure 
 condition, as weakness, fainting, or even epilepsy, 
 the diagnosis is often based upon this irregularity, 
 though its nature is not understood. To many 
 minds it is satisfying to detect an abnormal sign, 
 even though it has no connection with the complaint 
 from which the patient suffers. This tendency to be 
 misled by the detection of an abnormal sign is seen 
 very frequently in patients who may have a cardiac 
 murmur. All sorts of symptoms can be referred 
 back to this, and treatment for an innocent murmur 
 is often undertaken with unnecessar}^ energy to the 
 neglect of the essential cause of the patient's suffering 
 {see Chapter XXI.). 
 
( 109 ) 
 
 Chapter XL 
 
 SYMPTOMS OF AFFECTIONS IN 
 
 THE REGION OF DISTRIBUTION OF 
 
 CEREBRO-SPINAL NERVES. 
 
 58. Headache. 
 
 59. Sensory and Motor Symptoms. 
 
 60. Differential Diagnosis. 
 
 The functional and organic symptoms of affec- 
 tions of the external body waU and the Umbs are 
 usually so manifest that it is not necessary to deal 
 with them. Here certain phenomena are discussed, 
 connected more particularly with the reflex sensory 
 symptoms. 
 
 There are many phenomena resulting directly 
 from stimulation of some part of the external body 
 wall and limbs which, at first sight, are not easily 
 understood, and often simulate the sj^mptoms of 
 visceral disease. It is necessary to allude briefly to 
 the more important of these. 
 
 58. Headache. — There is much obscurity in 
 regard to the mechanism by which tlie pain of 
 headache is produced. I have made a number of 
 observations in all kinds of headache, and must 
 confess that I see no clear explanation. The con- 
 ditions inducing the headache, or associated with it, 
 are so varied tliat all sorts of theories can point to 
 some circumstances for their support. 
 
110 Chapter XI. 
 
 Certain forms of headache stand out very dis- 
 tinctly, and are of considerable diagnostic value, 
 such as the headache associated with cerebral 
 tumour, kidney disease, migraine. Others may arise 
 reflexly from some peripheral irritation, as eye- 
 strain, but I am somewhat doubtful of these cases 
 said to arise reflexly from more distant organs, as 
 from the abdominal viscera. A stomach headache is 
 the most common, but as absorption of toxins takes 
 place so readily from the digestive tract, I am not 
 clear as to the real nature of headache of this class. 
 
 The real confusion arises because of our in- 
 ability to identify the structures in which the pain 
 is felt ; whether, for instance, it is in the scalp or in 
 the membranes of the brain, or whether the real seat 
 may be in the central nervous system., and the pain 
 referred to the periphery. Whether the membranes 
 of the brain are sensitive or not still seems to be a 
 matter of some doubt, and personally, I have not had 
 sufficient opportunity of testing these membranes. 
 Even if it were the scalp in which the pain was felt, 
 Ave would have to question and consider what part 
 of the nerves is stimulated, whether, for instance, 
 their peripheral distribution, or some deeper part. 
 The variations of pain in the head, as felt by indi- 
 viduals, would seem to point to the stimulation 
 arising in different places, and it is probably for 
 this reason that so many theories can be found to 
 explain headache. 
 
 59. Sensory and Motor Symptoms. — The view 
 here expressed that pain is a function peculiar to 
 certain nerves of the cerebro-spinal system necessi- 
 tates the consideration whether any given pain is 
 referred {i.e., originates reflexly from some viscus), 
 
■Sym'ptoyns of Affections of Cerebrospinal Nerves. Ill 
 
 whether it is due to some lesion of the tissues sup- 
 plied by the sensory nerve, or whether it arises from 
 some affection of the nerve itself. In considering 
 this subject it must be remembered that pain stimuli 
 originating in the external body Avail may be referred 
 to other parts, and may be accompanied by muscular 
 contractions — symptoms of the same nature and 
 mechanism as the viscero-sensory and viscero-motor 
 reflexes. This is notably the case in joint affections, 
 where the pain is not infrequently referred to areas 
 at some distance from the joint. The best instance 
 is the pain felt on the inner side of the knee in 
 disease of the hip joint. As a matter of fact the 
 pains caused by joint affections are nearly all felt at 
 some distance from the joint. Thus, pain in affec- 
 tions of the shoulder joint may be felt down the arm 
 as low as the elbow, and the pain from the knee joint 
 may be referred over the head of the tibia. In many 
 joint affections the contractions of the muscles that 
 move the joint may be so strong as to lead to the idea 
 that the joint is ankylosed. This is particular^ 
 the case with some affections of the shoulder joint. 
 The joint may be immobile until the patient is deeply 
 under chloroform, when it will be found freely 
 movable. There can be little doubt that the pain and 
 the muscular contraction are due, not to a local 
 stimulation of the peripheral nerve, but to a central 
 stimulation. Hilton had called attention to the 
 resemblance of the symptoms in joint affections to 
 those of affections of serous cavities like the abdo- 
 men, and there can be little, if any, doubt that he was 
 right. In hip-joint disease the pain in the neighbour- 
 hood of tlie knee is usually put down to a stimulation 
 of a periplieral nerve that supplies tlie skin on tlie 
 
112 Chapter XL 
 
 inside of the knee, but though the pain is felt in the 
 distribution of this nerve, the real explanation is that 
 there has passed from the hip joint into the spinal 
 cord a stimulus which has excited the cord at the level 
 from which the obturator nerve arises. At this level 
 there also pass out the nerves supplying the muscles 
 around the hip joint, so that in addition to the pain 
 there is the stiffness and contraction of these muscles 
 which modifies the gluteal fold. This stiffness is 
 comparable to the slight hardening or increase in 
 tone of the flat abdominal muscles in visceral 
 disease, while the permanent contraction is like the 
 hardened abdominal muscles in visceral disease, and 
 the conditions are really due to an hritable focus in 
 the spinal cord at the level of the third or fourth lum- 
 bar segment produced by the lesion in the hip joint. 
 
 This view of the cause of symptoms opens up 
 the question of the nerve-supply of joints and the 
 sensitiveness of fche synovial membrane. I lean to 
 the idea that the synovial membrane, like the peri- 
 toneal, is insensitive to direct stimulation, and that 
 the pain arising from its stimulation is referred. 
 This may, perhaps, mean that the nerve-supply of the 
 joint arises not from the cerebro-spinal nervous 
 system, but from the autonomic. Pain may arise 
 from the contraction of muscles due to an increased 
 sensibility of the muscle, as well as from irritability 
 of the nerve-centres, as in reflex hyperalgesia. In 
 certain forms of rheumatism muscular contraction 
 may be present, giving rise to the " stiffness " in the 
 joints, best observed after a long rest. With gradual 
 exercise of the muscles the stiffness passes off. 
 
 Pain may arise from violent spasmodic contrac- 
 tion of the muscles, as in cramp. The pain in what 
 
Symptoms of Affections of Cerebrospinal Nerves. 113 
 
 is called muscular rheumatism is often due to con- 
 traction of voluntary muscles, as in lumbago, 
 stiff-neck, pluerodynia. 
 
 While these contractions are usually due to 
 some temporary affection of the muscles, similar 
 contractions may arise from irritation of the motor 
 nerves by some disease process as spinal caries. 
 
 80. Differential Diagnosis. — On account of the 
 fact that pain originating in any part of a nerve 
 in its course from the brain to its periphery is 
 referred to its peripheral distribution, there is often 
 a difficulty in determining the source of the pain 
 stimuli. The differential diagnosis must, therefore, 
 depend on a knowledge of how the pain arises, the 
 relationship of the nerve-supply of different regions 
 of the body to the central nerve-supply, and its 
 connection wdth the visceral nerve-supply. In the 
 absence of any demonstrable cause of stimulation at 
 the periphery, it is necessary to consider the possi- 
 bility of stimulation at more central parts. The 
 symptoms that may arise from an irritation of a 
 nerve-trunk, as from pressure, neuritis, or herpes 
 zoster, resemble in a great many respects those that 
 arise from visceral disease. So great, indeed, is 
 this resemblance that even the most experienced may 
 be led astray. Thus, the pain and hyperalgesia of a 
 stomacli affection may simulate the symptoms 
 produced by caries of tlie spine {see page 70), and the 
 shoulder-pain of gall-stone disease may be mistaken 
 for a neuritis. 
 
 It might have been supposed that pain due to 
 the stimulation of a nerve at its periphery, or at its 
 trunk, would have liad a distribution peculiar to 
 tlio peripheral distribution of the nerve branch so 
 
114 Chapter XI. 
 
 stimulated. If the region of the pain had been 
 limited to the part of the periphery stimulated, or 
 to the distribution of the nerve trunk, such a limita- 
 tion of the field of pain and hyperalgesia might have 
 given the desired indication, but, as has already 
 been shown (page 29), the stimulation of the peri- 
 phery of a sensory nerve, or of its trunk, causes a 
 spreading of the pain by reason of a central radia- 
 tion. It foUows that a local irritation may produce 
 such widespread phenomena as to simulate central 
 irritation. It is for this reason that the various 
 forms of " neuritis " so closely resemble the pains of 
 visceral disease, pains due to pressure on the trunk 
 of the nerve, or herpes zoster. 
 
 For the purpose of differential diagnosis it is 
 necessary to know how the pains of visceral disease 
 arise and spread. This knowledge can only be 
 acquired by careful study of individual cases, for 
 though certain general laws underlie the production 
 of these symptoms, there are differences in individual 
 cases. In doubtful cases the knowledge that in 
 visceral disease certain associated phenomena can 
 arise may often help to clear up a doubtful case. So 
 far as I can I deal with the characteristics of the 
 symptoms in the organs I have been able to study. 
 This description is far from complete, and does not take 
 into consideration symptoms that arise from certain 
 viscera (as the pancreas or spleen), because I have had 
 no opportunity of studying the symptoms in these 
 cases with sufficient precision, and the descriptions 
 usually given are too indeterminate to be of real value. 
 
 Before deciding that any given case is a neuritis 
 or a neuralgia, the possibility of visceral disease 
 should be carefully considered. 
 
( 115 ) 
 
 Chapter XII. 
 
 AFFECTIONS OF THE DIGESTIVE ORGANS. 
 
 61. The Nerve Supply of the Digestive Tract. 
 
 62. Distribution of Sensory Symptoms in 
 
 affections of the Digestive Tract. 
 
 63. Appetite. 
 
 64. Hunger. 
 
 65. Nausea. 
 
 66. Mouth and Fauces. 
 
 67. Tongue. 
 
 68. Swallowing. 
 
 69. (Esophagus. 
 
 61. The Nerve Supply oi the Digestive Tract.^ 
 
 The nerve supply of the digestive tract is derived 
 partly from the autonomic and partly from the 
 cerebro-spinal system. If one glances at Langlej^'s 
 diagram it will be seen that the autonomic supply 
 is derived from three regions : (1) from the bulbar 
 autonomic division by the vagus, distributed to 
 the walls of the gut from mouth to descending 
 colon ; (2) from the sympathetic cU vision b}' the 
 splanchnics, which supply the stomach, smaU intes- 
 tine, and greater part of the great intestine ; and 
 (.3) from the sacral autonomic division, which sup- 
 plies the descending colon and rectum. 
 
 The cerebro-spinal nerve supply is limited to 
 the oral and anal orifices. The sensations at the 
 
116 Chapter XII. 
 
 oral end are divided into those of common and 
 special sensations. The sensory nerves are derived 
 from the fifth cranial and glosso-pharyngeal, and 
 supply the mouth, fauces, and a small portion of 
 the upper end of the oesophagus ; the exact extent 
 has not been accurately defined. The mouth differs 
 from the skin in sensibility, touch being less acute 
 and less perfectly localised, though temperature 
 and pain senses are well developed. The nerves of 
 special sensibility (taste) in the tongue are derived 
 from the glosso-pharyngeal, fifth, and chorda tym- 
 pani nerves. The olfactory nerve, too, must be con- 
 sidered as an accessory nerve of digestion, for it has 
 remarkable effects in stimulating reflexly the salivary 
 and gastric glands, and also in the appreciation of 
 flavour. It has also, at times, a powerful effect in 
 inducing attacks of vomiting. 
 
 The distribution of the cerebro-spinal system 
 of nerves to the anal end of the gut is of very 
 small extent, being limited to little more than the 
 inner side of the external sphincter. So far as I 
 have been able to make out, the mucous membrane 
 covering the internal sphincter is devoid of direct 
 sensation. 
 
 62. Distribution of Sensory Symptoms in 
 affections of the Digestive Tract. — The nature of 
 the nerve supply explains the character of the 
 sensory symptoms evoked by affections of the diges- 
 tive tract. Limiting the study at present to the 
 subject of pain, it will be found that from the top 
 of the oesophagus to the anus there is, in the great 
 majority of instances, a limitation of the distribu- 
 tion of the pain to an area extending down the 
 centre of the body from about the middle of the 
 
Affections of the Digestive Organs. 117 
 
 Fig. 8. 
 
 The shaded parts show the areas in which jiain is felt in affections 
 of the digestive tnbe. Peristalsis ))assing through the whole digestive 
 tube may give rise to pain felt descending in the shaded area. 
 
 A. Area in which i>ain is felt in affections of the oesophagus. 
 
 B. Area in which pain is folt in affections of the stomach. 
 
 C Area in which pain is fdlt in affections of the small intestine. 
 D. Area in which pain is foit in affections of the large intestine. 
 
118 Chapter XIL 
 
 sternum to the symphysis pubis (shaded area in 
 Fig. 8). 
 
 If pain be produced by stimulating the 
 oesophagus, as, for instance, by a hot drink, the pain 
 is alwa3^s referred to the region over the lower part 
 of the sternum. Usually this pain is supposed to 
 be perceived " in the oesophagus," but if this sensa- 
 tion were in the oesophagus there is no reason why it 
 should not be felt better in the back, for the oeso- 
 phagus is nearer the posterior cutaneous surface 
 than the anterior. Pain arising from the stomach 
 is limited, in the vast majority of cases, to the 
 epigastrium. The best idea of intestinal pain is 
 found in watching a case of peristalsis of the bowel. 
 A painful peristalsis may start with pain referred 
 to the lower part of the epigastric region, then 
 it slowly descends with a grinding intermitting 
 severity until it reaches above the pubes, when the 
 call to defecate becomes urgent, and rehef is at once 
 found with the expulsion of a loose motion. In 
 such an instance the fluid has traversed the whole 
 intestinal tract, and the peristaltic waves have 
 passed into all quarters of the abdominal cavity, yet 
 the pain has descended in an even and unvarying 
 direction down the centre of the abdominal wall. 
 
 It is well to remember this feature of pain due 
 to peristaltic contraction of the gut, for it will be 
 found of frequent diagnostic importance in solving 
 the source of severe colic-like pains. As already 
 remarked, contraction of non-striped muscles is the 
 most frequent cause of violent visceral pain, and, as 
 a rule, when the pain is violent, it can be very 
 accurateh^ localised. This limitation of the pain to 
 the middle line of the body is characteristic also of 
 
Affections of the Digestive Organs. 119 
 
 the pain of other hollow viscera, as the gall-ducts, 
 uterus, and bladder, while the pain of renal colic 
 (contraction of the ureter and pelvis of the kidney) 
 is distinctly unilateral. 
 
 63. Appetite. — All actions that are performed 
 periodically or intermittently, in wliich volition par- 
 ticipates, are accompanied by sensations which make 
 known the time when the act has to be performed. 
 These sensations are in themselves not unpleasant 
 at first, but are accompanied b}" a desire to perform 
 voluntarily an act which will gratify that desire. 
 Thus, if the breath be held the desire to breathe is 
 not painful, but there is a longing for the sensation 
 of full inspiration. So, in regard to the call for 
 micturition and defecation, the sensation is one call- 
 ing for the gratification of a sense of relief. To 
 this categor}^ belongs the desire for nourishment, 
 liquid or solid — the appetite. 
 
 Appetite itself is a sensation so vague that no 
 definite description of its mechanism can be given, 
 though it is probably dependent on the digestive 
 glands in the mouth and the stomach. The con- 
 sciousness of appetite is accompanied by increased 
 secretion of these glands — so much so, that even the 
 contemplation of a satisfying meal may cause the 
 " mouth to water." The appetite or desire for food 
 may be increased by the sight or odour of tempting 
 viands, or even by the mental contemplation of them, 
 and an abundant flow of the gastric juices may 
 result from such stimulation. 
 
 The appearance of a normal appetite follows 
 the efficient absorption of food and its ex])enditure 
 in the production of energy. Thus it is seen at its 
 best in tliose wlio work in the open air. Tlie 
 
120 Chapter XII. 
 
 gratification of an appetite being amongst the most 
 elemental of pleasures, the presence of appetite is 
 a rough indication of health. Man's environment 
 so often prevents its display that means are taken 
 to excite an appetite by providing food in a manner 
 that will supply the craving. 
 
 These artificial aids, used to create appetite, 
 diminish the value of this sensation as a diagnostic 
 aid. The loss of appetite, as seen in animals 
 (horses, cattle), is the most important sign of im- 
 paired health, and its return is an indication of 
 restoration to health. In man also it has signifi- 
 cance, but, as man resorts to all sorts of artificial 
 aids, this significance is often diminished. Still the 
 question of loss and return of appetite affords 
 valuable aid in diagnosis. When an individual 
 loses his appetite it may be taken as an indication 
 that all is not well. The loss of appetite maj^, with 
 reasonable probability, be referred to a diminished 
 excitability of the secretory glands or their nerves. 
 The secretory reflexes which are associated with 
 appetite may be played upon in a great variety of 
 ways, as by mental excitement, impaired metabolism 
 (as in enforced rest), increased temperature and the 
 agents inducing it, affections of the digestive tube 
 and other organs. The symptom of anorexia, loss 
 of appetite, merely indicates, therefore, that there 
 is something wrong in the economy. Further ex- 
 amination may reveal the cause, and the behaviour 
 of the appetite may often prove a safe guide as to 
 the progress or retrogression of the ailment. 
 
 Certain results follow the loss of appetite ; the 
 tongue becomes furred, the mouth unpleasant from 
 the lack of the mechanical friction of the tongue 
 
Affections of the Digestive Organs. 121 
 
 against the palate and the absence of juices from 
 the inactive glands, abdominal discomfort arises 
 from the accumulation of flatus, and the bowels are 
 inactive from absence of stimulus. 
 
 An increased desire or craving for food (bouli- 
 mia) may arise during convalescence from a long 
 illness, such as typhoid fever. The craving is 
 probably due to the tissues losing the poisoned fluids, 
 returning to their normal state, and requiring 
 suitable nourishment of which they were deprived 
 during the illness. An abnormal appetite may be 
 one of a group of symptoms, referable either to the 
 nervous system, as in hysteria, or to conditions in 
 which there is no sign of mental defect, as in chloro- 
 sis, diabetes mellitus, intestinal worms. Enormous 
 quantities of food may be taken by those who are 
 thus affected. 
 
 Craving for certain forms of food is a frequent 
 sign, but there is often a craving for things that are 
 not food, and that are not digestible. This per- 
 verted appetite may arise as a matter of habit, for 
 the custom of eating earth (geophagy) is prevalent 
 among natives of widely separated countries. In 
 some cases the earth may contain nutritious proper- 
 ties, but in many cases it is used, not for its nutritive 
 value, but merely for the gratification of a perverted 
 taste, or to satisfy the craving in the absence of 
 proper food. Perversion of appetite is common 
 amongst the insane, but it is also present as a 
 bad habit amongst others, as children, chlorotic 
 females, pregnant women, and others who have no 
 particular ailment. The objects eaten or swallowed 
 are of the greatest variety, as chalk, coal, earth, 
 plaster, ashes, pebbles, etc. 
 
122 Chapter XII. 
 
 64. Hunger. — While the anticipation preceding^ 
 the performance of a periodic act may be pleasant 
 from the prospect of gratification, the undue delay 
 of performance results invariably in the sensation 
 becoming one of distress. Abstinence from food 
 may convert the sensation of appetite into one of 
 hunger, and hunger implies distress, and when 
 pushed to extreme is probably the most clamant of 
 all desires. Hunger becomes more than a mere 
 excess of appetite. Appetite is probably, as already 
 stated, the outcome of the active stimulation of 
 certain digestive glands, while hunger is the craving 
 of the whole body for nourishment, and the digestive 
 tract, with its limited sensations, is the vehicle for- 
 the sustenance of the whole economy. This is seen 
 by the fact that hunger may exist when the stomach 
 is full, the appetite gratified, but the food prevented 
 from reaching the tissues in consequence of an intes- 
 tinal fistula. Apart from hunger due to starvation, 
 an increased craving can be induced by measures 
 taken to stimulate the appetite, by cooking, and the 
 various means of providing " tempting bits," and 
 this may be carried so far as to become a perverted 
 habit. Perverted tastes may arise, however, from 
 custom, or as a symptom of disease. 
 
 65. Nausea. — The unpleasant sensation, nausea,, 
 is -often associated with loss of appetite and certain 
 affections of the stomach. Though it often comes 
 on at an early stage in the act of vomiting, it may 
 arise without vomiting, just as vomiting may 
 occur without any previous feeling of nausea. It 
 is associated with the digestive function, and its 
 appearance is accompanied by a stimulation of some 
 digestive glands, as shown by profuse flow of saliva.. 
 
Affections of the Digestive Organs. 123 
 
 In certain affections of the stomach, as in the gastric 
 catarrh of alcohoHcs, it is the most distressful 
 symptom, occurring usually after a long fast, as in 
 the morning before food is taken. It maj^ arise 
 suddenly from some reflex cause, as from a bad 
 odour, an offensive sight, or the appearance of 
 unattractive food. In addition to the disagreeable 
 sensation there is often some spasmodic contraction 
 of certain muscles, as the diaphragm with closure of 
 the glottis, as in the preliminary stage of vomiting. 
 Accompanying the nausea there is often a feeling 
 ilpfjaintness, the pulsej^ecomes soft, weak, and rapid^ 
 and the face^blanched, due in all probability to the— 
 action of the vagus diminishing the force of the 
 hea rt beat, and producing a vaso-m otor depression . 
 
 66.^outh and Fauces. — The pain complained 
 of in affections of the mouth and fauces may be local 
 or referred, or both. Local pain in the mouth may 
 be present in inflammatory affections of the mucous 
 membrane. In toothache it may be felt not only in 
 the affected tooth, but in neighbouring teeth, and the 
 jaw may become painful and tender. The pain may 
 be felt so severely in places apart from the offending 
 tooth that it requires some care to detect which tooth 
 is at fault. The pain may be referred to parts out- 
 side the mouth, in the cheek, or in some portion of the 
 head, and the skin may become very hyperalgesic. It 
 is necessarv in any case of " neuralgia " of the face 
 and the head to carefully examine the condition of 
 every tooth. 
 
 Tlie fifth cranial nerve is particularly liable to 
 stimulation from affections other than those arising 
 from the mouth, and the presence of pain in the dis- 
 tribution of the fifth nerve may be due to a variety 
 
124 Chaj>ter XII. 
 
 of causes. The most striking of these conditions is 
 when there is some distinct affection of the nerve 
 itself or the nerve ganghon, in the disease called 
 trigeminal neuralgia or tic douloureux. Before the 
 full character of this complaint is revealed in all its 
 terrible characteristics, there is a period in which it 
 resembles so closely the characters of a toothache 
 that at first it is almost invariably mistaken for this 
 complaint, and one decayed tooth after another is 
 removed. The pain continuing to recur, the dentist 
 next attacks the sound teeth, and not infrequently 
 every tooth is removed, yet pain continues to recur in 
 the edentulous jaw. Relief may be found after the 
 removal of one or more teeth, but, as with the opera- 
 tion for nerve stretching, it is but temporarj^ It is 
 not possible in the early stages to distinguish between 
 a case of true tic and a toothache. In both the pains 
 ma}^ recur at intervals, and, when there is hyperal- 
 gesia of the skin of the cheek in toothache, the resem- 
 blance between the two conditions is very complete. 
 Thus, stroking of the hair may be exquisitely pain- 
 ful, and may bring on a spasm of pain. When one 
 decayed tooth after another is removed with no last- 
 ing benefit, then the true nature of the complaint 
 may be suspected, but as one is loth to come to the 
 conclusion that the case is one of true tic douloureux, 
 the teeth extraction continues. 
 
 Another instructive form of pain occurs in cer- 
 tain forms of angina pectoris, where the pain is not 
 onty present in the chest and arms, but may be felt 
 in the lower jaw and throat. The pain of angina 
 pectoris may even start here, and be limited almost 
 entirely to this region. The feeling is described as a 
 sense of intense soreness along the lower jaw, akin to 
 
Affections of the Digestive Organs. 125 
 
 what is felt in some forms of toothache. The nerves 
 supplying the fauces, and the voluntary muscles en- 
 gaged in swallowing, may also be Iwpersensitive, so 
 that the patient has a good deal of pain in swallow- 
 ing. In rare cases, after a severe attack of angina 
 pectoris, the patient ma}^ complain of pain in 
 swallowing for weeks after the attack has passed off. 
 Doubtless, in such cases, the violent stimulation has 
 reached the medulla and upper part of the cord by 
 the vagus, and the stimulation has affected the 
 sensory cells in the neighbourhood and left an 
 irritable focus, as witnessed by the hyperalgesia of 
 the muscles and mucous membrane shown in the 
 act of swallowing. 
 
 Inflammator}" affections in the fauces often 
 cause great pain in the act of swallowing. When the 
 tonsils are acutely inflamed the increased secretion 
 of mucus continuously excites the act of swallowing 
 and causes great distress. The pain is felt not only 
 in the inflamed parts, but extends into the sides of 
 the neck, and up into the ear. The skin of the neck 
 behind the jaw may become hyperalgesic, and 
 frequently there can be detected enlarged and 
 tender glands behind the jaw. 
 
 A number of patients may complain of pain on 
 swallowing, and when careful investigation is made 
 it will be found to be due to a form of infection very 
 common amongst those who use false teeth where the 
 utmost cleanliness is not observed. The patient fre- 
 quently complains of a sore throat, and if the fauces 
 be inspected a slight redness of the pillars can be 
 detected. If the patient wears a plate on the roof of 
 the mouth, and this be removed, the underlying 
 mucous membrane will be found swollen and red, and 
 
126 Chapter XII. 
 
 from this place to the fauces there can be detected an 
 extension of the inflammation in the form of small 
 red dots. Sometimes the surface of the mucous 
 membrane, under the plate, may be covered with 
 patches of thrush, and an infective process may 
 extend to the parotid and sub-lingual glands, causing 
 severe inflammation and swelling of these glands. 
 Inspection of the mouth may reveal other abnor- 
 malities, as ulcers. 
 
 A very interesting instance of referred sensation 
 is seen in passing a bougie into the eustachian tube. 
 When a catheter is passed into the eustachian tube 
 for the purpose of insuflation, the sensation pro- 
 duced by the catheter is referred to the back of the 
 nose. If a bougie be passed along the catheter into 
 the eustachian tube, the sensation is at first referred 
 to some place between tiie back of the nose and the 
 ear. If the bougie be pushed further in, a part is 
 reached where the sensation is suddenly referred to 
 the neck behind the jaw. This transference of the 
 sensation is doubtless due to the parts being supplied 
 by nerve fibres from different sources — the exact 
 nature of the supply I am unable to determine. 
 
 67. Tongue. — In health the tongue should be 
 evenly and steadily protruded, moist, and of a 
 slightly translucent pale red colour. A tremulous 
 tongue should lead to an inquiry into the alcoholic 
 habits, and an unevenly protruded tongue to the 
 question of paralysis. 
 
 The principal cause of a furred tongue is 
 absence of friction, usually due to deficiency of 
 saliva and insuflicient mastication. Too much stress 
 has been laid upon the supposed association of the 
 furred tongue with certain " catarrhal " conditions 
 
Affections of the Digestive Organs. 127 
 
 of the stomach and bowels. A person with no 
 appetite has a furred tongue because he does not 
 masticate. A person who bolts his food, or who 
 washes his food into his stomach by drinking while 
 eating, or who hves on " slops," has a furred tongue 
 from the same cause. The posterior third of the 
 tongue in some is alwa3"S furred, and in these it will be 
 found that the palate is high and arched, so that the 
 tongue does not come into contact with the roof of 
 the mouth. ]\Iouth breathers also have a tendenc}^ to 
 a furred tongue, for the playing backwards and 
 forwards of the air over the tongue dries it, and 
 favours the formation of the fur. This is especially 
 the case in fevers where the hot air passing over the 
 tongue dries it. This tendency is further increased 
 by the absence of mastication — the patient being so 
 often fed on slops. In fever a fur ma}^ appear 
 in spite of all precautions. A very striking 
 prognostic sign may be found in carefully watching 
 the tongue in febrile states, for the ea,rliest 
 symptom that the fever is about to jdeld may 
 be the appearance of a small clean spot on the 
 tongue. 
 
 68. Swallowing. — The act of swallowing, so far 
 as it is carried out within the region of distribution 
 of cerebro-spinal nerves, is a voluntary and conscious 
 act ; but as soon as the bolus passes beyond into the 
 region supplied by the autonomic nervous system, it 
 becomes involuntar}" and unconscious. During the 
 act the respiration is inhibited and the levator palati 
 raises the palate and shuts off the nasal cavities. 
 Bilateral paralysis of this muscle, as after diph- 
 theria, leads to fluids regurgitating down the nose 
 during the act of swallowing. 
 
128 Chapte7- XII. 
 
 Pain accompanying the act of swallowing is due 
 most frequently to some inflammatory infection of 
 the tonsils or fauces. It is generally referred to the 
 neck behind the jaw, or up into the ear. Inspection 
 of the fauces will generally reveal the cause. In 
 rare cases, as already cited, there may be a hyperal- 
 gesia of the mucous membrane and of the muscles 
 with a good deal of pain on swallowing. 
 
 There is sometimes shown a curious relationship 
 between the tonsils and the nerve supply of the 
 external ear. In a number of cases I have found 
 during a tonsilitis an attack of herpes zoster occur, 
 the eruption appearing on the lobe and pinna of the 
 ear. This has occurred so frequenth^ that the asso- 
 ciation is more than casual, and I suspect some 
 intimate central relationship between the nerve 
 supply of these parts. Herpes zoster has been shown 
 by Head and Campbell to be due to a destructive 
 inflammation of the ganglia of the sensory root, and 
 it is difficult to explain the definite relationship of 
 the tonsilitis and the herpes on the ear, but the fact 
 is one worthy of consideration in the investigation of 
 the relationship of the viscera to the cerebro-spinal 
 nerves. 
 
 69. The (Esophagus.^ — The nerve supply of the 
 oesophagus being derived entirely from the autonomic 
 system, we get no direct response to stimulation. Pain 
 arises rather easily from stimulation, especially, as 
 everyone has experienced, on the drinking of hot 
 fluids. The pain thus excited is referred distinctly 
 to the front of the chest, and although the heart and 
 lungs are interposed between the site of pain 
 and the oesophagus, and although the oesophagus 
 itself is nearer the back of the chest than the 
 
Affections of the Digestive Organs. 129 
 
 front, everyone unhesitatingly refers the pain as 
 being felt in the oesophagus. Nevertheless, after a 
 good many observations, I have come to the concki- 
 sion that the laws governing the sensibihty of the 
 oesophagus are the same as those governing the 
 sensibihty of the other portions of the digestive tube, 
 and that the oesophageal pain is a referred pain and 
 not direct. That its sensibiht}^ is different from that 
 of the stomach is, I think, undoubted. The pain in 
 swallowing hot fluids, for instance, is more readily 
 induced bv the oesophagus than by the stomach. 
 Also the stomach contents, though giving rise to no 
 sensation when in the stomach, may cause great 
 discomfort when the}^ regurgitate into the oesophagus, 
 and it is for this reason that I assign the disagreeable 
 sensation of heart-burn to the acrid stomach contents 
 escaping into the oesophagus {see p. 141). 
 
 Some recent observations by Hirst, Cook and 
 Schlesinger lead them to the conclusion that the 
 sensation of heat and cold on swallowing fluids is 
 actually felt at the lower end of the oesophagus, but 
 their observations do not disprove, as they seem to 
 think, the referred character of the sensation. The 
 view I hold that the sensations of heat and cold are 
 really due to a reflex stimulation of the peripheral 
 vaso-motor nerves is not disproved because in some 
 cases the sensation is felt " deeper " than the skin ; 
 and, although I am far from asserting that the hy- 
 ])othesis I put forward is absolutely correct, the 
 matter is not the simple one these observers seem to 
 i magine. 
 
 In some cases, particularly in females of a 
 neurotic habit, the moment a hard piece of food, as 
 a small crust of bread, or even a soft bolus or fluid, 
 
 K 
 
130 Chapter XII. 
 
 touches the upper part of the oesophagus, the 
 oesophagus at once contracts with such violence and 
 persistence that no food can be taken for some time. 
 Sometimes a small portion of food may be grasped 
 in the spasm, when the spasm may last for hours, 
 and the patient be in great suffering on account of 
 the difhculty in breathing and the excessive flow of 
 saliva that cannot be swallowed. The forcible pas- 
 sage of a bougie or probang at once gives relief. In 
 a large number of cases I have found the systematic 
 passage of a bougie the best means of treatment. In 
 some rare cases the seat of the spasm may be lower 
 down. 
 
 In stricture of the oesophagus, if the stricture 
 be high up the food is rejected at once, if low down 
 it may be delayed for some time. Sometimes the 
 oesophagus wall contracts strongly, and, as in 
 obstruction of the bowel, pain may arise from the 
 peristalsis, and is always referred to the front of 
 the chest, at a level near that of the stricture. Great 
 care should be taken in all cases in the passage of 
 an exploratory bougie, lest injury be done to the 
 walls. 
 
( 131 ) 
 
 Chapter XIII. 
 
 AFFECTIONS OF THE DIGESTIVE ORGANS. 
 THE STOMACH. 
 
 70. The Nature of the Symptoms. 
 
 71. The Nerve Supply of the Stomach. 
 
 72. The Site of Pain in Affections of the Stomach. 
 
 73. The Character of the Pain. 
 
 74. Hyperalgesia. 
 
 75. Superficial Reflexes. 
 
 76. Viscero-motor Reflexes. 
 
 77. Vomiting. 
 
 78. Pyrosis and Heart-hum. 
 
 79. Air Suction. 
 
 80. Functional Symptoms. 
 
 81. Structural Symptoms. 
 
 82. The Diagnosis of Stomach Affections. 
 
 83. Pain in Gastric Ulcer. 
 
 70. The Nature of the Symptoms. — The 
 
 stomach being an organ that daily makes itself 
 known by sensations of pleasure or discomfort, forces 
 its symptoms upon all. Considering its highly com- 
 plex organisation it is a wonderfully long-suffering 
 organ, for it not only digests food suitable for the 
 whole organism, but it has to submit to improper 
 food, to the gratification of gluttonous desires, and 
 to the caprices of perverted tastes. It cannot be 
 
132 Chapter XIII. 
 
 wondered at that it should so often become deranged 
 in structure and function, and that these derange- 
 ments should be of various kinds. 
 
 Its accessibility has permitted many observa- 
 tions to be made on its functions in health and 
 disease, and has afforded scope for the ingenuity of 
 the physiologist, the chemist, and the clinician. 
 Although continual progress is being made in the 
 discovery of its properties, it must be admitted that 
 little of practical importance has been evolved for 
 the purpose of diagnosis and treatment of the great 
 majority of patients. So far as the physiologist is 
 concerned he cannot acquire the necessary infoima- 
 tion, because symptoms of disordered digestion are 
 usually the outcome of years of improper feeding. 
 Food unsuitable for the digestive powers of the 
 stomach deranges the functions of its secretory 
 glands and the structures of its walls, and it must be 
 confessed, we are ignorant of the nature of these 
 clianges. It is for this reason that so little advance 
 has been made in diagnosis and treatment, apart 
 from the progress of surgical methods, and of the 
 examination of the stomach contents. Some light 
 may be thrown on obscure diseases by the observation 
 of the progress through the alimentary canal of a 
 bismuth meal by the X-rays. These methods, how- 
 ever, are applicable to but a very small proportion 
 of sufferers from stomach affections. 
 
 Attempts are continually being made to classify 
 affections of the stomach, and the lack of agreement 
 in these classifications is merely due to the fact that 
 attempts are made to differentiate what cannot be 
 differentiated. This will be realised when the nature 
 of stomach symptoms is considered. Apart from 
 
The Stomach. 133 
 
 some characteristic vomits (blood, mucus), and cer- 
 tain changes indicated in the position of the organ 
 (and these refer only to a very small proportion of the 
 cases), all the symptoms are of a reflex nature, pain, 
 cutaneous and muscular hyperalgesia, muscular con- 
 traction, vomiting, air suction. As any adequate 
 stimulus may suffice to produce these symptoms, and 
 as this adequate stimulus ma}^ arise from the most 
 varied causes, trivial or severe, it follows that there 
 is a great similarity in the symptoms in diseases of 
 the most varied kinds. Hence it is impossible in 
 many cases to tell the nature of the affection ; for 
 instance, a passing simple " incUgestion " arising 
 from one indiscreet meal may present the s^miptoms 
 of " gastritis " or ulceration. For this reason it often 
 happens that no satisfactory diagnosis can be made 
 in the early stages of a chronic stomach complaint. 
 To ascertain the true nature of many stomach affec- 
 tions it is necessary to wait and observe the results 
 of treatment and the progress of the disease. When 
 patients come in a late stage of the complaint the 
 peculiar features of any given disease may have 
 become so evident that an accurate diagnosis can be 
 made ; but these form but a small proportion of the 
 chronic cases that the practitioner has to treat. 
 
 I have already pointed out that in visceral 
 disease certain areas in the spinal cord may become 
 for a time so irritable that stimuli from the peri- 
 phery give rise to an exaggerated response, as when 
 the skin becomes hyperalgesic and the recti muscles 
 contracted. This irritable focus in the cord is of 
 great frequency in stomach affections. Not only does 
 slight stimulation of the skin produce pain, but a 
 stimulus reaching the irritable focus from any 
 
134 Chapter XIII. 
 
 source may produce pain, and it is for this reason 
 that the ingestion of food is so frequentl}?' accom- 
 panied by pain. When pain occurs after food it 
 must not be assumed that there is an inflammation 
 of the mucous membrane, or that the stomach is itself 
 hypersensitive. The ingestion of food under normal 
 circumstances is accompanied by reflex processes 
 which are not perceived, and pain merely indicates 
 that there is an irritable focus in the cord through 
 which these reflex processes pass. The lesion induc- 
 ing the irritable focus in the cord may not neces- 
 sarily be a stomach lesion at all, but may arise from 
 a neighbouring organ whose reflex centre in the 
 spinal cord is in close proximity to that of the 
 stomach. In gall-stone colic the pain may be so 
 violent as to invade the stomach area in the cord, 
 and an illustration of the pain arising on the ingestion 
 of food in a case of hyperalgesia due to gall-stone 
 disease is given on page 90. 
 
 In true lesions of the stomach this irritable 
 focus in the cord is readily produced, and its presence 
 is demonstrated by the ease with which pain is in- 
 duced in certain stages of digestion by the hyperal- 
 gesia of the skin and muscles of the epigastrium, and 
 by the hardened epigastric muscles. 
 
 71. The Nerve Supply of the Stomach. — The 
 stomach is supplied by nerves from the dorsal sym- 
 pathetic and from the vagus. The origin of the 
 s^^mpathetic has not been exactly determined, as the 
 experimental attempts to find the efferent fibres that 
 supply the stomach have not been very successful, so 
 that the place of origin in the spinal cord is best 
 inferred from clinical observations of the area in 
 which the pain and hyperalgesia arise. 
 
The Stomach. 135 
 
 The epigastric region is essentiall}' the place to 
 which the sensory symptoms are referred, and it is 
 tlie upper part of the left rectus muscle which con- 
 tracts first in response to stim.ulation from the 
 stomach. The nerve supply to the skin of this region 
 comes from the sixth and seventh thoracic nerves, 
 and the upper portion of the rectus is supphed by 
 the sixth. When the pain is severe, and tends to 
 radiate, it generally goes to the left of the epigas- 
 trium, but may invade the regions of the front of 
 the chest supplied by the fifth and fourth thoracic 
 nerves. I have seen the symptoms in rare cases 
 resemble attacks of angina pectoris, and it has 
 seemed to me that the cause of the pain in such cases 
 was violent peristalsis of the cardiac end of the 
 stomach. 
 
 The burning pain of heart-burn is generall}^ felt 
 over the lower part of the sternum, in the region of 
 distribution of the fifth thoracic nerve in the chest. 
 It has seemed to me that the immediate cause of this 
 pain is the regurgitation into the oesophagus of the 
 acrid contents of the stomach. The frequency' with 
 which in these cases some of the stomach contents 
 regurgitate into the mouth confirms this view. 
 
 The result of vagus stimulation is difficult to 
 determine in stomach cases. Pain may be felt in the 
 neck and jaw in severe gastric colic, very like that 
 felt in some cases of angina pectoris, and this, I can 
 only conclude, is a stimulus reaching the fifth cranial 
 and upper cervical nerve centres, by means of the 
 vagus. The brow pain felt in swallowing ice is 
 often spoken of as a vagal reflex, but this pain arises 
 not from the stomach, but from the back of the 
 mouth. This can be demonstrated, in suitable cases, 
 
136 Chapter XIII. 
 
 by keeping the ice against the soft palate, when the 
 pain will be evoked. The same peculiar pain can also 
 be evoked by immersing the scalp in cold water. 
 
 In rare cases vagal stimulation, excited by 
 swallowing or by the ingestion of food into the 
 stomach, can produce irregular action of the heart, 
 of the nature of heart-block, or of extra-systoles. 
 
 72. The Site of the Pain in Affections of the 
 Stomach. — In 1892 I published a paper, in which I 
 gave the results of a careful inquiry into the site of 
 pain in 320 cases of affections of the stomach. In 
 the analysis I found that 95 per cent, referred their 
 pain to the epigastrium. Since that time I have kept 
 records of some thousands of cases, with the same 
 results. Whatever the nature of the lesion the pain 
 is referred with great certainty to the epigastrium 
 (B. Fig. 8, page 117). It may radiate from here up 
 into the chest, or to the left. It is not infrequently 
 accompanied by a pain in the back, and the patient 
 sometimes states that the pain strikes from the front 
 through to the back. It might be inferred from the 
 situation of the pain that the pain itself was actually 
 in the stomach, but one can demonstrate that it is 
 really referred to the peripheral distribution of the 
 cerebro-spinal nerves in the abdominal walls. Thus, 
 in many cases, the skin and muscles in the area in 
 which the pain is felt are hyperalgesic, and it is but 
 reasonable to infer that the pain felt by the patient 
 is referred to a region where the sensory nerves are 
 so demonstrably affected. The movements of the 
 stomach do not cause a displacement of the pain, 
 and when the stomach itself is shifted, as by deep 
 inspiration and expiration, there is no accompany- 
 ing shifting of the pain. In localised affections of the 
 
The Stomach. 137 
 
 «tomach (as ulcer), however varied the situation may 
 be from cardiac to pyloric end, the pain in tlie great 
 majority of cases is referred by the patient to some 
 part of the epigastric region {see p. 148). 
 
 73. The Character of the Pain and its 
 Relation to the Ingestion of Food. — Although the 
 stomach is a hollow muscular viscus, severe cramp- 
 like pain from violent peristalsis is of rare occur- 
 rence. It will usually be found, in the long run, 
 that the so-called " cramp of the stomach," in which 
 there is pain of great severity referred to the 
 epigastrium, is due to gall-stone colic. I have 
 watched many patients for years who suffered from 
 these severe attacks, and found that they all turned 
 out to be cases of gall-stone disease. In later years 
 I have had little difficulty in recognising their 
 origin, because of the peculiar distribution of the 
 reflex phenomena in gall-stone disease {see p. 159). 
 Violent cramp-like pain may rarely arise in stomach 
 affections, but the pain tends to radiate higher into 
 the chest, and, ma}^ be, into the Jaw (vagus stimula- 
 tion). More frequently the pain of stomach 
 affections is of a dull prolonged boring character. 
 Its position being so definitely situated in a region 
 remote from the seat of the lesion (as in gastric 
 ulcer) shows that it is the outcome of a stimulation 
 of an irritable focus in the spinal cord. The pain 
 is therefore more prolonged, and varies little in in- 
 tensity. Such a distinction of the character of the 
 pain can usually be made, and seems to account for 
 the persistent boring pains in gastric ulcer and in 
 other conditions. 
 
 Tlie relation of tlie pain to the ingestion of food 
 is verv variable. In some the introduction of food 
 
138 Chapter XIII. 
 
 into the stomach causes immediate pain, or the pain 
 may come on at variable intervals after food. When 
 it comes on two or three hours after food, relief 
 may sometimes be obtained from taking more food. 
 No very certain conclusions can be drawn from this 
 relation of pain to the ingestion of food. Attempts 
 have been made to diagnose the position of an ulcer 
 from this relationship, but there is no ground for 
 such a deduction. As a matter of experience the 
 pain in gastric ulcer may come on at any period 
 whatever its situation. This will be appreciated 
 when it is recognised that the ingestion of food or 
 some stage of its digestion acts as a stimulant to an 
 irritable focus in the spinal cord {see page 87). The 
 occurrence of the pain one or two hours after the 
 food, with symptoms of peristalsis (as recognised 
 by the wavy character of the pain) and with acrid 
 regurgitations into the oesophagus, is fairly charac- 
 teristic of one form of dyspepsia, sometimes spoken 
 of as "hyperchlorhydria," in which the trouble is sup- 
 posed to be due to an excessive secretion of hydro- 
 chloric acid. This form of indigestion often j'ields 
 readily to suitable treatment, but it is not infre- 
 quently associated with gastric ulcer and gall-stone 
 disease, and this association should be kept in mind» 
 
 74. Hyperalgesia. — In addition to the pain other 
 sensory phenomena may arise, the chief of which is 
 hyperalgesia of the skin and deeper structures. The 
 area which becomes hyperalgesic is the epigastric. 
 It may be limited to a small area in the middle, but 
 it is usuall}' diffuse with indefinite borders, extending 
 sometimes as an irregular band round the left side 
 to the spine. 
 
 The h3^peralgesia may not be present in the 
 skin, but in the muscles, or in the sensitive layer 
 
The Stomach. 139 
 
 outside the peritoneum. This can be shown by first 
 testing the skin and finding the sensibiUt}^ normal, 
 then pressing so that the muscle is stimulated ; or 
 by pushing the finger between the recti when the 
 peritoneal layer may be found sensitive. Of course, 
 in the latter case, one cannot assert that the pain is 
 elicited from this layer alone, for the pressure may 
 affect other structures, but in view of the observa- 
 tions of Ramstrom this conclusion is justifiable {see 
 page 35). 
 
 75. Superficial Reflexes. — Associated with this 
 hyperalgesia there is invariably an increase of the 
 reflexes, superficial and viscero-motor. The super- 
 ficial is demonstrated by the liveHness of the response 
 when the skin is stimulated, the upper part of the 
 right rectus contracting rapidly and powerfully. Not 
 only is the increased reflex activit}^ shown in the 
 response to the stimulation of the skin in the epigas- 
 trium, but it is also shown by the greatly extended 
 cutaneous field from which it can be elicited. Nor- 
 mally the reflex of the upper portion of the rectus 
 muscle is obtained from an area limited to the epi- 
 gastrium, but with an ii'ritable focus in the cord the 
 cutaneous area, stimulation of which will cause a 
 reflex contraction of the upper portion of the rectus, 
 may extend as high as the axilla. The extension of 
 this area follows some peculiar law, as responses 
 cannot be elicited from the whole of the left chest, 
 but only from an area extending in an irregularly 
 shaped hand up the side to the axilla. 
 
 76. Viscero-motor Reflexes. — Tlie viscero- 
 motor reflex is recognised by a permanent rigidity 
 of the upper division of the left rectus muscle. Tliis 
 ma>' be so slio;ht as to be evidcMit as an increase in the 
 
140 Chapter XIII. 
 
 tone of the muscle and detected onl}^ on comparison 
 with the other parts of the muscular wall of the 
 abdomen, or it may be hard and resistant. In seek- 
 ing for this reflex gentle exploration is needed to 
 avoid the production of the superficial reflex. 
 
 77. Vomiting. — Vomiting as a S3^mptom of 
 stomach affection is somewhat infrequent and of very 
 variable significance, and the most persistent vomit- 
 ing may arise reflexly from other organs, as in the 
 persistent vomiting of catarrhal jaundice, preg- 
 nancy and brain affections. As a symptom of stomach 
 affections the frequency of the vomiting and the 
 nature of the material vomited constitute the best 
 evidence. An occasional attack of vomiting may 
 arise from a great many causes. In persistent vomit- 
 ing, if reflex vomiting from other organs can be 
 excluded, some inflammatory affection maj^ be recog- 
 nised, and the possibility of gastric ulcer considered. 
 The response to treatment is an important factor in 
 diagnosis. 
 
 Certain characteristics at the time of vomiting 
 give information. The morning sickness of preg- 
 nancy and of the alcoholic is very characteristic. The 
 vomiting, once a day, or every day or two, of large 
 quantities is suggestive of the dilated stomach 
 secondary to pyloric stenosis. The character of the 
 material vomited is also of importance. If the con- 
 tents of the stomach contain the food that has been 
 taken many hours before, some obstruction to its 
 passage is suggested. The thick viscid mucus 
 vomited is characteristic of a somewhat violent 
 gastritis. The presence of blood (coffee-ground 
 vomit) is characteristic of ulceration. Inquiries 
 should always be made for the presence of " tarry " 
 
The Stomach. 141 
 
 stools. The vomiting of large quantities, sometimes 
 with brown froth, is characteristic of dilatation of 
 the stomach. Vomiting with a faecal odour usually 
 indicates obstruction of the bowel. The absence of 
 hydrochloric acid in the vomit suggests the possi- 
 biUty of cancer. 
 
 78. Pyrosis and Heart-burn. — The food may 
 regurgitate back into the oesophagus. Sometimes 
 this is normal (merycism), and is of the nature of the 
 return of the cud in ruminants. In certain cases, 
 when the stomach contents become abnormally sour 
 and acrid, strong peristalsis may produce pain with 
 regurgitation of some of the contents into the 
 oesophagus, and thus give rise to the painful burning 
 sensation described as " heart-burn." This vadjy be 
 accompanied by the return into the mouth of some 
 of the contents of the stomach, sometimes insipid to 
 the taste, sometimes sour and acrid (pj^'rosis, water- 
 brasli). One form of this condition has received the 
 name of hyperchlorhydria, because an excess of 
 hydrochloric acid is present in the stomach contents, 
 and because it can be relieved by alkalies. But this 
 increase in hydrochloric acid is but one of the 
 abnormal manifestations, and excess in its secretion 
 is not necessarily the disease, nor the cause of tlie 
 symptoms, for the administration of hydrochloric 
 acid reheves the symptoms, and the presence of 
 hydrocliloric acid in the oesophagus does not cause 
 h(nirt-burn. There are other acrid substances of 
 unknown nature present which evidently excite the 
 peristalsis of the stomach. 
 
 79. Air Suction. -Flatulence is a common com- 
 plaint with dyspeptics, but true flatulence, i.e., 
 flatulence due to evolution of gases in the stomach, 
 
142 Chapter XIII. 
 
 is relatively rare. The vast number of people who 
 suffer from " attacks of wind," and who appear to 
 expel large quantities with a loud noise, owe their 
 attacks to air spasmodically sucked into the oesopha- 
 gus or into the stomach. These may start with a 
 slight feeling of distension after meals, when the 
 patient endeavours to obtain relief by expelling 
 wind. In this attempt air is unconsciously sucked 
 into the oesophagus, and its noisy expulsion is sup- 
 posed to be an evidence of air being expelled from 
 the stomach. Som.etimes the air is sucked into the 
 stomach, and its expulsion is accompanied by some 
 flatulence that was present in the stomach, and in 
 consequence considerable relief is obtained. Some 
 people when suffering from pain get a measure of 
 relief by sucking air voluntarily into the stomach 
 and then expelling it. 
 
 This air suction occurs most frequently in 
 people of a neurotic temperament, and the attacks 
 may come on when they are put out, worried, or 
 suffering from affections of other organs. When a 
 patient complains of attacks of flatulence coming on 
 suddenly as during sleep, it will often be found that 
 the patient is an air-sucker. It might seem that an 
 uncontrollable reflex would cause the air suction, for 
 patients during an attack of angina pectoris may 
 hold themselves in such a manner that air is uncon- 
 sciously sucked in, and its expulsion is often accom- 
 panied by such relief that the origin of the suffering 
 is put down to a stomach affection. Attacks of 
 air suction may be stopped at once by the mouth 
 being kept wide open by a gag. Willie's article in 
 the Edinburgh Hospital Reports (Vol. I.) throws a 
 great deal of light on the subject. 
 
The Stomach. 143 
 
 / 80. Functional Symptoms. — The symptoms 
 that arise from changes in function are available in 
 relatively few cases. Those clue to alteration in the 
 secretion are mainly limited to the recognition of an 
 excess of mucus, or an increase or diminution of the 
 amount of free hydrochloric acid in the stomach 
 contents, obtained either from the vomit or by the 
 stomach tube. There are so man}^ individual varia- 
 tions in the amount of gastric juice secreted and in 
 the relative proportion of hydrochloric acid present, 
 that deductions drawn from an examination of the 
 stomach contents must be applied with the greatest 
 caution. 
 
 Increase in the amount of hydrochloric acid is 
 indicative of no definite lesion, and the absence of 
 free hydrochloric acid, though suggesting the possi- 
 bility of cancer, is by no means diagnostic, as it may 
 be absent in a variety of conditions. Save that its 
 absence necessitates the consideration of the question 
 of cancer, it is doubtful if the symptom is of any 
 special importance. Functional derangement of the 
 digestive fluid may be detected by the delay of 
 digestion. This delay is recognised by the retention 
 by the stomach of portions of undigested food, and 
 by observing the time taken to digest a test meal, 
 and by the observation of the passage of a bismuth 
 meal through the stomach by the X-rays. 
 
 Dilatation of the stomach is an evidence of a 
 loss of the function of tonicity in the muscular wall, 
 and can be detected by careful percussion, or by the 
 presence of splashing when the stomach is shaken by 
 succussion, or by tapping over the stomach. The 
 extent of the dilatation can often be made out by 
 distending the stomach witli carbonic acid gas. The 
 
144 Chapter XIII. 
 
 simplest method is to give the acid part of a seidlitz 
 powder in solution first, followed by the alkaline. 
 The evolution of the carbonic acid gas causes a 
 visible swelling in the abdomen due to the distension 
 of the stomach. 
 
 The use of the X-rays in the examination of th& 
 digestive tract has been of the greatest service. By 
 giving a meal containing a large quantity of bismuth 
 the movements of the food can be detected. Obser- 
 vation by this means has shed an unexpected light 
 upon the position and shape of the normal stomach, 
 and shows that the description usually given is quite 
 wrong. In quite healthy people the stomach may 
 be as low as the um.bilicus. In fact so variable is 
 the shape and position of the stomach in presumably 
 healthy people that no certain standard is yet 
 recognised. In consequence of this the recognition 
 of abnormal conditions of the stomach by the X-rays 
 is mostly limited to cases of very great increase in 
 size. 
 
 The retention of portions of food in the stomach 
 for a considerable time affords evidence of the 
 inefficiency of the peristaltic contractions to empty 
 the stomach of its contents. Although dilatation is 
 seen in its most characteristic form in emaciated 
 people with pyloric stenosis, yet it may be of con- 
 siderable extent where there is no obstruction ; and 
 there may be difficulty in deciding whether the 
 dilatation is secondary to the pyloric stenosis. A 
 long history of stomach trouble with pain, particu- 
 larly if referred to the lower part of the epigastrium, 
 suggests pyloric stenosis. In rare cases a history of 
 vomiting blood, or of huge liquid vomits at intervals, 
 is also suggestive of pyloric stenosis. Apart from 
 
The Stomach. 145 
 
 pyloric stenosis dilatation of the stomach is a very 
 common condition, and may be present when there 
 is no symptom pointing to digestive insufficiency. 
 At other times dilatation may be found associated 
 with all kinds of symptoms. 
 
 The cause of dilatation is, as I have said, a lack 
 of tonicity in the muscular wall. It is impossible to 
 account for its appearance, and althougli it may 
 be spoken of as a symptom of " atonic dyspepsia " 
 yet it may be present with no dyspepsia. 
 
 81. Structural Symptoms. — Apart from the 
 evidences of dilatation which have been alluded to, 
 the symptoms produced by changes in the organ itself 
 are limited to ttie detection of tumours in the stomach 
 wall. In the earl}^ stages they are impossible to 
 recognise, partly because ot the manner in wliicli 
 they occur as a somewhat diffuse thickening of the 
 stomach wall, and partly because of the unyielding 
 contraction of the overlying muscles. It is only when 
 the tumour is in the anterior wall, or has increased 
 to a considerable size, that it can be detected. By 
 that time the patient's condition, if the tumour is 
 malignant, will have suggested the serious nature of 
 the complaint. 
 
 Constriction of the stomach, however, may arise 
 as a result of contraction of gastric ulcers (hour- 
 glass contraction). The detection of this condition 
 is a matter of some difficulty, but it may be suspected 
 when in washing out the stomach a portion of tlie 
 fluid poured in cannot be drawn off. 
 
 82. The Diagnosis of Stomach Affections.— 
 From the foregoing discussion it will be seen that 
 in the vast majority of stomach affections there are 
 few signs that may be considered distinctive of any 
 
146 Cha2Mr XIII. 
 
 one complaint. When a diagnosis can at once be 
 made in any given case, the patient has been suffering 
 for a considerable time. As the general practitioner 
 is usually consulted long before a definite physical 
 sign, as a tumour, blood-vomit, or dilatation, is 
 apparent, and as the symptoms of ailments from 
 the simplest to the most serious are at first identical, 
 it is necessary to adopt other methods in order to 
 arrive at a diagnosis, such as watching the progress 
 of the affection, its response to treatment, and the 
 general condition of the patient. 
 
 As diets are so varied, the personal predilection 
 of the doctor may lead him to assume that the 
 patient's trouble at first is due to some dietetic error. 
 In this he may be right, and it is always best in any 
 given case to start the observation by ordering the 
 patient the simplest and most easily digested form 
 of food. My own practice, in all doubtful cases, is to 
 attend to decayed and deficient teeth, to prescribe a 
 diet in which the food is given in small amounts, the 
 solids dry so as to ensure efficient and thorough 
 mastication, and the fluid mostly in the form of milk, 
 also smaU in quantity. With people who have to 
 foUow their dail}^ work (which is the case with the 
 majority of patients who consult the general prac- 
 titioner), the food should be taken every two hours. 
 When at work this may be limited to a dry crust, to 
 be thoroughly and slowly masticated. At other times 
 meat or fish with dry bread or toast may be given, if 
 the patient is able to digest it with comfort. The 
 quantity must be regulated at aU times by the suffer- 
 ing of the patient. By this simple process the 
 majority of cases of indigestion due to error in diet 
 wiU be relieved. Speed}^ relief after such a change 
 
The Stomach. 147 
 
 of diet, or from some simple remedy, must not be 
 taken as an evidence that the stomach is free from 
 any serious lesion — all that has been done has been 
 to remove the stimulus that was adequate to produce 
 the reflex symptom (pain, hyperalgesia). This is a 
 point on which it is necessary to insist, for many 
 €ases of severe stomach disease may be thus tem- 
 porarily relieved. In such cases the history must be 
 inquired into, and the presence of other symptoms 
 sought for. Persistence of suffering and of hyperal- 
 gesia of the epigastric skin and muscle, with con- 
 tracted recti, are signs usually indicative of ulcera- 
 tion. When these dietetic changes are foUowed by 
 no improvement, rest in bed is the next step, and the 
 patient may have to lie many months before improve- 
 ment sets in. When there is dilatation, washing out 
 the stomach and examination of the contents is of 
 use. 
 
 The appearance of sj^mptoms of indigestion in 
 persons over the age of forty years, with wasting, 
 should at once arouse the suspicion of malignant 
 disease. In all cases the appearance of the patient 
 should be studied, and in case of blanching the ques- 
 tion of haemorrhage should be carefully inquired into. 
 
 The possibility of gall-stone disease should 
 -always be borne in mind in chronic forms of indi- 
 gestion. In severe suffering the temperament of 
 the patient may aggravate the symptoms, for the 
 reaction of a slight stomach lesion in a neurotic 
 subject may cause widespread sensory phenomena. 
 
 83. Pain in Gastric Ulcer. — As gastric ulcer can 
 frequently be definitely localised, the comparison of 
 the site of the ulcer with the site of pain sheds a 
 light upon the mechanism of visceral pain, and 
 
148 Chaj)ter XIII. 
 
 illustrates the practical value of the method of 
 examination Adhere the reflex symptoms are care- 
 fully observed. I have watched patients with gastric 
 ulcer continuously for a great number of years, and 
 have had the opportunity of verifying the diagnosis 
 post mortem, or at operation, in a good number. The 
 result of these observations has been to show that, 
 though the actual site of the ulcer had no direct 
 relation to the place where the pain was felt, there 
 was a fairly definite relation explicable by the 
 nervous connection of the parts. In many cases the 
 patient can localise the pain with great definiteness 
 in some limited region, and the skin and deeper 
 tissues may there be hyperalgesic. In such cases I 
 have found that when the ulcer was situated near the 
 cardiac end of the stomach the site of pain and 
 hyperalgesia was in the upper part of the epigas- 
 trium, when the ulcer was in the middle of the 
 stomach the site of pain and hyperalgesia was in 
 the mid-epigastrium, and when the ulcer was at the 
 pylorus the pain was felt at the lowest portion of 
 the epigastrium. 
 
 To illustrate, not only the justification of this 
 view, but, more important, its practical utility, I will 
 cite some typical instances. I was called into con- 
 sultation to see a young woman twenty hours after 
 perforation of the stomach had taken place. The 
 patient had suffered for many months from pain 
 after food. She located the site of this pain with 
 great certainty in the upper part of the epigastrium., 
 over the xiphisternum. I reasoned from this that 
 the perforated ulcer would be near the cardiac end 
 of the stomach. The incision opening the abdominal 
 cavity was, therefore, made as far to the left as 
 
The Stomach. 149 
 
 possible. On opening the abdomen there was found 
 a large quantity of fluid, and a considerable quantity 
 of flaky lymph covered most of the exposed organs. 
 The stomach was carefully searched, and we found it 
 lather firmlv adherent at the cardiac end to the 
 posterior wall of the abdomen. We inspected the 
 whole of the stomach except the adherent part, and 
 there can be no doubt that the adhesions surrounded 
 the ulcer. We resolved not to break down these 
 adhesions, as it would have been impossible to drag 
 this portion of the organ sufficiently far out to enable 
 us to stitch it. The abdomen was very efficienth' 
 flushed, the wound stitched up, and the patient 
 made a good recovery. 
 
 Another patient I saw in consultation suffered 
 from peritonitis, resulting from perforation of a 
 gastric ulcer. She was a servant girl, twenty years 
 of age. For three years she had suffered at var3dng 
 times from severe indigestion, and, a year previous 
 to my examination of her, she had vomited a 
 quantity of blood. The pain from which she 
 suffered was situated in the upper part of the 
 epigastrium, just over the xiphoid cartilage (in the 
 shaded area of Fig. 9), and was felt through to the 
 back. When admitted to the hospital, the abdomen 
 was hard and tense, the pulse very soft and 160 per 
 minute. The abdomen was extremely tender to the 
 touch ; but on closer examination this tenderness 
 was found to be purely cutaneous, the hyperaesthesia 
 extending beyond the limits of the abdomen — over 
 the lower part of the thorax and down over the 
 thighs. In a few days the hypersesthesia disappeared, 
 except in a diffuse, ill-defined area about the 
 epigastrium : tiie greatest tenderness always being 
 
150 
 
 Chapter XIII. 
 
 Fig. 9. 
 
 The shaded area shows site of pain, X corresponds to the position of 
 the ulcer in the stomach as found at the post-mortem examination. 
 
 over the upper part of the epigastrium. The patient 
 sunlc and died. At the post-mortem examination 
 there was found much matting of the stomachy 
 bowels, and hver in the upper part of the abdomen 
 by recent soft peritonitic adhesions. The stomach 
 was found perforated by a large ulcer near the car- 
 diac end, its position in situ being nearly as far out 
 
The Stomach. 151 
 
 as the mid-axillary line (indicated by x, Fig. 9). 
 There were two other superficial ulcers in the imme- 
 diate neighbourhood, but they were nearer the 
 oesophageal opening than the perforation. 
 
 A girl, aged fourteen years, who had had pain 
 after food for many months, referred the situation 
 of the pain with great precision to a spot in the 
 middle of the epigastric region (Fig. 10). She was 
 suddenly seized with collapse and severe pain over 
 the upper part of the abdomen. There could be no 
 doubt that it was a case of perforation of the 
 stomach. Within eight hours we opened the abdo- 
 men, and as I had noted the situation of the pain 
 previous to the rupture, I suggested that the ulcer 
 would probabty be found in the middle of the 
 stomach. The incision was therefore made well to 
 the left of the middle line. The perforation was 
 readily met Avith in the middle of the stomach on 
 the lesser curvature, in a position corresponding to 
 the + in Fig. 10. It was stitched up, and the patient 
 made an excellent recovery. 
 
 A female, aged thirty-two years, for ten years had 
 frequentl}^ vomited large quantities of blood, and 
 suffered from severe pain in the epigastrium. The 
 pain was always felt with the greatest intensity at the 
 lower part of the epigastrium, corresponding to the 
 area shaded in Fig. 11. From this region the pain 
 would frequently strike round the left side, and be 
 felt severely over the sixth and seventh dorsal verte- 
 brae. The painful area in the epigastrium was often 
 extremely sensitive to the touch, and the cutaneous 
 hypersesthesia sometimes extended as a broad band 
 round the left side. The last note I made about the 
 patient was on 1st April, 1897, to the effect that the 
 
152 
 
 Charier XI I L 
 
 Fig. 10. 
 
 The shaded area uiiows the site of pain, and the + the position of the 
 jastric ulcer as found at the operation. 
 
 patient " vomited a large quantity of blood yester- 
 day. The pain is felt very severely midway between 
 the xiphoid sternum and the umbiHcus, striking 
 round towards the left side " ; and then follows a 
 diagram noting the area, as marked in Fig. 11. 
 
The Stomach. 153 
 
 In treating this patient, at an early date, a 
 l)lister the size of a florin had been apphed over the 
 painful area in the epigastrium. So much rehef 
 was obtained when the cutaneous surface was raw, 
 that savin ointment was used to keep the wound 
 from heahng, until all symptoms of pain had dis- 
 appeared. During the last five years of her life (she 
 died of phthisis) the patient had been in the habit, 
 from time to time, of applying the blister herself 
 whenever there was a recurrence of the pain. At 
 the post-mortem examination the effects of a recent 
 blister were still evident, as a superficial erosion, 
 occupying the lower part of the epigastrium, corre- 
 sponding exactly with the area shaded in Fig. 11. 
 
 The patient died suddenly on 7tli July. At the 
 post-mortem examination held next day, an ulcer, 
 1 in. in diameter, with slightly thickened edges, was 
 found situated partly in the stomach and partly in 
 the pylorus. I requested my colleague. Dr. Brown, 
 to note exacth' what position the ulcer occupied in 
 relation to the external bod}' wall, and he, carefully 
 noting the situation, indicated an area corresponding 
 to X in Fig. 11. 
 
 Another case had been under my care for ten 
 years for repeated attacks of epigastric pain. The 
 pain in this case was very constant, unless during 
 three pregnancies when she was quite free. She con- 
 sulted an eminent surgeon who wrote to me stating 
 that tlie patient had an ulcer in the middle of the 
 stomach and on the posterior wall, and he recom- 
 mended an operation for her relief. 1 re-examined 
 the patient and made the following note in my dairy : 
 "That, inasmuch as the pain is situated at the lowest 
 part of tlio epigastric region, and as there is also 
 
154 
 
 Chapter XIII. 
 
 Fig. 11. 
 
 The shaded area shows the site of pain, x the site occupied by the- 
 ulcer at the pyloric orifice of the stomach as found at the post-mortem 
 examination. 
 
 here a limited area of tenderness of the skin, the 
 ulcer should be found at the pyloric orifice." This 
 latter view was verified at the operation subsequently 
 performed. 
 
 A patient whom I had attended for twelve 
 years with mitral stenosis, and who died in 1907, 
 aged thirty-six, suffered severely from gastric ulcer 
 
The Stomach. 155 
 
 in 1899, so that she had to be kept in bed for two 
 months, and be fed with the greatest care. The pain 
 gradually abated, but kept recurring at intervals. 
 It wa3 always referred to the epigastrium, but 
 radiated widel}^ Thus I made this note on INlay 
 13th, 1903 : " Has severe pain starting at the shaded 
 area (as in Fig. 11) and passes round to the left side. 
 There is no tenderness of the skin or muscles, and 
 no vomiting. Stomach resonance as low as the 
 umbilicus." She died in February, 1907, from her 
 heart affection, and at the post-mortem examination 
 an ulcer was found at the pyloric end of the stomach 
 — at some distance from the epigastrium. The 
 relative positions of the site of pain and of the ulcer 
 were the same as shown in Fig. 11. 
 
( 156 ) 
 
 Chapter XIV. 
 
 THE LIVER, GALL-BLADDER AND DUCTS. 
 
 84. Nerve Supply. 
 
 85. Reflex Symptoms in Gall-stone Disease. 
 
 86. Gastric Symptoms in Gall-stone Disease. 
 
 87. The Result of Reflex Symptoms. 
 
 88. Functional Symptoms in Gall-stone Disease. 
 
 89. Structural Sympto^ns in Gall-stone Disease. 
 
 90. Fever in Gall-stone Disease. 
 
 91. Nature of Reflex Symptoms in Affections of 
 
 the Liver. 
 
 92. Functional Symptoms in Affections of the Liver. 
 
 93. Structural Symptoms in Affections of the Liver. 
 
 84. Nerve Supply. — The symptoms associated 
 with the liver, gall-bladder, and ducts, in many cases 
 resemble those of the stomach so closely that there 
 is often a difficulty in differentiating the one from 
 the other. This will be understood when it is borne 
 in mind that developmentally the liver and its 
 appendages are an outgrowth of the digestive tube 
 immediately below the stomach. The region in the 
 cord from which the nerve supply passes is at, and 
 immediately below, the region of the stomach supply, 
 from the seventh to the ninth thoracic ; so that with 
 severe stimulation the irritable focus in the cord in- 
 vades the nerve supply of the stomach. As in stomach 
 
The Liver, Gall- Bladder and Ducts. 157 
 
 affections, the reflex phenomena appear in the epigas- 
 trium, but in gall-bladder affections the hyperalgesia 
 is most common on the right side, and the upper part 
 of the right rectus muscle becomes contracted. The 
 symptoms also tend to spread to the right side and 
 lower down in the abdominal Avail. In addition to 
 the thoracic nerve suppty the liver and gall-bladder 
 and ducts are also supplied by the phrenic nerve 
 (third, fourth and fifth cervical) and by the vagus. 
 
 85. Reflex Symptoms in Gall-stone Disease. — 
 The reflex S3'mptoms in affections of the liver itself 
 are often not very distinctive, while those of the gall- 
 bladder and ducts are frequently violent and very 
 characteristic. This difference is due to the fact 
 that the former is a glandular structure, while the 
 latter contain non-striped muscular fibres which, we 
 have seen, may provoke the most violent sensory 
 phenomena. 
 
 The pain in gall-stone disease varies much in 
 severity. It may begin with a sense of uneasiness in 
 the epigastrium, or over the lower ribs on the right 
 side. A small area of cutaneous or muscular hyper- 
 algesia may be detected somewhere in the region in 
 which the pain is felt, and also in the upper portion 
 of the right rectus. This muscle ma}^ be more or less 
 contracted. These symptoms may be slight and 
 variable, and continue for months or years, or the 
 patient may be seized suddenly with violent pain, 
 with or without these preliminary symptoms. The 
 pain in the majority of cases of gall-stone colic is 
 situated in the middle line, about the lower part of 
 the epigastrium. It may come on gradually and 
 remain for an indefinite period, sometimes varying 
 sli(i;litly in intensity. From this place it tends to 
 
158 
 
 ChajJter XIV. 
 
 Fig. 12. 
 
 The shaded area shows the region of cutaneous hyperalgesia after an 
 attack of gall-stone colic. The + is the position of a tender point in 
 many cases in gall-stone disease, and is over the place where a twig of the 
 ninth thoracic nerve passes out of the rectus abdominis muscle. 
 
 \ 
 
 spread to the right side, and may be felt with great 
 severity below the edges of the ribs. Sometimes it 
 may extend round to the back, and be felt most 
 severely over the ninth and tenth ribs. In rare cases 
 the pain may only be felt in the back. 
 
 The pain, intermitting slightly, may remain for 
 many hours, unless relieved by a sedative. Frequenth^ 
 after the subsidence of the pain the skin and muscles 
 of the upper part of the right side of the abdomen 
 
The Liver, Gall- Bladder and Ducts. 159 
 
 become ven^ tender to touch, and the muscles hard 
 and contracted. In Fig. 12 the area of cutaneous 
 hyperalgesia is shown in the patient in whom I first 
 discovered the presence of hyperalgesia in 1891. 
 
 In a great many cases, after the subsidence of 
 the attack, the hyperalgesia may persist for several 
 weeks, and, during this period, severe attacks of 
 pain are very hable to be provoked, so that the 
 patient is scarcely able to move about. 
 
 In a small percentage of cases pain, sometimes 
 of great severity, is felt on the top of the right 
 shoulder, striking down the outside of the arm. It 
 is very necessary to recognise the relationship 
 between pain in this region and gaU-stones. I have 
 known patients in whom there was tliis pain in the 
 shoulder and in the arm treated for years for 
 " neuritis," and the passage of a gall-stone has been 
 followed at once by rehef. In many cases this 
 shoulder pain is not very severe, and the patient may 
 not refer to it. If, however, inquiry be made, the 
 patients frequently declare they have had pain 
 in the right shoulder, wliich they thought was 
 " rheumatic." When this shoulder pain is severe 
 -and the chief complaint, if due to gall-stone disease a 
 careful search will reveal evidences in the upper part 
 of the abdomen, in the hyperalgesia of the skin, in 
 the contraction of the muscles, and in the history of 
 the patient which leave little doubt as to the cause 
 of the shoulder pain. 
 
 86. Gastric Symptoms in Gall-stone Disease. — 
 In persistent " dyspepsia " and heart-burn, the 
 question of gall-stones should always be considered. 
 I have already referi'ed to the association of pain on 
 the ingestion of food into the stoniach with 
 
160 Chapter XIV. 
 
 gall-stone disease. One frequently sees patients with 
 a history of " acute gastritis " of which the symptoms- 
 are described as attacks of severe pain in "the 
 pit of the stomach," or " cramp of the stomach," fol- 
 lowed by a period when ingestion of food causes- 
 pain. Such a history wih, in the majority of cases, 
 be found really to have been due to gall-stone colic, 
 with the subsequent condition of hyperalgesia 
 associated with an irritable focus in the cord. 
 
 Nausea and vomiting are frequent accompani- 
 ments of gall-stone colic, and their occurrence with 
 the pain in the " pit of the stomach " might seem ta 
 confirm the conclusion that the case is one of 
 " gastritis," or " cramp of the stomach." 
 
 87. The Result of Reflex Symptoms.— When 
 we come to consider the effect of this hyperalgesia^ 
 contracted muscles and exalted reflexes, we get a 
 picture that is often very misleading. After the 
 attacks of severe pain have subsided the patient may 
 be unable to breathe freely, each inspiration being 
 checked, as it is in pleurisy, by spasm of the inter- 
 costal muscles, and severe pain may be felt over 
 the lower ribs on the right side. Such symptoms are 
 sometimes mistaken for pleurisy. If a careful ex- 
 amination be made, it can be demonstrated that 
 there is an extensive field of hyperalgesia, extending 
 up into the chest and implicating the intercostal 
 muscles. The exercise of hyperalgesic muscles is 
 always limited on account of their increased tone, 
 and the tonic contraction tends to increase with their 
 continued action. It is for this reason that patients 
 with gall-stone and persistent hyperalgesia of the 
 abdominal muscles are comparatively at ease when 
 at rest. On moving about there gradually comes on 
 
The Lirer, Gall - Bladder and Ducts. 161 
 
 a feeling of pain and dragging round the abdomen, 
 and the patient is unable to " stretch " himself freely. 
 This is simph" due to the fact that the exercise of 
 the hyperalgesic muscles has increased their tonic 
 contraction and their sensitiveness, so that their 
 exercise is painful and the extent of their movement 
 becomes greatly limited, 
 
 88. Functional Symptoms in Gall-stone 
 Disease. — It is in only a small proportion of cases 
 that jaundice is present in gall-stone disease. If 
 the stone is situated in the common duct, or can 
 cause pressure on the common duct, so as to obstruct 
 the channel, then jaundice arises. When the jaun- 
 dice is so slight that it is difficult to determine 
 whether it may not be due to a sallow complexion, a 
 careful inspection of the sclerotic may reveal a faint 
 tinge. It may be necessary in cases of doubt to 
 examine the urine or blood for minute traces of bile 
 pigment. 
 
 89. Structural Symptoms in Gall-stone 
 Disease. — It is onh' in ver}' rare cases that gall- 
 stones can be detected in the gall-bladder. It can 
 only be done when the stones are so numerous as to 
 cause a tumour, or when the stones cause the gall- 
 bladder to become distended with fluid. This can 
 only happen at a late stage in the disease, and when 
 all the associated reflex phenomena have disappeared, 
 for the presence of hyperalgesia means also the 
 presence of a lively muscular reflex, which effectually 
 prevents the hand reaching the gall-bladder. When 
 the abdominal muscles are lax the distended gall- 
 l)ladder may be felt as a tumour, and, in rare 
 instances, the stones have been palpated. The liver 
 is sometimes said to " enlarge and become tender." 
 
162 Chapter XIV. 
 
 As, however, the writers who describe this have not 
 appreciated the association of this so-called " tender 
 liver " with contracted muscles, this observation 
 needs to be verified. For my part I have never been 
 able to satisfy myself as to a slight liver enlargement 
 when there is hyperalgesia and contracted muscles. 
 The muscles are so tender on pressure and contract 
 so firmly that it is impossible to palpate the liver ; 
 the percussion note also becomes altered with a 
 contracted muscle. 
 
 90. Fever in Gall-stone Disease. — In the great 
 majority of cases of gall-stone disease there is no 
 fever, except, it may be, a slight rise at the time of 
 an attack of colic. In some cases there is an asso- 
 ciated inflammation of the gall-ducts, and, as a 
 consequence, febrile attacks may occur of a very 
 characteristic type. These are generally very sudden 
 in their onset and in their subsidence. The patient 
 begins to feel chilly and shivery, and when his tem- 
 perature is taken it will be found to be considerably 
 raised — 101-104°. He may have rigors. In the 
 course of one to three days the temperature returns 
 to normal. 
 
 In more advanced stages of cholangitis the 
 temperature may remain continuously above normal 
 with frequent exacerbations. With the formation 
 of pus the temperature usualh^ remains continuously 
 high. 
 
 In all obscure cases of intermittent temperature 
 the possibility of gall-stones should be considered. 
 Except malaria, there is no disease which gives such 
 characteristic febrile attacks. In many cases a 
 shght jaundice can be detected. 
 
The Liver, Gall -Bladder and Ducts. 163 
 
 91. Nature of Reflex Symptoms in Affections 
 of the Liver. — I have dealt fully with the reflex 
 symptoms in gall-stone disease, because in this com- 
 plaint the}^ are seen in their most striking form. In 
 disease of the liver the same areas may be affected 
 though the symptoms are less violent. As I have 
 pointed out, it is doubtful if the affections of the 
 parenchyma of an organ ever give rise to pain, unless 
 the fibrous covering is affected or stretched. As a 
 rule in liver affections there is little pain, unless this 
 hyperalgesia of the external body wall and the tender 
 structures are stimulated, as in exercise of the 
 muscles, when pain will be felt in the muscles so 
 exercised. This is well seen in cases of rapid in- 
 crease in the size of the liver from heart failure, 
 when the capsule is stretched, and when, if the 
 patient moves about, there is considerable pain felt 
 in the muscles over the liver, in front and round to 
 the back. The enlargement of the liver due to heart 
 failure offers an excellent opportunity for the study 
 of the reflex symptoms of liver affections. These 
 symptoms are seen most strikingly when the heart 
 failure sets in with some rapidity, as in certain cases 
 of paroxysmal tachycardia, especially when the 
 tachycardia is due to auricular fibrillation, or where 
 heart failure sets in as a consequence of the perma- 
 nent establishment of auricular fibrillation. In cer- 
 tain cases this abnormal rhythm is suddenly 
 developed, and in the course of a few hours the heart 
 dilates and the liver becomes very considerabl}' 
 enlarged. If the patient keeps at his work, feeling 
 weak and breathless, severe pain is suffered from 
 across the back and round in front over the liver. If 
 he be examined a patch of cutaneous hyperalgesia 
 
164 Chapter XIV. 
 
 may be found embracing a considerable portion of 
 the upper part of the right side of the abdomen. 
 The muscles below the ribs in front will be found 
 hyperalgesic and contracted, and the erector spinae 
 muscles at the level of the eighth to twelfth ribs will 
 also be found hyperalgesic {see Fig. 16, page 234). If 
 the heart should suddenly return to the normal, the 
 liver enlargement subsides in a few hours, and the 
 hyperalgesia disappears. If, however, the abnormal 
 rhythm persists, then with rest in bed the hyperal- 
 gesia gradually diminishes until one can palpate the 
 liver through the abdominal wall, and even take 
 tracings from the enlarged and pulsating liver. 
 
 In enlargement of the liver due to other causes, 
 as hypertrophic cirrhosis, cancer, chronic and sub- 
 acute abscess, the reflex symptoms are of the same 
 nature but less acute. I have no experience of acute 
 inflammatory affections of the liver, so cannot tell 
 the nature of the symptoms present. 
 
 Severe and persistent vomiting may arise in 
 liver affections. In the early stages of " catarrhal 
 jaundice," before the jaundice appears, the patient 
 may suffer from the most violent and persistent 
 attacks of vomiting, and the cause may remain 
 unsuspected till the jaundice appears. 
 
 92. Functional Symptoms in Affections of the 
 Liver. — Jaundice is, of course, the most striking, 
 and needs no further description. In all cases of 
 sallow or dirty grey complexion, the liver should be 
 carefully examined. When chronic liver affections 
 produce jaundice, or alter the complexion, there is 
 generally present also a considerable degree of wast- 
 ing. This wasting, with an enlarged liver and a faint 
 jaundice tinge, is very suggestive of malignancy. 
 
The Liver, Gall -Bladder and Ducts. 165 
 
 In some cases of chronic heart failure there 
 may be wasting, enlarged liver, jaundice, slight or 
 severe, which simulate malignancy so closeh" that a 
 mistaken diagnosis is not uncommon. If the heart 
 be examined the evidences of heart disease are 
 always so marked that no difficult}^ should be met in 
 recognising the real nature of the hver trouble. 
 
 93. Structural Symptoms in Affections of the 
 Liver. — Xormalh' the upper margin of the liver 
 dullness corresponds to a transverse line drawn at 
 the level of the junction of the sternum and the 
 xiphi-sternum. The lower edge corresponds in the 
 nipple line to the right costal margin. 
 
 Organic sj'mptoms may be recognised as an 
 enlargement of the organ, or a diminution of its 
 size. When there is much muscular hyperalgesia it 
 is often difficult to define the limits of the organ. 
 In the absence of this, little difficulty is found in 
 detecting the extent of the liver enlargement. This 
 is better done by palpation than by percussion, as a 
 distended bowel ma}" communicate a resonant note, 
 particularly with enlargement of the left lobe. In 
 enlargement of the organ from heart failure the 
 organ can sometimes be felt to pulsate. This is per- 
 ceived by putting the left hand behind and pressing 
 forward the liver, while the right hand is laid over 
 the liver, which will be found to heave gently with 
 each cardiac contraction. The extent to which the 
 liver may enlarge is very great, and its lower margin 
 may extend as low as the brim of the pelvis. 
 
 The surface of the enlarged liver niay be nodu- 
 lar, as in cancer and cirrhosis. In the great majority 
 of cases the enlargement of the liver is downwards, 
 but in hydatids of the liver, the cyst being on the 
 
166 Chapter XIV. 
 
 upper margin, the liver dullness may extend 
 upwards to the third rib. Percussion gives rise to 
 the characteristic thrill due to vibration set up in 
 the fluid contents of the cyst. 
 
 The liver may be pushed down by abnormal con- 
 ditions in the chest, as in emphysema or pleural 
 effusions, or it may be displaced downwards on 
 account of laxity of its ligaments and of the abdo- 
 minal muscles (hepatoptosis). 
 
 It may be dragged up into the chest, as in the 
 retraction that follows the absorption of a long- 
 standing pleuritic effusion. 
 
 Diminution of the size of the liver may occur, 
 as in atrophic cirrhosis, when it is the lower border 
 that recedes. 
 
( 167 ) 
 
 Chapter XV. 
 
 THE GREAT AND S:\IALL INTESTINE. 
 
 94. Difficulties in Diagnosis. 
 
 95. Pain. 
 
 96. Appendicitis. 
 
 97. Affections about the Anus and Perineum. 
 
 98. Perineal Reflex. 
 
 99. Functional Symptoms. 
 100. Structural Sy^nptoms. 
 
 94. Difficulties in Diagnosis. — The difficulties 
 in diagnosis of affections of the bowels are very 
 great. The great length of the tube, with its coils 
 confusedly mixed so that there is no safe guide to 
 the localit}^ of manj/ portions, the continual shifting 
 of each portion with the peristalsis of the gut, and 
 our very imperfect knowledge of many of its func- 
 tions, all combine to render diagnosis of bowel 
 affections a matter of great uncertainty. There is a 
 misconception, almost universal, as to the position 
 and form of the great intestine, many pictures of 
 this portion of the gut showing it as passing in 
 swelling folds up the right side, across the upper 
 part of the abdomen, and down the left side from 
 the splenic flexure tc the rectum. It is further stated 
 that the position of this gut can be made out by per- 
 cussion. With the exception of the caecum, which 
 is more or less fixed in its place, and usually dis- 
 tended with gas, no part of the gut can be accur- 
 ately mapped out. To Ix'ilin witli, it is doubtful if 
 
168 Chapter XV. 
 
 the descending colon is ever distended in the manner 
 shown in the pictures. When empty of faeces it lies 
 behind coils of small intestine, a contracted narrow 
 tube. The study of the movements of the bowel 
 after bismuth meals shows that the transverse colon 
 varies extraordinarily in its position in different 
 people. The ready distension of any portion of the 
 small intestine renders attempts to differentiate the 
 particular portion distended a matter of the greatest 
 uncertainty. 
 
 A similar confusion exists in regard to the 
 localisation of pain. The sensation of pain is fre- 
 quently so diffuse that no clear indication of its 
 exact site can be obtained in many cases. When 
 severe pain arises from peristalsis the situation 
 can often be localised with a certain amount 
 of precision, but here the recollections of the 
 patient are extremely unreliable. I have fre- 
 quently been struck by the discrepancy between 
 the patient's account of the position of the pain 
 described from memor}^ and the actual position to 
 which he refers the pain when asked to locate it while 
 suffering from an attack of pain. For this reason 
 the account given by the patient must be taken with 
 great reserve. 
 
 To a certain extent the confusion also depends 
 on the shifting of the site of pain. The cause of pain 
 in the intestine is often due to strong peristalsis, 
 and in disease the peristalsis often does not appear 
 at the site of the lesion, but at some distance above 
 it, whence it gradually descends, and as the wave 
 passes over coil after coil the position of the pain 
 shifts likewise. Peristalsis may be stimulated below 
 the disease, as, for instance, when the irritating 
 
The Great and Small Intestine. 169 
 
 secretion from an inflamed portion of the gut causes 
 painful peristalsis as it is conveyed along the bowel. 
 
 On account of these and other reasons the 
 diagnosis of bowel conditions is often extremely 
 unsatisfactory, though the recognition of the difficul- 
 ties should lead to a more careful scrutiny of the 
 symptoms in each individual case. In the matter of 
 pain, the patient should, if possible, be interrogated 
 at the time he is suffering, and the position of the 
 pain localised as he feels it. If this is impossible, 
 then he should be asked to pay strict attention when 
 it recurs to note the exact site of the onset and the 
 subsequent radiation of the pain. 
 
 95. Pain. — I have already pointed out that the 
 pain from peristalsis of the bowel is usually limited 
 to the central areas of the bod}^ In order to recognise 
 the area in which the pain from any given portion 
 of the bowel may arise, I have taken careful observa- 
 tions in cases of obstruction of the bowel, as one was 
 frequently able to demonstrate the site of the lesion 
 by operation or post-mortem examination. It is 
 well known that the bowel below the obstruction 
 oeases to contract ana lies inert. On the other hand, 
 the bowel above the point of obstruction is usually 
 stimulated to violent peristalsis in the attempt to 
 overcome the obstruction. In consequence of this 
 violent peristalsis severe colic-like pains are set up. 
 Careful observation of the patient during an attack 
 will reveal the fact that the pain starts high up in 
 the abdomen, passes gradually lower and lower, till 
 it reaches a climax at some definite part ; then it 
 ceases and does not descend lower. If when the pain 
 stops this part be noted, the situation of tlie ob- 
 struction can be localised within certain limits. 
 
170 Chapter XV. 
 
 Unfortunately the limits are still wide ; nevertheless^, 
 the information is extremely useful. If we take the^ 
 usual divisions of the areas of the abdomen as in 
 Fig. 8, page 117, it will be found that the peristalsis- 
 of the small intestine gives rise to pain limited to 
 the umbilical region, never descending below that 
 area. The cases in which I have specially studied 
 the pains due to obstruction of the small intestine 
 have been strangulated hernias, and I have had 
 abundant opportunities in operating to verify the 
 situation of the obstruction. This localisation of 
 the pain in the umbilical region is supported by 
 the experience acquired in the case of peristalsis,, 
 with the intestine exposed, cited on page 40. An 
 attempt has been made to find out whether the local- 
 isation might not be more exact, by noting the level 
 of the pain, but the sensation is evidently too diffusa 
 to permit of such exact localisation. One would 
 naturally expect to find a distinct relationship 
 between the level of the pain and the position of the 
 obstruction, but owing to this diffusion I failed to 
 satisfy myself in any given case of the exact limits 
 of the pain. The pain, when very severe just at the 
 lowest limits, also extends widely across the abdomen 
 at the same level. In many cases a diffuse area of 
 hyperalgesia of the skin and muscles may be detected,, 
 but it has been of such a vague character that I 
 have not found it of much value as an aid in 
 diagnosis. 
 
 In obstruction of the large intestine the pain 
 due to the peristalsis descends to the hypogastric 
 region (Fig. 8, page 117), and here certain limited 
 deductions can be drawn from the level at which the 
 pain stops. The cases I have studied have been. 
 
The Great and Small Intestine. 171 
 
 patients with obstruction at the splenic flexure, or 
 at the sigmoid flexure, and cases of hard masses of 
 faeces retained in the rectum. In the obstruction at 
 the splenic flexure the pain did not descend below 
 the middle of the hypogastric area, while the pain 
 due to peristalsis below the splenic flexure was felt 
 about, and below, the middle of the h3^pogastric area. 
 I have observed a number of cases with faecal masses 
 in the rectum, too large and hard for their expulsion 
 by the anus, the pain being felt above the pubis. In 
 these cases the situation of the pain and straining 
 efforts seemed identical with the pains and straining 
 during labour. This agrees with what has already 
 been said about the situation of pain in diarrhoea and 
 with distending enemata immediately before the 
 expulsion of the fluid contents of the rectum. 
 
 In many people scybalous masses may lie in 
 different parts of the bowel, and their presence may 
 set up, after a time, violent peristalsis, in some cases 
 accompanied by diarrhoea. Once the violent peri- 
 stalsis begins it does not subside until the scybalae 
 are shifted. The people in whom I have observed this 
 most frequently have been young women who have 
 neglected their bowels. The pains are very severe, 
 and the motions will often contain greyish hard 
 lumps. After the bowels have been voided a large 
 area of hyperalgesia and muscular contraction over 
 the abdominal wall is left. This tenderness and 
 hardness and the history of colic-like pains give rise 
 to many wrong diagnoses, the principal error being 
 to attribute the symptoms to peritonitis. 
 
 96. Appendicitis.^The nature of the symptoms 
 in appendicitis lias already been indicated on page 
 4.3. From the study of the case given there it will be 
 
172 Chapter XV. 
 
 seen that the symptoms are entirety reflex. In ever}^ 
 case there are features pecuhar to the individual, so 
 that great variations as to the amount of pain, 
 extent of hyperalgesia and muscular contraction are 
 met with. But the nature of the symptoms and their 
 distribution and mechanism of production are suffi- 
 ciently indicated in the illustrative case given on 
 page 42 to make clear the principles underlying the 
 most salient symptoms of appendicitis. 
 
 There are a few symptoms present in excep- 
 tional cases that need a passing notice. The nature 
 of the attacks of " appendicular colic " is to me very 
 obscure. In some cases the pains have been so dis- 
 tinctly referred to the umbilical region that I have 
 considered the question whether the intestine above 
 the inflamed appendix may not have been stimulated 
 to violent peristalsis. That the colic in appendicitis 
 may be due to violent peristalsis, at all events in 
 some cases, seems possible from the following experi- 
 ence. A man aged 40 years had suffered for four 
 3^ears from violent attacks of colic and pain in the 
 abdomen. He had seen several physicians and sur- 
 geons and ultim.ately a diagnosis of gall-stones was 
 made, and he was operated upon. No gall-stones 
 were found and no relief was obtained from the 
 operation. I was asked to see him and I obtained, 
 with difficulty, a clear notion of the site of his 
 suffering and the spread of the pain. The pain 
 started always just at the lower part of the epigastric 
 region and descended slowly in the middle, increas- 
 ing in severity to the lowest part of the umbilical 
 region (space c. Fig. 8, p. 117). It might stop in this 
 neighbourhood for some time, but did not descend 
 lower. From this account, it was reasoned that the 
 
The Great and Small Intestine. 173 
 
 pain was due to some hollow viscus, that as it per- 
 sisted most severely in the central regions of the 
 abdomen, gall-stone colic and the colic from a renal 
 calculus could be excluded. The only hollow viscus 
 that could cause pain in this region was the small 
 intestine, and the radiation of the pain indicated that 
 the peristalsis had started high up and stopped at the 
 end of the small intestine. A painful peristalsis 
 occurs onl}^ above the provoking cause, so that we 
 could infer the cause would be found at the lower end 
 of the small gut. Moreover, as in the great majority 
 of cases the appendix is the provoking agent at this 
 place, the probability was that the appendix was 
 affected. Acting on this diagnosis an operation was 
 performed. The small intestine was found deeply 
 injected, especially at its lower extremity, and the 
 appendix was found red, inflamed and adherent to the 
 neighbouring structures, the adhesions obstructing 
 the lumen of the lower part of the small intestine. 
 The removal of the appendix and adhesions was 
 followed by complete freedom from attacks of colic. 
 
 The appendix wall itself contains a muscle 
 coat, and the contents are frequently confined by 
 blocking of the passage, so it ma}' perhaps be sur- 
 mised that the colic arises from a spasm of the 
 muscle coat. The reference of the pain to the middle 
 line would be in accordance with the experience that 
 peristalsis of any portion of the digestive tube causes 
 pain in the middle line, and parts that have 
 developed from the tube, as the gall-ducts and 
 appendix, follow the same law. 
 
 I cannot satisfactorily account for the predomi- 
 nant symptoms from the appendix being so distinctly 
 one-sided, seeing that it is developmentally a portion 
 
174 Chapter XV. 
 
 of the digestive tube. But it is interesting to note 
 that, as in the case of the gall-bladder and ducts, and 
 even of the heart, though the most severe pains may 
 be situated across the middle line, the radiations and 
 persistence of the phenomena are one-sided. 
 
 In extension of the inflammation in appendicitis 
 other structures become involved, and these then 
 •give rise to the symptoms peculiar to themselves. 
 When the inflammation affects the parietal peri- 
 toneum, and adhesions form with it, these symptoms 
 will be found characteristic of peritoneal adhesions, 
 as pain and tenderness over the part {see page 200). 
 This fact may account for many of those aberrant 
 symptoms in appendicitis, as when it is situated in 
 the pelvis and adherent to adjacent parts. 
 
 97. Affections about the Anus and Perineum. 
 — A somewhat complicated series of symptoms arise 
 in affections about the anus, in consequence of the 
 nervous distribution passing gradually from the 
 autonomic to the cerebro-spinal system. As at the 
 junction of other mucous and cutaneous surfaces the 
 sensibility becomes profoundly modified, and there is 
 a transition area where certain forms of cutaneous 
 sensibility, such as pain, become more acute. This 
 difference in sensibility is well seen in the case of 
 piles, for so long as the pile does not encroach upon 
 the tissues supplied by the cerebro-spinal nerves, no 
 direct pain is felt, whereas pain of the most distress- 
 ing character is felt when the pile encroaches on the 
 mucous membrane supplied by the cerebro-spinal 
 sensory nerves. Pain, however, may be felt from an 
 internal pile, and it is then referred to the back, over 
 the upper part of the sacrum. I have seen much 
 relief afforded from this pain by free haemorrhage 
 
The Great and Small Intestine. 175 
 
 from an internal pile. This referred pain is some- 
 times extremely distressing in cases of ulceration 
 within the rectum, especialh^ after the bowels are 
 moved. When the ulceration or fissure involves the 
 sensitive marginal mucous membrane, the pain 
 becomes at times agonising and prolonged, and is 
 
 ielt in an ill-defined area all around the anus and 
 
 ov er the sacrum. 
 
 There is an intimate relationship between this 
 region and the bladder, irritation at the anus pro- 
 ducing frequent micturition, and sometimes spasm 
 of the sphincter vesicae. This reflex is well seen in 
 women where the perineum has been torn at the birth 
 of a child and afterwards stitched up, retention of 
 urine being a frequent result. This reflex is prob- 
 ably limited to the skin of the perineum, as if care 
 be taken in stitching the perineum not to include the 
 skin in the stitches retention of urine is less likely 
 to occur. The skin supply for this region is from 
 the lower sacral nerves, and the nerve supply for 
 the sphincter vesicae is from the autonomic sacral 
 nerves — that is, from the same region of the cord. 
 98. Perineal Reflex. — A curious connection 
 exists between the perineum and the respiratory and 
 other centres. This is seen particularly well in par- 
 turition, where, when the child's head presses on the 
 perineum, the contraction of the uterus is sometimes 
 greatly stimulated, and the mother is compelled to 
 " bear down " with uncontrollable energy. In 
 patients lightly under chloroform the traction niade 
 by the forceps when the head reaches the perineum 
 somewhat causes the patient to breathe in a deep 
 and laboured fashion. Apart from its scientific 
 interest this latter reflex has to bo borne in mind in 
 
176 Chapter XV, 
 
 the administration of chloroform, as by the deep 
 respiratory movements a greater amount of chloro- 
 form may be taken than is desirable. 
 
 99. Functional Symptoms. — Our knowledge of 
 the symptoms arising directly from abnormal func- 
 tions of the digestive tube is limited to the condition 
 of the fsecal evacuations. These again must be 
 studied in association with other phenomena, as 
 pain, fever, distension of the abdomen. It is scarcely 
 necessary to insist on the systematic examination of 
 the faeces by the physician himself in all abdominal 
 cases, and the patient should be instructed to observe 
 for himself the character of the dejecta. The char- 
 acter of the normal stool is fairly constant, soft and 
 moulded, yellowish-brown in the adult, pale whitish 
 yellow in children and the milk-fed. The colour 
 may vary with the food and with drugs. The absence- 
 of bile gives the characteristic pale drab-coloured 
 stools. There may be an admixture of the stool with 
 abnormal contents from the intestinal tract, as blood,, 
 mucus and pus. Blood from near the anus, as in 
 piles, is usually unmixed with the faeces, either free 
 or staining the faecal mass. When its origin is- 
 higher up it becomes mixed with the food, and under- 
 going certain chemical changes, becomes black and 
 " tarry " looking. The character of the m^ucus in the 
 stools may give some idea as to its source ; small 
 jelly-like masses accompany the diarrhoea from an 
 inflamed swollen gut, shreds or membrane-like pieces- 
 are seen in affections of the colon and rectum. Other 
 abnormal constituents may be present, as undigested 
 food, gall-stone, intestinal sand. 
 
 The character of certain stools is fairly typical,. 
 as the diarrhoeic, with hard scybalous masses,. 
 
The Great and Small Intestine. 177 
 
 indicating that scj^balse are lodged in some part of the 
 digestive tract, and setting up irritation ; the " pea- 
 soup " stools of typhoid fever and of pneumonia ; the 
 "rice water " stools of cholera ; the " frothy stools " 
 of infantile cliarrhcea. The shape of the stool may 
 be modified by its passing through a constricted 
 passage near the anus. The recognition of obstruc- 
 tion, partial or complete, need not be insisted upon. 
 
 Indirectly there are signs of functional dis- 
 turbance, as in the poor nutrition. Absorption of 
 toxic products ma}' interfere with the functions of 
 other organs, particularly the heart, causing weak- 
 ness, irritability, and pain. The skin of the armpits 
 and of the abdomen may become of a dirt}^ j^ellow 
 colour from the same cause. 
 
 100. Structural Symptoms. — Symptoms due to 
 changes in the bowels are very often difficult to make 
 out, owing to the mobility of these organs, and the 
 ease with which they can become distended with 
 flatus. Except the caecum and a small portion of 
 the ascending colon and the rectum, there is no part 
 in which changes can be with certainty located on 
 account of shifting and distension of the intestinal 
 coils. In addition to this, tumours and thickenings 
 in any part of the abdomen so readily conve}" the 
 tympanitic note from the bowel that percussion is 
 seldom of much use in detecting these when they are 
 in the walls of the bowel. A further complication 
 arises when small portions of the muscles of the 
 abdominal wall become hard and contracted {see 
 page 72). Manifest changes in the bowels should 
 alwaj's be considered with reference to the reflex 
 phenomena already described. 
 
( 178 ) 
 
 Chapter XVI. 
 
 AFFECTIONS OF THE URINARY SYSTEM. 
 
 101. Symptoms of Affections of the Kidney. 
 
 102. Symptoms of Affections of the Pelvis of the 
 
 Kidney and Ureter. 
 
 103. Symptoms of Affections of the Bladder. 
 
 101. Symptoms of Affections of the Kidney. — » 
 
 As in the affections of other glandular organs, 
 there are practically no sensory symptoms evoked 
 by disease of the kidney structure. Backache is 
 sometimes put down as present in inflammation of 
 the kidney, but considering how frequent backache 
 is, some doubt may be entertained whether the kidney 
 is the cause. For a great many years I have carefully 
 inquired into the symptoms in all sorts of cases of 
 albuminuria, acute and chronic, and I could find no 
 evidence of pain of any form referable to the kidney 
 trouble. Ail the symptoms of kidney disease (apart 
 from alteration in the size of the organ) are found 
 in the chemical examination of the urine, in the 
 frequent micturition, or as the result of its impaired 
 secretion on other organs and systems (vomiting, 
 headache, convulsions, changes in the cardio-vascular 
 system, dropsy). 
 
Affections of the Urinary System. 179 
 
 Functional Symptoms. — In the routine exami- 
 nation of all cases inquiry should be made into the 
 question whether the patient has to get up at night 
 to pass urine, and, if such is the case, the urine 
 should be examined for albumen or sugar. The pres- 
 ence of albumen should lead to the careful examina- 
 tion of other systems, particularly the heart and 
 blood vessels, because it is the effect of the impaired 
 kidney function on these that offers the best guide 
 as to the importance of the albuminuria. It must be 
 borne in mind that the presence of albumen is not in 
 itself a matter of moment. It only indicates that 
 albumen is passing through the secretory cells, and 
 long experience has taught that when this happens 
 there is an injur}^ to these cells which prevents the 
 ehmination of other matters, which, being retained 
 in the blood, have a deteriorating influence on 
 other organs. It is for this reason that the 
 significance . of the kidney affection is often deter- 
 mined by the symptoms in other organs and 
 tissues. 
 
 Structural Symptoms. — It is only when there is 
 a considerable increase in the size of the kidney that 
 we can detect its presence clinically with assurance. 
 And even then the subject has to be of a somewhat 
 spare habit. Normally we recognise a certain full- 
 ness under the lower ribs in either flank, which 
 rather indicates its presence than gives a clue to its 
 size. It is the relative greater fullness on one side 
 that leads to the recognition of the increase in the 
 size of this organ, and the absence of this fullness 
 which leads to the suspicion of a displaced kidney. 
 Tlie nature of the enlargement in any given case is 
 surmised from the presence of other symptoms, as 
 
180 Chapter XVI. 
 
 pus or tubercle bacilli in the urine, the cancerous 
 cachexia, etc. 
 
 Movable Kidney. — The careful palpation of the 
 abdominal cavity with the walls relaxed may reveal 
 a movable kidney. It is often present without symp- 
 toms, but its presence may be associated with a good 
 deal of vague, indefinite pain, dilatation of the 
 stomach, and more or less nervous disturbance of a 
 " neurasthenic " kind. Obscure attacks of vague 
 pains, nausea and collapse have been ascribed to a 
 movable kidney, and it is well to bear this in mind, 
 for such attacks may be attributed to appendicitis 
 or other intestinal lesion, or to renal colic. 
 
 102. Symptoms of Affections of the Pelvis of 
 the Kidney and Ureter. — Nerve Supply of the 
 Ureter. — The efferent nerves supplying the pelvis of 
 the kidney and the ureter come from the inferior 
 mesenteric, spermatic and hypogastric plexuses. The 
 level at which these nerves leave the cord can be 
 inferred from the study of the nerves implicated in 
 the reflex phenomena in cases of renal calculus. 
 From this study the nerves passing from the pelvis 
 of the kidney and the ureter can be inferred to 
 reach the spinal cord at the level of the lower 
 thoracic and upper lumbar nerves. The distribu- 
 tion of the pain and the stimulation of the muscles 
 to contraction, in a case of renal colic, such as that 
 described on page 44, give a clue to the cerebro- 
 spinal nerves reflexly stimulated by the sympathetic 
 nerves from the pelvis of the kidney and the ureter. 
 The pain arising in the back above the crest of the 
 ilium, passing round the front and slanting down 
 into the testicle, as in the shaded area of Fig. 13, 
 page 183, traverses the fields of distribution of 
 
Affections of the Urinary System. 181 
 
 several spinal nerves from the eleventh thoracic to 
 the second lumbar. In like manner the contraction 
 of the muscles that accompany the pain gives a clue 
 to the motor cerebro-spinal nerves that have been 
 stimulated. In the case described on page 44 con- 
 traction of the fiat muscles over the ihac fossa (the 
 external and internal obliques, and the transversalis 
 abdominis) was produced, the lower portion of these 
 muscles being supplied b}' the lower thoracic nerves. 
 The contraction of the cremaster muscle, which is 
 often such a distinct feature in cases of renal colic, 
 implies a stimulation reaching the spinal cord at the 
 level of the first and second lumbar nerves. It is 
 interesting to note that a portion of the fibres of the 
 cremaster are continuous with the internal oblique, 
 and both of these muscles contract in renal cohc. 
 The genital branch of the genito-crural nerve con- 
 tains tlie motor nerve to the cremaster muscle, and 
 also the sensory nerve to the tunica vaginalis, which 
 latter becomes so hyperaesthetic in renal colic when 
 the pain " shoots into the testicle," and it is manifest 
 that it is to the peripheral distribution of this nerve 
 that the pain is referred. It is to be remembered 
 that the scrotal covering of the testicle is supplied 
 by the sacral nerves, and the skin of the scrotum is 
 never affected in renal colic. (For further evidences 
 of testicular sensibility see p. 37.) 
 
 Non-striped muscle enters into the structure of 
 the pelvis of the kidney and of the ureter, and in 
 consequence we have the reflex symptoms developed 
 to a very marked and characteristic extent. Wliile 
 any circumstances that can arouse the severe con- 
 traction of this muscle seem to provoke the pain and 
 attendant phenomena, the presence of a renal 
 
182 Chapter XVI. 
 
 calculus is, in the great majority of cases, the 
 immediate cause. The following description, while 
 referring to renal calculi, also applies to other 
 causes, as pus or tuberculous ulceration, which may 
 set up a painful contraction. 
 
 The position of the pain, its characteristic 
 radiation, and the attendant muscular contraction, 
 have been referred to and illustrated by the case 
 described on page 44. The place where the pain 
 starts is of very great importance as giving an idea 
 of the approximate site of the stone. It must be 
 remembered that the gradual shifting of the pain 
 from the back round to the front and down to the 
 groin is not an indication that the stone itself is 
 gradually being shifted and driven down the ureter. 
 Nor must it be imagined that because the distribu- 
 tion of the pain has a vague resemblance to our 
 notion of the position of the ureter that the pain is 
 felt " along the ureter." The pain in its radiation 
 is passing along some path in the spinal cord, and 
 thereby affects the cord centres of the nerves dis- 
 tributed to the body wall in the area shaded in 
 Fig. 13. Doubtless the peculiar path is directly 
 associated with the nerve supply of the pelvis of the 
 kidney and of the ureter, and as each part passes 
 into peristalsis a definite portion of the spinal cord 
 receives a corresponding stimulus, just as happens 
 in the case of the peristalsis of the bowel. 
 
 Bearing this in mind, it will be seen that when 
 the pain keeps recurring and starting from the 
 same place the stone is stationary, and its presence 
 stimulates a peristaltic contraction. Hence when we 
 find repeated attacks starting at the back we m.ay 
 safely infer that the stone is lodged in or near the 
 
Affections of the Urinary System, 183 
 
 Fig. 13. 
 
 The shaded area shows the distribution of the cutaneous hyperalgesia 
 after an attack of renal colic. The band traverses portions of the fields 
 of distribution of the eleventh and twelfth thoracic nerves and of the first 
 lumbar. The tunica vaginalis and the lower portion of the left abdominal 
 muscles were also hyperalgesic. 
 
 pelvis of the kidney. There is some doubt whether a 
 stone in the kidney surrounded by glandular tissues 
 and not protruding into the pelvis can ever arouse 
 the pain characteristic of renal calculus, for it seems 
 that contraction of muscle is the cause of the pain, 
 and the calculus acts as a stimulus to the contraction. 
 The explanation of the locality of the pain is 
 that the spinal centres of some fibres of the eleventh 
 thoracic nerve which are distributed in the back 
 
184 ■ Chapter XVI. 
 
 are first stimulated, that as the peristaltic wave 
 passes down it sends stimuH to other centres of 
 the eleventh and twelfth nerves whose fibres are 
 distributed in the area shaded in Fig, 13, and later to 
 the genital branch of the genito-crural nerve which 
 is distributed to the tunica vaginalis ; hence the pain 
 which shoots into the testicle and the tenderness of 
 the testicle, or rather of the tunica vaginalis, after 
 an attack of renal colic. 
 
 In a number of cases the stone seems to stick on 
 its way down the ureter, and the pains then start at 
 a lower level. One may sometimes find a patient with 
 a history of attacks of pain starting in the back, 
 then after a time starting somewhere in the front of 
 the abdomen ; then they have ceased, and the symp- 
 toms of irritation of the bladder have appeared for 
 a period, followed by the expulsion of a calculus and 
 complete relief. 
 
 I am disposed to think that in these cases the 
 stone is lodged at the entrance of the ureter into the 
 bladder. We know from observation on the bowel 
 that violent peristalsis takes place above the point 
 of obstruction, while the bowel below does not con- 
 tract, and it seems that the same is true of the ureter. 
 In these cases the pain passes down as low as the 
 testicle, and this would imply, if my reasoning is 
 right, that the peristalsis has extended to the lowest 
 portion of the tube. It is not likely if the stone were 
 lodged in the middle of the ureter, and completely 
 blocking the lumen, that a peristalsis would be set 
 up in the part below. This is a point worth con- 
 sidering by those who have the opportunity of 
 locating the stone by operation, and seems to be 
 the explanation in the following case. 
 
Affections of the Urinary System. 185 
 
 Male, aged 32, consulted me, A\dth the following 
 history. He had emigrated to America two years 
 previously. For the first year he had enjoyed good 
 health, but during the past j^ear he had been in such 
 constant suffering that his health was shattered, and 
 he had returned to his native country, in the hope 
 that the change might do him good. He was spare 
 and thin, walked with a slight stoop, and his face 
 was drawn and anxious. In conversation he was 
 nervous and irritable, and I had the greatest diffi- 
 culty in getting from him a distinct account of his 
 complaint, as he had become extremely neurotic, and 
 mixed his mental impressions and his digestive 
 troubles with the description of pains in various 
 parts of his body. With strict inquiry I found that 
 his illness began with severe attacks of pain in his 
 back, which he referred to the left lumbar region. 
 For three months these attacks continued until he 
 became weak and ill. After this the pain shifted, 
 starting over the iliac fossa and striking into the 
 testicle, and his testicle became tender, so that it hurt 
 him to wear his breeches. In the past few months 
 this pain had disappeared, and he was now suffering 
 from great perineal pain, especially at the end of 
 micturition. From the account given by the patient 
 the salient points have been selected, leaving out the 
 numerous other symptoms from which he suffered, 
 and which he had mixed up in almost inextricable 
 confusion, besides giving his own irrelevant 
 views as he went along. It was evident that 
 the patient had had a renal calculus, which had 
 shifted its position and was now in his bladder, 
 and his long suffering had reacted on the 
 nervous system, producing very characteristic 
 
186 ChapUr XVI. 
 
 neurotic or nem'asthenic symptoms. I somidecl his 
 bladder and could find no stone, but assured kim 
 that there was a calculus in Ms bladder. A few days 
 after he again called to see me, a totall}- chflferent 
 man. erect and sniihng, and held out to me, in the 
 palm of his hand, a calculus, the size of a smaU 
 bean, which he had passed the previous day. My 
 reading of the symptoms was, a renal calculus, at 
 first lodged in the pelvis of the kichiey, then at the 
 lower part of the ureter, and finally in the bladder. 
 The suffering had weakened and exhausted the ner- 
 vous system and produced other ^^idespread pheno- 
 mena. I have already drawn attention to the Avell- 
 known fact that prolonged suffering tends to produce 
 a hypersensitive nervous system, so that other affec- 
 tions, such as gastric flatulence, produce exaggerated 
 symptoms. 
 
 The reflex symptoms resulting from a renal 
 calculus may be much more extensive, and give rise 
 to s^Tnptoms indicative of other lesions, as already 
 referred to on page 76. There I have instanced a 
 case where I was summoned to do a laparotomy for 
 obstruction of the bowel. When I saw the patient 
 the s^iTuptoms certainly pomted to an obstruction of 
 the bowel, for no faeces or flatus had passed for two 
 days, the abdomen was greatly distended, and aU the 
 muscles firm and rigid. 
 
 The nerve supply of the viscera and their con- 
 nection with the cerebro-spinal nerves is fairly con- 
 stant. Sometimes it would seem as if the centres 
 in the cord were at a slightly different level, so that 
 the sensor}' symptoms were referred to regions 
 higher or lower than the usual level. Such is the 
 
Affections of the Urinary Systeyn. 1S7 
 
 Fig. 1-L 
 
 The shaded area corresponds to the ate of pain and cutaneous hyper- 
 algesia in a case of renal calculus after an attack of colic. 
 
 interpretation I give for the high situation of the 
 sensory symptoms in the following case. 
 
 ^lale, born 1864, consulted me in October, 1900, 
 complaining of severe spasms of pain from wliich 
 he had been suffering five days. He had had similar 
 attacks twelve years before. He referred the pain 
 with great definiteness to the area shaded in 
 Fig. 14, page 187, this area corresponding to 
 a region of deep cutaneous hyperalgesia — that 
 
188 Cha'pter XVI. 
 
 is to say, the skin here was very tender if 
 gently raised and gently pinched, but showed no 
 increased sensitiveness to light scratching with a 
 pin-head. This area of tenderness extended round 
 to the spine. I was in doubt as to the cause of these 
 attacks of pain. The onset and character of the sen- 
 sation corresponded to an attack of renal colic, but I 
 had never seen a case with the pain and tenderness 
 so high. Under treatment (rest and opium) the 
 attacks subsided. He again consulted me for a 
 similar series of attacks in October, 1903. He had 
 had an occasional attack in the interval, but they 
 were becoming more frequent. There was still 
 present the characteristic area of deep cutaneous 
 hyperalgesia, as in Fig. 14. During one of these 
 attacks the pain suddenly passed into the left lumbar 
 region, and then round to the front of the abdomen, 
 to the groin and into the left testicle. At the same 
 time he was conscious of the testicle being forcibly 
 drawn up. When I examined him there was much 
 tenderness on pressing the lumbar muscles and the 
 left testicle. Under rest and opium the pain sub- 
 sided, and two days later in voiding urine he passed 
 a small calculus. There was complete freedom from 
 pain until October, 1905, when he again had a few 
 attacks of pain referred to the area shaded in Fig. 
 14. This pain passed downwards to the groin and 
 testicle, and again he was conscious of the testicle 
 being firmly drawn up. He rested in bed four hours, 
 and upon micturating he passed another small 
 calculus. He has remained free from any further 
 attack. 
 
 103. Symptoms of Affections of the Bladder. — 
 The bladder in its development is derived from two 
 
Affections of the Urinary System. 189 
 
 sources, the allantois and the cloaca. From the 
 former there comes the upper division, and from 
 the latter the fundus of the bladder (the trigone). 
 The nerve supply of the bladder is hkewise from 
 two sources, from the upper lumbar region and 
 from the sacral autonomic (second and third sacral) 
 {see Fig. 1, page 27). As a result of this nerve supply 
 the sensory symptoms are felt in two regions, in the 
 hypogastric region, where the upper lumbar nerves 
 are distributed, and in the perineum and along the 
 penis, where the sacral nerves are distributed. The 
 pain from an over-distended bladder, as in retention 
 of the urine, is felt mainly above the pubis, and 
 resembles in its situation and character the pain of 
 uterine contraction or the pain of peristalsis of the 
 lower end of the great gut. This pam is intermittent 
 in character, and is due to the passage of waves of 
 contraction over the bladder. When there is much 
 irritation of the bladder, as in acute infiam.mation of 
 its mucous membrane, or in the presence of a stone, 
 the contraction of the bladder at the end of micturi- 
 tion is sometimes very severe, and the pain is then 
 felt both above the pubis and in the perineum, also 
 along the penis. In many cases of stone, the pain 
 from the perineum to the point of the penis is the 
 most distinct, being felt most severely at the end of 
 micturition, but severely also at other times, and 
 particularly if the patient is jolted. The viscero- 
 motor-reflex is usually not well marked, but I have 
 noted contraction of the lowest division of the recti 
 in cases of stone in the bladder. 
 
 The act of micturition is a reflex that may be 
 stiiiLulatcd into activity in a groat many ways. Nor- 
 mally there is a distinct relationship between the 
 
190 Chapter XVI. 
 
 distension of the bladder and the act, filhng of the 
 bladder setting up refiexly the contraction of the 
 muscular wall, which results in the expulsion of the 
 urine. In the child the act of micturition is purely 
 reflex, but with advancing age the individual 
 acquires m.ore or less voluntary control of the act of 
 mictiurition. 
 
 In addition to the muscle wall of the bladder the 
 abdominal m.uscles may assist by compressing the 
 bladder, and in expelling the last drops the perineal 
 muscles (especially the levator ani and the accelera- 
 tor urinse) play an important part. The act of 
 micturition in the infant, or the calls to micturate 
 in the adult, may be so frequent as to raise the 
 question of some abnormal accentuation of the 
 stimulus. This may arise in a great many ways, as 
 in the excessive quantity of urine secreted (in 
 diabetes and certain forms of Bright' s disease), the 
 irritating nature of urine as in concentrated or very 
 acid urine, the presence of abnormal ingredients as 
 oxalates, pus, blood, calculi. The wall of the bladder 
 may be inflamed and irritated, so that a small quan- 
 tity of normal urine may serve as a stimulus. Stimuli 
 from other organs and tissues affecting the spinal 
 centres of the bladder may provoke frequent mic- 
 turition, as in affections of the kidney, ureter, anus, 
 and perineal region. Or there may be an irritable 
 focus in the cord, due to lesion of some other viscus, 
 which invades the bladder centre, so that impressions 
 from the healthy bladder have an exaggerated effect 
 and cause the frequent micturition seen in such cases 
 as renal calculus, appendicitis, affections of the 
 ovar}^ and uterus, and piles. In these cases there 
 wiU always be found some region of hyperalgesia in 
 
Affections of the Urinary System. 191 
 
 the external body waU characteristic of the particu- 
 lar organ at fault. A cause of frequent micturition 
 often overlooked is over-distension of the bladder 
 from some such obstruction as enlarged prostate in 
 the male, or pregnancy or pelvic tumour in the 
 female. Examination of the resonance above the 
 pubes may reveal the dullness due to a distended 
 bladder in the male, but when there is a pregnant 
 uterus, or other tumour, it may not be possible to 
 recognise the distended bladder. The doctor, misled 
 by an account of frequent micturition, may fail to 
 detect the trouble, and ver}^ serious consequences may 
 result from this being overlooked. In pregnancy, 
 with retention of urine of this sort, the patient may 
 die if relief is not speedih' obtained. 
 
 Functional SymjAoms — Although the chief 
 function of the bladder is to retain and expel the 
 kidney secretions, it, like other mucous membranes, 
 has a secretion of its own. The secretion is normally 
 only perceptible in ver}^ delicate analysis of the 
 urine. The contents of the bladder may irritate the 
 mucous membrane, so that its secretion may be more 
 abundant, and may become perceptible as a haze at 
 the bottom of the glass when the urine has cooled 
 and stood for some time. This mucous secretion may 
 increase in quantity with the irritation or inflam- 
 mation of the bladder wall, till the urine becomes 
 thick and viscid, and even blood-stained, according 
 to the degree of inflammation. Pus also may be 
 secreted from the inflamed mucous membrane, or 
 from an ulcer. These abnormalities, however, are to 
 be detected by following the usual routine of urine 
 •examination, with which I do not propose to deal. 
 
192 Chapter XVI. 
 
 Structural Symptoms. — Changes of the organ 
 can only be detected by its increase in size above the 
 pubes, or by exploration with the finger in the rectum 
 or vagina. In either case, when abnormalities are 
 detected, additional evidence has to be sought by 
 examination of the bladder by the catheter, by 
 sounding, by X-raj^s, or by use of the cystoscope. 
 
( 193 ) 
 
 Chapter XVII. 
 
 AFFECTIONS OF FEMALE PELVIC ORGANS. 
 
 104. The Uterus. 
 
 105. The Ovaries. 
 
 106. The Vagina. 
 
 I have been unable to satisfy myself as to the 
 sensibility of some parts of the female pelvic organs. 
 The uterus above the cervix is certain!}^ insensitive 
 to ordinary stimuli, for I have many times tested 
 the interior, with my whole hand in the uterus, dur- 
 ing and after labour, and in scraping out the 
 contracted uterus. The pains during labour are 
 undoubtedlv referred, as I shall describe later. I 
 cannot form any definite opinion of the sensibiUt}^ of 
 the cervix, or for that matter of the vagina. In 
 regard to the cervix I have been able to pinch it and 
 to prick it, with no sensation, but on the other hand 
 great pain is often experienced when an attempt is 
 made to dilate it. But whether this is a direct or 
 a referred pain I could not decide. The patient is 
 so conscious of the stimulation of the external geni- 
 tals and to the discomfort in the sensitive parts, that 
 her statements become affected by suggestion, and 
 the reference is too confused to be of use. In the 
 same way the extent of the supply of cerebro-spinal 
 nerves to the vagina is not understood, nor could I 
 
194 Chapter XVII. 
 
 determine the limits by stimulation, for the sensory 
 nerves are modified for special sensations. The 
 tendency to exaggerated reflexes in most cases adds 
 to the confusion, for such patients will say they 
 experience a sensation before they are stimulated, 
 and in their apprehension they anticipate or 
 exaggerate the result. A further complication 
 results from the difficulty in diagnosis, it being very 
 rare to obtain a satisfactory proof of the nature of 
 the ailment in cases showing what seemed the most 
 typical evidence of referred symptoms. In the fol- 
 lowing brief description the subject is dealt with 
 so far as reliable evidence could be obtained. 
 
 104. The Uterus. — The pain of uterine con- 
 traction is a distinctly referred one, though this 
 seems scarcely probable on superficial observation. 
 In palpating the pregnant uterus during labour the 
 onset of the contraction and the pain are simul- 
 taneous and evidently so distinctly related that it 
 seems improbable that the pain is not a direct one, 
 especially when the pain is so often described as 
 being felt across the abdomen in the region where the 
 uterus is felt contracting. But if the matter be in- 
 quired into more carefully it will be found that the 
 pain is frequently not felt across the abdomen, but 
 across the back at the level of the top of the sacrum. 
 Here again the hasty observer has attributed the 
 pain to the child's head " distending the cervix," or 
 " pressmg on the lumbar plexus " ; but this pain is 
 referred here before the cervix is distended, and also 
 after the child is expelled, during the " after-pains," 
 when the uterus can be found to contract, although 
 the patulous cervix is untouched. This pain in the 
 back is found not only in labour at full term, but also 
 
Affections of Female Pelvic Organs. 195 
 
 during a miscarriage. The pain referred to the 
 front of the belly, between the umbilicus and pubes, 
 is also present when the uterus is not an abdominal 
 organ but a pelvic one, as in miscarriage, after- 
 pains, and other causes that induce uterine contrac- 
 tion. It is well seen in the severe spasms of pain 
 that occasionally occur when some fluid from a 
 vaginal douche escapes into the uterus and sets up 
 uterine spasm. 
 
 In rare cases we may find the pains due to the 
 contraction of the pregnant uterus referred to a 
 distinctly lower level, and in one case the pains were 
 all felt across the upper front portion of the thighs. 
 
 Ver}^ exact delimitation of the area of pain is 
 not possible, but the region in wliicli uterine pain 
 may occur extends from the tenth thoracic to the 
 third lumbar nerves, though in any individual case 
 it is restricted to a limited portion of that 
 distribution. 
 
 105. The Ovaries. — The nerve supply of the 
 ovary is not exactly known, but, like the testicle, its 
 development starts higher up in the abdomen than 
 the position it occupies in adult life. The testicle 
 has been shown to be developed between the tenth 
 and twelfth dorsal vertebrae, and the nerve supply 
 presumably comes from the same region. So far as 
 I have been able to make out, the pain felt in ovarian 
 trouble is referred to the lowest part of the abdomen 
 of one side, and over the groin in the position in 
 which the testicular pain is felt. The lowest portion 
 of the abdominal muscles in this situation readily 
 becomes hyperalgesic and contracted. This cliarac- 
 teristic region of tenderness has often misled 
 observers into the beUef that the pain evoked by 
 
196 Chapter XVII. 
 
 pressure in this region was due to a " tender ovary,'* 
 a statement with some truth in it, but not in the 
 sense intended, for the ovary itself in such cases is 
 not affected by the pressure, the pain of the pressure 
 arising from the stimulation of the hyperalgesic 
 skin or muscle. 
 
 Beyond an indefinite patch of hyperalgesia of 
 the skin in the region of the groin, extending some- 
 times for a variable distance down the thigh, I have 
 not been able to make out much that is rehable in 
 regard to the hyperalgesic area of ovarian disease. 
 It is in these cases we often find such widespread 
 areas that it is doubtful how much is due to the 
 actual ovarian lesion. 
 
 Associated with all forms of pelvic trouble are 
 a number of other reflexes. Thus the breasts fre- 
 quentty become tender, especially at the menstrual 
 period. A cough is sometimes spoken of as being 
 " uterine," or of ovarian origin, but I have not been 
 able to convince myself of such a thing. Vomiting 
 is a frequent reflex symptom, particularly in preg- 
 nancy, but here it is probably not of a reflex nature, 
 but toxsemic. As I have already remarked, it is 
 sometimes a pure reflex, as in the vomiting associated 
 with the uterine pains. The effects of stimulation of 
 the ovary have not led to a very definite result, partly 
 because of the difficulty in doing this without stimu- 
 lating the sensitive orifice (anal and vaginal). The 
 ovary, like the testicle, is partly covered by germinal 
 epithelium, and this may modify the sensitivity. 
 
 106. The Vagina. — The character of the pain 
 in vaginal affections is so ill-defined that it is difficult 
 to say whether it is direct or referred. This is seen 
 in the cases of urethral caruncle, where the pain 
 
Affections of Female Pelvic Organs. 197 
 
 may be of a very severe form and the localisation so 
 vague that the detection of the cause is often a 
 matter of some difficulty. It resembles in some 
 respects the severe vague pain of an anal fissure. 
 A powerful reflex contraction of the muscles that act 
 as sphincter of the vagina, on certain conditions of 
 irritation of the vaginal mucous membrane, ma}' 
 produce vaginismus. 
 
( 198 ) 
 
 Chapter XVIII. 
 
 PERITONITIS AND PERITONEAL 
 ADHESIONS. 
 
 107. Insensitiveness of the Peritoneum. 
 
 108. Symptoms in Peritonitis. 
 
 109. Symptoms in Peritoneal Adhesions [Parietal), 
 
 110. Symptoms in Peritoneal Adhesions ( Visceral). 
 
 107. Insensitiveness of the Peritoneum. — I 
 
 have already referred to the fact that the serous 
 surface of the peritoneum is insensitive to any form 
 of stimulation, but that the external layer of 
 the parietal peritoneum is an extremely sensitive 
 structure, stimulation of which produces the sensa- 
 tion of pain (page 35). It is commonly assumed that 
 the peritoneum is an extremely sensitive structure^ 
 particularly when inflamed. I must say, however, 
 that I have found no evidence of any increase in the 
 sensibility of the inflamed serous surface when I 
 have stimulated it directly, and I have done 
 this repeatedly in patients free from any form 
 of analgesic. To a certain extent the popular 
 misconception of the sensibility of the peritoneum 
 has arisen from the fact that no attention has been 
 paid to the hyperalgesia of the structures of the 
 external body wall, including the external layer of 
 the parietal peritoneum. The result has been that 
 the evidence of peritonitis is almost invariably based 
 
Peritonitis and Peritoneal Adhesions. 199 
 
 on the pain and tenderness on pressure — evidence 
 which, as I have endeavoured to demonstrate, is not 
 due to peritonitis, but to the hyperalgesia of the 
 structures of the external wall. That peritonitis 
 may produce these symptoms is true, but it does so in 
 the same way as the viscera produce them — i.e., by 
 reflex stimulation. The reason of the insensibility 
 of the peritoneum is the same as that for the insen- 
 sibility of the viscera, namely, that the nerve supply 
 of the peritoneum arises from the sympathetic, with 
 the exception of the external layer of the parietal 
 peritoneum, where the nerve supply is from the 
 cerebro-spinal nerves. 
 
 108. Symptoms in Peritonitis. — If we take a 
 case of acute peritonitis a careful analysis of the 
 symptoms reveals their true nature. Thus, in a case 
 of ruptured gastric ulcer, where there was an exten- 
 sive peritonitis limited to the upper part of the 
 abdomen as shown b}^ post-mortem examination, the 
 patient lay on her back with the knees drawn up, 
 partly to relax the abdominal muscles, and partly to 
 avoid the pressure of the bed-clothes on the abdo- 
 minal wall. She shrank at the first attempts to pal- 
 pate the abdomen, and when the skin was tested it 
 was found extremely hyperalgesic, the lightest touch 
 producing the sensation of pain. The area over 
 which this hyperalgesia extended had no definite 
 relation to the extent of the peritoneal inflammation. 
 Thus, for instance, in marking out the limits of the 
 cutaneous hyperalgesia 1 found it extended for a few 
 inches up over the chest and down over the thighs, 
 the margin fading awa}^ indefinitely. The sensibility 
 of the muscles of the abdominal wall could not be 
 tested on account of the liyperalgesia of the skin over 
 
200 Chapter XVIII. 
 
 them. They were, however, partially contracted, and 
 the lightest palpation produced a rapid and strong 
 reflex contraction. 
 
 In less extensive peritonitis these symptoms 
 may be limited to a small portion of the abdominal 
 wall, and when they are present it is impossible to 
 distinguish them from the hyperalgesia and muscular 
 contraction due to some visceral affection. The 
 hyperalgesia following an attack of gall-stone colic, 
 or due to a gastric ulcer, is almost invariably attri- 
 buted to a " peritonitis," and this view is supposed 
 to be proved when, during operation for gall-stones, 
 a certain number of peritonitic adhesions are found. 
 While peritonitis can produce hyperalgesia of the 
 external body wall, it should always be borne in 
 mind that the viscera can also do this, and when 
 hyperalgesia is found in gastric ulcer, after gall- 
 stone, renal or bowel colic, the cause of the hyper- 
 algesia is in all likelihood not peritonitis, but the 
 presence of an irritable focus in the spinal cord, the 
 outcome of the violent visceral stimulation. 
 
 109. Symptoms in Peritoneal Adhesions 
 (Parietal). — I have broken down adhesions and 
 found them insensitive, but when tlie}^ are attached 
 to the parietal peritoneum, dragging on them may 
 produce severe pain. Ramstrom also describes the 
 serous surface of the parietal peritoneum as insen- 
 sitive, but that pulling on the adhesions attached to 
 the parietal layer causes pain, thus agreeing with my 
 own observations. I attribute this to the fact that 
 the inflam.mation that resulted in the production of 
 the adhesions had extended to the peritoneal layer 
 supplied by the cerebro-spinal sensory nerves. The 
 difficulty in distinguishing between visceral pain 
 
Peritonitis and Peritoneal Adhesions. 201 
 
 and the pain due to the invasion of the external 
 body wall is very great. In naany visceral aihnents 
 the inflammatory affection extends and involves the 
 sensitive structures of the abdominal wall, and with 
 this extension a new train of symptoms arises, which 
 may lead to wrong inferences if these differences in 
 the sensibiht}^ of the structures are not clearly kept 
 in view. One can easily see how appendicitis may 
 give rise to symptoms which are entirety confined to 
 the reflex group, until the inflammation extends to 
 the abdominal wafl, when another series of symp- 
 toms may arise which are produced by a different 
 mechanism, and are detected in the immediate region 
 of the inflammation. 
 
 For the study of the symptoms of adhesions 
 those formed after operation offer the best oppor- 
 tunity, inasmuch as their presence can be inferred 
 and the operation has determined the condition of 
 the viscera. Maylard says : " It is doubtful whether 
 any opening of the general peritoneal cavity ever 
 takes place without the subsequent formation of 
 adhesions, for no tissues of the body seem so ready 
 to exude a. plastic cementing material, which glues 
 almost at once anv structure Ivina; in contact with 
 it." It is probably due to these adhesions that so 
 much pain and tenderness is felt after some simple 
 abdominal operation, even when the operation is 
 purely exploratory, and no injury has been done 
 to any viscus. The hyperalgesia in such cases is 
 often muscular, and associated with a lively reflex of 
 the hyperalgesic muscles, so much so that their exer- 
 cise, as in walking, may result in their shortening, 
 from an increase of their tonic contraction, for a 
 longer or shorter time. Small portions of these 
 
202 Chapter XVIII. 
 
 muscles may remain firmly contracted for long 
 periods, and som.etimes they so closely resemble a 
 tumour in the abdomen that it is impossible to 
 tell whether the hardness is a contracted muscle 
 or not. 
 
 In a case of pyloric stenosis, in which gastro- 
 enterostomy had been performed, muscle pain and 
 tenderness persisted in the left rectus muscle. As 
 the patient experienced no relief, she again con- 
 sulted the surgeon who had performed the operation. 
 He detected a small tumour in the abdomen, and 
 insisted on an operation for its removal. I thought 
 the tumour was a contraction of a portion of the 
 fibres of the left rectus muscle at the upper portion 
 of the second interseptal division. As, however, the 
 surgeon was very confident of his opinion, and I was 
 less sure of mine, the abdomen was opened. No 
 tumour was detected, but there were numerous fine 
 adhesions attached to the parietal peritoneum, 
 stomach, and bowel. It was manifest that the 
 apparent tumour had been entirely muscular, this 
 contraction being in the nature of a reflex, for there 
 was no extension of the inflammation from the 
 adhesions to the muscles. 
 
 110. Symptoms in Peritoneal Adhesions 
 (Visceral). — Adhesions limited to the visceral peri- 
 toneum may produce no symptoms, or they ma}^ pro- 
 duce very well-marked reflex contraction of the mus- 
 cles, with more or less hyperalgesia of the skin or 
 muscles. This subject has not been worked out, and 
 I have only been able to investigate it to a limited 
 extent. It seems, however, one worthy of attention, 
 and there are plenty of opportunities for its study, 
 if careful notes of the condition be made before 
 
Peritonitis and Peritoneal Adhesions. 203 
 
 operation. For man}^ j-ears I applied it in the diag- 
 nosis of ovarian tumours to ascertain whether there 
 were hkel}' to be adhesions or not. Then I found 
 that when the muscles of the belly-wall were not 
 contracted and not tender there were no adhesions 
 between the ovarian cyst and surrounchng structures. 
 When, however, there was much muscular contrac- 
 tion and h3'peralgesia, adhesions were always found 
 between the tumour and the surrounding organs. 
 As, however, these observations were made and veri- 
 fied in only some twent}" cases, they are manifestly 
 insufficient for a definite statement, but I put forth 
 this suggestion as a line of observation well worth 
 consideration. 
 
( 204 ) 
 
 Chapter XIX. 
 
 AFFECTIONS OF THE LUNGS AND PLEURA. 
 
 in. Nature of the Subjective Sensations. 
 
 112. The Respiration. 
 
 113. Reflex Symptoms. 
 
 114. Functional Symptoms. 
 
 115. Structural Symptoms. 
 
 116. Affections of the Pleura. 
 
 117. Nature of the Pain in Pleurisy. 
 
 111. Nature of the Subjective Sensations. — 
 
 Owing to the constitution and the accessible situation 
 of the organs, the ph^^sical signs of affections of the 
 lungs are readily ascertained, and have been so well 
 explored that I shall do little more than touch upon 
 some of the reflex phenomena. Even though these 
 phenomena can be so readily recognised, their 
 mechanism is far from clear. The chief reflex which 
 presides over the movements of respiration involves 
 the employment of the muscles of the body-wall over 
 such a large area that the symptoms often become 
 very complicated. The subjective sensations of the 
 patient arise also from such a number of causes that 
 it is often impossible to understand how they are 
 produced. As in other parenchymatous organs, no 
 form of stimulation of the lung tissue seems to be 
 capable of producing sensation directly or reflexly. 
 
Affections of the Lungs and Pleura. 205 
 
 Below the epiglottis there is no sensation elicited 
 from stimulating the air passages, though coughing 
 is readily induced in certain regions. The lung 
 itself is insensitive to stimulation when healthy (as 
 is seen when an exploring needle penetrates the 
 lungs) or when diseased. It is well known that the 
 lung may be acuteh^ inflamed, torn by an apoplexy, 
 ulcerated and scooped out by a tuberculous process, 
 and no sensation be felt by the patient. When pain 
 arises in connection with affections of the lung, it 
 is from the implication of the pleura in the disease 
 process, or from the muscles of respiration becoming 
 sore and tender from excessive exercise. 
 
 Although no pain arises in connection with 
 lung affections, other sensations appear, as the sense 
 of breathlessness, " air hunger," and a sense of suffo- 
 cation. These sensations may be the occasion 
 of acute distress, and provoke attempts at deep 
 hispiration. 
 
 Dr. Haldane considers it " probable that ' air 
 hunger ' is always due to excitation of the respira- 
 tory centre in consequence of an abnornaal condi- 
 tion of the blood. Nothing else is known to produce 
 ' air-hunger.' The excitation may be due to (1) excess 
 of COo. This is the normal excitant. The excess of 
 CO., may be due to hindrance to entry or exit of air 
 (asthma, bronchitis, etc.), or to hindered penetration 
 of CO2 from the blood to the alveolar air (pneumonic 
 or dropsical conditions in the lung). A second cause 
 is diminished alkalinity of the blood. This acts just 
 hke CO2 on the centre. A typical example is tlie 
 liyperpncea of diabetic coma (oxy butyric acid in the 
 blood). If want of O,. arises in the tissues from hin- 
 dered absorption of 0^ by the lungs, from defective 
 
206 Chapter XIX. 
 
 circulation (as in certain forms of heart failure) 
 or other cause (COo poisoning, poisoning by nitrites, 
 or other substances, which disable the haemoglobin, 
 etc.), the blood also becomes less alkaline from lactic 
 acid formation, or lactic acid is formed in the centre 
 itself. The centre is thus stimulated, and hyperpnoea, 
 as a secondary result of want of Oo, results. Want 
 of Oo does not seem to be a direct stimulus to the 
 centre. It is only in a limited number of cases that 
 pure Oo can relieve dyspnoea." 
 
 112. The Respiration. — The movements of 
 respiration consist ' in the contraction of certain 
 muscles, increasing the size of the chest cavity, and 
 producing the inspiratory act. The muscles em- 
 ployed in the act of respiration are the diaphragm, 
 the external intercostal muscles, the levatores cos- 
 tarum, and serratus posticus superior. As these 
 muscles in their contraction enlarge the cavity of the 
 chest by raising the thorax and twisting the costal 
 cartilages, and thus stretch the elastic tissue of the 
 lungs, so when they cease to act the thorax falls by 
 its own weight, assisted by the recoil of the costal 
 cartilao;es and of the elastic tissues of the luna^s. The 
 thoracic cavity is thus reduced, and the air is ex- 
 pelled. It is possible that the internal intercostal 
 muscles contract with each expiration. In both forced 
 inspiration and expiration a large number of acces- 
 sory muscles may take part in the respiratory 
 movements. 
 
 Although the nerve supplj^ of these muscles 
 involved in respiration come from widely separated 
 portions of the cord, they are all under the dominance 
 of one centre in the medulla oblongata — the 
 respiratory centre — the noeud vital of Flourens, 
 
Affections of the Lungs and Pleura. 207 
 
 situated in close proximity to the nuclei of the 
 vagus nerves. 
 
 The normal rate of respiration is from fourteen 
 to sixteen per minute, when the body is at rest. 
 Abnormalities are usually considered from the stand- 
 point of increase in rate and violence of the act of 
 respiration. There are, however, conditions of slow 
 respiration, apart from mechanical obstruction, 
 which are of some interest as thej^ are associated 
 with certain neurotic conditions, and the slow re- 
 spiration produces a form of heart irregularity (sinus 
 arrh3'^thmia). However variable the rate. Dr. Haldane 
 points out that the alveolar ventilation will be the 
 same— the frequent breathing being shallow, and the 
 slow breathing deep. 
 
 Although the ph^^siology of respiration so 
 clearly defines the method by which respiration is 
 regulated, 3'et there is nothing so perplexing to 
 explain as the influences that operate in producing 
 abnormal forms of respiration. In any given case 
 of increased frequency of respiration it is difficult or 
 impossible to say whether the condition is the result 
 of imperfect aeration or reflex stimulation. The 
 presence of non-striped muscle fibres in the smaller 
 bronchi leads to the surmise that these may become 
 tonically contracted, and therefore prevent the 
 entrance of air to the alveoli. 
 
 This action seems all the more probable when 
 we reflect that asthma is so often the outcome of a 
 remote stinaulation, as from the nasal cavity, and 
 that muscular contraction is very susceptible to 
 reflex stimulation. Dyspnoea of a very severe form 
 may arise from pcriplieral stimulation, as is seen in 
 pneumonia, or pulmonary apoplexy, when tlie 
 
208 Chapter XIX. 
 
 breathing may be greatly increased in frequency 
 and in violence. The alteration in the breathing is 
 not the outcome of a diminution of the breathing 
 space by the inflammatory exudation, or apoplexy, 
 for the rate of breathing may suddenly return to 
 the normal, with no diminution in the extent of the 
 affection of the lung. Presumably here the increased 
 respiration is the outcome of a reflex, but whether 
 the stimulation played directly upon the respiratory 
 centre, or whether it caused a reflex spasm of the 
 bronchial muscles, we cannot tell. The dyspnoea 
 arising from other sources is equally obscure. Dr. 
 Haldane considers " the respiratory trouble in heart 
 failure to be due (at least mainly) to the slowed cir- 
 culation, and consequent imperfect aeration of the 
 tissues. The deficiency of 0. in the tissues will cause 
 increased formation of lactic acid, and consequent 
 diminished alkalinity of the blood, and consequent 
 necessity for an abnormally great removal of CO2 
 from the blood. The increased respirations may also 
 materially assist the circulation by aspirating more 
 venous blood towards the heart. The breathless 
 healthy person is breathless from excess of CO., in 
 the arterial blood. In heart disease there is no ex- 
 cess of CO2, or deficiency of 0^ in the arterial blood, 
 but this condition exists in the tissues owing to the 
 slow circulation. Slight hyperpnoea will diminish 
 the CO 2 in the arterial blood, and thus compensate 
 for excess of CO2 ; but hyperpnoea cannot appreci- 
 ably increase the oxygen in the arterial blood, and 
 therefore cannot compensate for the want of 0., in 
 the tissues. The patient is therefore blue, although 
 his breathing may not be noticeably increased. Exer- 
 tion during any condition where the circulation 
 
Affections of the Lungs and Pleura. 209 
 
 (particularly in the coronary vessels) is defective, and 
 cannot be increased in response to the increased need 
 for blood, will lead to a fall of blood pressure, the 
 heart being incapable of supplying enough blood to 
 correspond to the increased flow (vaso-dilatation) in 
 the working muscles. Fainting will thus be caused. 
 The same effect is seen in CO 2 poisoning, where even 
 a slight exertion produces fainting with absolute 
 certainty, and may be fatal." 
 
 113. Reflex Symptoms. — Cough. — Coughing is 
 essentially a reflex phenomenon, the centre for which 
 is one of the numerous areas associated with the 
 main respiratory one in the bulb. The stimulus is 
 conveyed from the periphery by some branch of the 
 vagus. The result of the stimulus is to cause first a 
 deep inspiration, which is followed by a closure of 
 the glottis, then by a sudden and powerful contrac- 
 tion of the muscles of expiration which forces the air 
 through the resisting glottis. By this process the air 
 drawn into the lungs by the prelimmary inspiration 
 is driven out with such force that all movable matter 
 in the larger tubes is swept out. The area that most 
 readily excites the cough reflex is the mucous mem- 
 brane of the larynx, the nerve supply being from 
 the superior laryngeal nerve, a branch of the vagus. 
 The respiratory tract below the larynx and the lung 
 tissue seem to be incapable of originating the stimu- 
 lus. The cough in affections of the lung arises only 
 \\lion the secretion has been carried by the contrac- 
 tions of the bronchial muscles, and by the cilia of 
 the respiratory tract so far upward as to reach the 
 sensitive region about the hirynx. Thus it is that in 
 pneumonia the cough may be only slight, and only 
 provoked when the secretion has passed up tlie 
 
210 Chapter XIX. 
 
 respiratory tube. In phthisis and abscess, and all 
 cases where there is abundant expectoration, it is to 
 be noted that the starting of a cough after a period 
 of quiescence is followed by a persistence until the 
 accumulated matter is expelled. The first cough 
 is initiated by the gradual conveyance of the phlegm 
 to the sensitive area, while afterwards the cough for- 
 cibly expels the contained matter, and so keeps up 
 the irritation until there ceases to be forced out any 
 more secretion. This sensitive region may be stimu- 
 lated by the inhalation of cold air, and it seems to 
 be the starting place of the spasm of uncontrollable 
 coughing in whooping-cough. While this is prob- 
 ably the true explanation of the great majority of 
 cases, coughing can also be excited by stimulation by 
 other means. When a pleuritic effusion is aspirated, 
 scratching the visceral pleura will often produce a 
 cough, or irritation of the branches of the vagus that 
 go to the stomach or ear may produce coughing. It 
 is always well to exclude the possibility of irritation 
 in the larynx, before assuming the presence of the 
 more remote stimulation. A very curious cough re- 
 flex is sometimes present in persons who have an 
 occasional extra-systole. This is usually due to the 
 ventricle contracting prematurely before the auricle, 
 and the individual may be conscious of this, and may 
 give at the same time a short cough — without the 
 preliminary inspiration. In hysteria violent and 
 persistent coughing may occur either from a trivial 
 laryngeal irritation, or it may be in consequence of 
 some other reflex irritation. 
 
 Sneezing. — A reflex of a somewhat similar 
 nature to that of coughing arises from stimulation 
 of the mucous membrane of the nose. It differs from 
 
Affections of the Lungs and Pleura. 211 
 
 a cough, inasmuch as there is no closure of the glottis, 
 and the blast of air is sent through the nose as well 
 as the mouth. It also differs from the act of cough- 
 ing in always being a pure rellex. Coughing can be 
 done voluntarily, but sneezing cannot. Sneezing can 
 be inhibited bj^ biting the upper lip, or pinching the 
 edge of the nasal bones, even after the preliminary 
 inspiration, and by a mental reaction, as when an- 
 other person is observed to imitate the act. 
 
 Persistent attacks of sneezing are commonly 
 associated with a swelling of the erectile tissue over 
 the turbinate bones in the nose, and a free secretion 
 from the mucous membrane of the nose and ej'es. 
 
 114. Functional Symptoms. — Aeration of the 
 blood. — Impaired function is seen in the degree of 
 aeration of the blood, and in the character of the 
 expectoration. Aeration of the blood is the main 
 function of the lungs, and imperfect aeration is 
 manifested in the production of the reflex phenomena 
 (air-hunger, increased respiratory movements) and 
 in the colour of the blood. The former of these 
 symptoms has already been discussed ; the latter is 
 observed mainly in an abnormal colour of the 
 external tissues, as in the lips, cheeks, or skin 
 generally. 
 
 As witli all other respiratory symptoms, the pro- 
 duction of the signs of imperfectly aerated blood is 
 obscure and complicated. The face may show a 
 slight degree of duskiness, the redness be a little 
 darker than that of health, or the redness of the Hps 
 a little deeper in cases, say, of mitral stenosis. Blue- 
 ness of the lips may be due to imperfect aeration of 
 the blood in the lungs, but it also may be due to 
 slowing of the circulation. It is remarkable how 
 
212 Chapter XTX. 
 
 much darker the venous blood becomes if the rate 
 of flow through the capillaries be diminished. This 
 is probably the cause of the cyanosis in congenital 
 heart disease. In some cases there has been found 
 a great increase in the number of red blood cor- 
 puscles, and a certain degree of duskiness is found 
 in cases of polycj^themia. Where there is a duskiness 
 due to some permanent condition as polycythemia, or 
 the cyanosis of congenital heart disease, exertion 
 often increases the depth of the cyanosis. 
 
 In failing hearts, with embarrassment of the 
 pulmonary circulation, a very considerable duskiness 
 may be evident, as also in cases where there is ob- 
 struction to the entrance of air into the lungs. As 
 the heart is exceedingly susceptible to oxygen, 
 imperfect aeration of the blood has a very marked 
 effect upon ifc, a diminished supply of oxygen acting 
 speedily in stopping its action, and in the adminis- 
 tration of chloroform this is one of the most impor- 
 tant facts to be borne in mind. 
 
 Expectoration. — Expectoration is the product 
 of perverted function, and may be due to a secretion 
 of the respiratory tract or lungs. It may also come 
 from regions outside the lungs, as when an abscess 
 or pleural effusion bursts into the lungs, or bronchi. 
 It is the most frequent cause of cough, and coughing 
 is due to the attempt to get rid of the secretion. The 
 expectoration is conveyed in the first place by the 
 contraction of the bronchial muscles, and by the cilia 
 of the respiratory tract to the bronchial tubes, till 
 an excitable part is reached, when coughing is in- 
 duced, and the blast of air expels the accumulated 
 secretion. The force exercised in compressing the 
 chest helps to expel secretion accumulated in an}^ 
 
Affections of the Lungs and Pleura. 213 
 
 part of the respiratory tract, or in the lungs and 
 pleural cavity, so long as there is an exit. 
 
 The character of the expectoration indicates its 
 source, a transparent and froth}^ expectoration com- 
 ing from the upper air passage, while the more viscid 
 comes from the lower, or from near the alveoli, as in 
 the early stages of pneumonia, when it is usually 
 stained more or less deeply with blood. A clear, 
 pink-stained mucus may result from a pulmonary 
 apoplexy. A purulent sputum is due to a lesion of 
 some standing. In bronchitis the sputum gradually 
 changes from a mucous to a muco-purulent character. 
 An abundant muco-purulent sputum is found in 
 chronic bronchitis and old standing catarrhal pneu- 
 monia. With an excess of fever, the latter conditio]! 
 may resemble an attack of acute croupous pneu- 
 monia, but the abundant purulent secretion serves 
 to indicate the nature of the illness. The secretion 
 from phthisical cavities is also purulent. When 
 large quantities of pus are expectorated, the source 
 is a cavit}^ in the lungs or pleura, or a subphrenic 
 abscess, as a, suppurating h\'datid cj'st of the liver. 
 
 The microscopic examination for bacilli and 
 elastic fibres is fully detailed in text-books. 
 
 115. Structural Symptoms. — Structural symp- 
 toms are recognised by changes in the consistence of 
 the lung tissue, in the invasion of the normal 
 resonant area by structures of more solid consistence, 
 changes in the shape of the chest wall, and the 
 presence of accessory sounds or the modification of 
 the normal respiratory sounds in auscultation. It 
 is not my purpose to enter into the details of these 
 changes, and I merely point out here that the exist- 
 ence of any abnormal state can only be ascertained 
 
214 Chapter XIX. 
 
 by thorough knowledge of the normal condition of 
 the lungs. The position of the lungs in relation to 
 other organs, the modification of the signs of the 
 lung in the different regions of the chest, should all 
 be famihar through the systematic examination of 
 a great number of healthy people. In all these ob- 
 servations, and more particularly in the examination 
 of abnormal or diseased lungs, the recognition of the 
 abnorm.al signs depends on the comparison of the 
 signs in one individual with another, or in the com- 
 parison of the signs on opposite sides in the indi- 
 vidual examined. As there are infinite gradations, 
 it requires careful training to recognise many of the 
 more delicate but none the less very important 
 phenomena. 
 
 116. Affections of the Pleura. — Insensitiveness 
 of the Pleura. — If the affection of the lung gives 
 rise to no sensation of pain, the same cannot be said 
 of the pleura, for the pains associated with pleurisy 
 may be of the most violent kind. In consequence of 
 this well-recognised fact, the pleura is supposed to 
 be an extremely sensitive structure, though, as a 
 matter of fact, it is as insensitive as the peritoneum 
 to ordinary stimulation. In a great number of cases, 
 when the ribs have been resected, I have repeatedly 
 explored the pleural cavity for any evidence of sen- 
 sation, and I could employ no form of stimulation 
 capable of producing pain. When I probed the vis- 
 ceral pleura, even to penetrating the lung, no sensa- 
 tion was produced ; when I scraped the surface of 
 the parietal pleura no sensation was produced, unless 
 I pressed with some force, when a vague sensation 
 was experienced, due probably to the pressure being 
 exercised on the structures of the external body wall. 
 
Affections of the Lungs and Pleura. 215 
 
 117. Nature of the Pain in Pleurisy. — From 
 
 the result of such experience one is forced to con- 
 sider carefully how the great pain felt in pleurisy is 
 produced. Inquiry into the nerve supply of the 
 pleura is fruitless, for there is practically no inform- 
 ation about the matter in either anatomical or 
 physiological text-books. Although I carried out a 
 series of careful dissections of intercostal nerves to 
 their finest branches, I could detect none entering the 
 pleura. Whether there is a laj^er containing fine 
 nerve endings outside the pleura similar to that 
 described by Ramstrom lying outside the peritoneum, 
 I do not know. A careful study of all the phenomena 
 connected with a painful pleurisy reveals the 
 mechanism by which it is produced, and gives some 
 indication of its nerve suppty. The most severe pain 
 occurs in the movements of respiration, and is due to 
 the painful contraction of the intercostal muscles. In 
 the abdominal muscles the muscular hyperalgesia 
 and tonic contraction can be demonstrated. It is not 
 so easy to do this in the case of the intercostal mus- 
 cles, but there is good reason for inferring that the 
 viscero-motor reflex is as definite in pleuritis as in 
 peritonitis. . The muscles are often tender on pres- 
 sure, and their contraction is not only painful but 
 ends in a spasm which restrains the movements of 
 the chest. The symptoms of pain and violent con- 
 traction are identical with those that occur when 
 the muscle is hyperalgesic, apart from a pleurisy, as 
 in the painful contraction of the intercostal muscles 
 in " muscular rheumatism," and in those cases where 
 the hyperalgesia extends into the cliest wall from 
 affections of other viscera, as in gall-stone disease 
 (see page 160). 
 
216 
 
 Chapter XIX. 
 
 Fig. 15. 
 
 Areas in which pain and hyperalgesia were present in a case of 
 diaphragmatic pleurisy. The shaded area on the left shoulder is in the 
 cutaneous distribution of the fourth cervical nerve, and is an evidence 
 of the conduction of a stimuhis from the diaphragm by the phrenic nerve, 
 which leaves the sjjinal cord with the fourth cervical nerve. The phrenic 
 nerve contains afferent fibres as well as efferent (motor), and it is in all 
 probability by the former that the stimulus is conveyed to the centre of 
 the fourth cervical nerve in the cord. The shaded area in the abdomen 
 is in the region of distribution of the 8th and 9th thoracic nerves. 
 
Affections of the Lungs and Pleura. 217 
 
 The mechanism of the pain can also be inferred 
 from those cases in which it is felt at a distance 
 from the inflamed pleura. When the diaphragm- 
 atic pleura is inflamed the pain may be felt in two 
 regions very widely separated, namely, in the abdo- 
 men below the ribs and on the top of the shoulder. 
 (Fig. 15.) 
 
 It not infrequently happens that the onset of 
 pneumonia is accompanied by a severe pain in the 
 abdomen, and the skin in the region where the pain 
 is felt may be found extremely hyperalgesic. (Not 
 infrequently, and particularly in the 3^oung, this pain 
 misleads in the diagnosis, giving the impression that 
 some abdominal viscus is at fault.) The area in 
 which this hyperalgesia is found is within the peri- 
 pheral distribution of the eighth and ninth thoracic 
 nerves. I have no distinct proof that in such cases 
 the pain and hyperalgesia are due to pleurisy, and 
 not to the lung affection, except for the very common 
 •experience that the inflammation of the lung is pain- 
 less, while inflammation of the pleura is usuaU}^ 
 associated with pain, and the hyperalgesia may be 
 detected in basal pleurisies without pneumonia. It 
 is evident that there must be some correlation 
 between the lesion and the area of hyperalgesia, and 
 as no nerve from the region of the eighth or ninth 
 thoracic nerves supphes the lungs, it is reasonable 
 to conclude that the nerve supply from the inflamed 
 pleura must be from this region. The pain felt in 
 the shoulder is more instructive. It is, however, a 
 somewhat rare phenomenon, but in the few cases I 
 have seen in which there has been cutaneous hyperal- 
 gesia, the area could be marked out very distinctly, 
 and was found to be within tlie distribution of the 
 
218 Chapter XIX. 
 
 fourth cervical nerve. I have already dealt some- 
 what fully with the distribution of the phrenic nerve 
 and its relation to the fourth and fifth cervical nerve 
 {see page 48). Its distribution being to the dia- 
 phragm, and not to the lungs, permits of the reason- 
 able inference that the pain and hyperalgesia in the 
 shoulder found associated with pneumonia are due 
 to the pleurisy and not to the pneumonia. 
 
 From the consideration of these facts we can 
 draw the inference that the pain in pleurisy is due 
 to a reflex stimulation (viscero-sensory reflex), and 
 that as there arises also a hyperalgesia of the inter- 
 costal muscles, their contraction is not only painful, 
 but their continued exercise increases the violence 
 and painfulness of their contraction. As happens in 
 all muscles affected by a visceral stimulus (viscero- 
 motor reflex), there is a great tendency with exercise 
 for the muscle to be tonically contracted, and hence 
 the constrained and limited movements of the chest 
 wall present in pleurisy. 
 
( 219 ) 
 
 CtT AFTER XX. 
 
 AFFECTIONS OF THE CIRCULATORY 
 SYSTE:\r. 
 
 118. Heart Failure. 
 
 119. The Nature of the Symptoms in Heart Failure. 
 
 120. Consciousness of the Hearfs Action. 
 
 121. Breathlessness. 
 
 122. Viscerosensory and Viscero-motor Reflexes. 
 
 123. The Viscerosensory Reflexes in Dilatation of 
 
 the Heart and Liver. 
 
 124. The Pain of Angina Pectoris is a Viscero- 
 
 sensory Reflex. 
 
 125. Evidences of the Viscero-motor Reflex. 
 
 126. Organic Reflexes. 
 
 127. Summation of Stimidi the cause of Angina 
 
 Pectoris. 
 
 There is no system in the body whose function 
 can be so well observed, and whose size and position 
 can be better made out, than that of the circulatory 
 system. As a consequence of this accessibility the 
 circulatory apparatus has received a great deal of 
 attention, and innumerable methods are employed 
 in the investigation of its action. The value of many 
 of these methods is unquestioned, but unfortunately 
 the tendency has been to place undue reliance on 
 the results obtained by mere physical examination, 
 
220 Chapter XX. 
 
 and to neglect the more important indications to be 
 derived from the reflex phenomena, chiefly expressed 
 in the sensations felt by the patient. 
 
 118. Heart Failure. — In order to realise fully 
 the meaning of cardiac symptoms, it is necessary to 
 appreciate the mechanism of heart failure. By 
 heart failure is meant the inability of the heart to 
 maintain the circulation efficiently. The lack of 
 efficiency may be made evident in extreme cases by 
 such signs as orthopnoea, dropsy, unconsciousness. On 
 the other hand, the failure of the heart to maintain 
 an efficient circulation may be manifest long before 
 these extreme S37mptoms appear. The first sign is 
 a feeling of distress when the patient makes an 
 effort. This may vary within very wide limits ; for 
 instance, turning over in bed may exhaust the 
 heart's strength, or the patient may be unable to 
 walk across the room, or up a flight of stairs, 
 without some form of discomfort checking him. 
 The exhaustion of the patient's strength in 
 such circumstances is seen simply as a limitation 
 of the heart's power to respond to effort. Each 
 individual has become accustomed to what he 
 can do with comfort, and he recognises his heart 
 failure by not being able to exert himself with com- 
 fort to the extent he had formerly done. The 
 symptoms produced in health by over-exertion are 
 frequently identical with those produced by slight 
 exertion when the heart has become weakened and 
 where this slight exertion is more than can be done 
 with comfort. It will thus be seen that the symptoms 
 of heart failure are really recognised by a limitation 
 of the field of cardiac response, that is, the patient 
 finds he is stopped, on a slight exertion, by the 
 
Affections of the Circulatory System. 221 
 
 symptoms which, when in health, only stopped him 
 after a prolonged, exhausting exertion. 
 
 This weakness of the heart can be expressed in 
 another wa}^ namely, the premature exhaustion of 
 reserve force. It is because the heart possesses the 
 power to lay up a reserve of force that it is able to 
 respond to calls on its energy, so that it can accommo- 
 date itself to the varying activities of the body. 
 When the body is at rest the heart not only over- 
 comes the resistances opposed to its work with ease, 
 employing only a portion of its power, but it is at 
 the same time building up a store of energy ready 
 to be hberated when the next call is made by the body 
 for more work. After severe bodily labour the store 
 of reserve forces become exhausted, and if the 
 labour be persisted in, there arises a feeling of dis- 
 tress, which expresses the exhaustion of the heart's 
 reserve force. It is this facultj^ of building up a 
 sufficient reserve store that distinguishes a healthy 
 heart from a weakened heart, and the first evidence 
 of weakness is shown by a too speedy exhaustion of 
 the reserve. This is made evident by distress being 
 aroused when the individual undertakes some form 
 of exertion he had been wont to do with ease — that 
 is, by a limitation of the field of cardiac response. 
 
 It will thus be seen that the sj^mptoms of heart 
 failure in the first instance arc personal, due to the 
 patient's recognition of his limitations. The estimate 
 is therefore a very variable one, and depends on each 
 individual recognising his own limitations, and 
 detecting when these limitations become narrowed. 
 Each individual obtains a fair estimate of his power 
 of exertion, and this is his measure of health. A 
 limitation of these powers in an intelligent patient 
 
222 Chapter XX. 
 
 calls attention to his condition. It will further 
 be observed that the main symptoms of exhaustion 
 of reserve force are the same when a healthy heart 
 exhausts its store after a prolonged effort as 
 when an enfeebled or diseased heart exhausts its 
 limited store by a slight effort. These symptoms are 
 in the main subjective and reflex, though certain 
 changes may also be made out in the size of the heart 
 and its rate and rhythm. It is, however, the sub- 
 jective and reflex symptoms that are of the greatest 
 importance, whatever may be the nature of the func- 
 tional disorder or structural lesion. 
 
 It will frequently be found that patients whose 
 hearts show many forms of functional and structural 
 abnormalities (valvular murmurs, cardiac enlarge- 
 ment, irregular action) have such a store of reserve 
 force that they can pursue laborious occupation 
 with ease and comfort, and live to a good age. On 
 the other hand, patients may show no physical sign 
 of abnormality ; the heart may be normal in size 
 and in rate, and regular in rhythm, and the sounds 
 be clear and free from murmur ; but the reserve force 
 be so small that the slightest exertion entails at once 
 distressful symptoms of heart exhaustion, and the 
 lives of these persons may be very precarious. 
 
 119. The Nature of the Symptoms. — The value 
 of symptoms thus depends upon the estimation of 
 the amount of reserve force stored up in the heart 
 muscle. An imperfect valvular apparatus is but an 
 embarrassment to the heart muscle in its work. We 
 can detect that valvular imperfection by the 
 presence of a murmur, but we can only draw a very 
 limited conclusion as to its bearing on the heart's 
 AYork. This is really obtained hy considering the 
 
Affections of the Circulatory System. 223 
 
 amount of reserve force, and the estimation of the 
 reserve is made by observing how the patient's heart 
 responds to effort. The same rule applies to other 
 forms of circulatory changes, as affections of the 
 myocardium and of the arterial S3^stem. When, 
 therefore, we detect what we consider to be an 
 abnormal sign, we must not draw our conclusions 
 from that sign alone, but must consider how far its 
 cause has proved an impediment to the heart's action, 
 and this is done by estimating the amount of reserve 
 force. In doing this a wise discretion must be 
 exercised, for other factors may have precipitated 
 the exhaustion. An individual may have an organic 
 lesion, as a valvular defect, but in addition may 
 have been subjected to a life that predisposes to 
 exhaustion, as excessive labour, improper or insuffi- 
 cient food, mental anxiety, sleeplessness, infections, 
 diseases of other organs ; and such factors, rather 
 than the mere valvular flaw, may be the actual cause 
 of the exhaustion of the reserve force. Or the 
 individual may have a sedentary occupation, wherein, 
 owing to lack of judicious exercise, his reserve force 
 has gradually diminished, until some unaccustomed 
 but not excessive effort calls attention to the limited 
 field of cardiac response. 
 
 Not only must a careful calculation be made of 
 these accessory, and it may be all-important, factors, 
 but there must be a recognition of the significance 
 of the cardiac abnormalities or supposed abnor- 
 malities. I do not enter here on the points which 
 indicate tlie nature and seriousness of such abnor- 
 malities as, for instance, murmurs and heart 
 irregularities, but I wish to insist upon the fact that 
 llie clinician should familiarise himself with such 
 
224 Chapter XX. 
 
 points. For instance, a young person may have 
 a fainting attack, and when lying quietly in bed 
 the pulse is found very irregular. This sign, which 
 is a perfectly normal one, though rarely recognised 
 as such, is not infrequently linked up with the 
 fainting attack, with which, as a matter of fact, it 
 has no connection, and the patient is subjected to 
 unnecessary treatment and restriction, and he 
 becomes alarmed by the idea that he has a 
 weak or diseased heart. In advanced life 
 another form of irregularity is of extreme 
 frequency (the extra-systole), and the recogni- 
 tion of its presence, with some limitation of 
 the field of cardiac response, often leads to the 
 conclusion that the irregularity is in some way 
 responsible for the other cardiac signs, and energetic 
 but futile means are taken in the attempt to cure 
 the irregularity. In the same way this morbid 
 dread of the unknown leads to the idea that certain 
 cardiac symptoms as pain, especially when dignified 
 by the term of angina pectoris, is of very grave 
 significance. If it be once realised that pain is as 
 constant a symptom in affections of the heart as in 
 other hollow muscular organs, and that the pain is 
 as readily induced by adequate causes in the heart 
 as in the stomach, a truer perception will be obtained 
 of the symptoms of many obscure heart affections. 
 I shall show later that pain is one of the expressions 
 of an exhausted heart muscle, and in order to 
 appreciate its significance the conditions that have 
 led up to the exhaustion of the heart muscle should 
 be ascertained — a matter usually of no great 
 difficulty — and these conditions will guide us to a 
 safe conclusion. 
 
Affections of the Circulatory System. 225 
 
 If the idea be followed up that the earliest of 
 heart symptoms are simply due to an exhaustion of 
 the store of reserve force, it will be found that there 
 is a great resemblance in the reflex symptoms 
 among all forms of heart affections — functional and 
 structural. The most important symptoms are 
 confined mainly to the patient's sensations and 
 demand careful consideration. The mechanism by 
 which they are produced is not at all times clear, 
 and some of them are undoubtedly reflex ; although 
 I cannot give a full explanation of their production, 
 I attempt here a brief description of the most im- 
 portant of the subjective symptoms and some of 
 the phenomena associated with them. 
 
 120. Consciousness of the Heart's Action. — 
 Under normal circumstances the movements of 
 the heart and circulation are carried on without 
 the individual being conscious of their action 
 unless he voluntarily directs his attention to the 
 subject. When the heart is over-stimulated it may 
 contract with such force that the individual 
 becomes conscious of its action. The stimula- 
 tion may arise from a great many circumstances, 
 as, for instance, from heat, either by a rise 
 in the patient's temperature or from a hot bath. 
 It may arise from nerve stimulation, as from mental 
 excitement, or from some peripheral irritation in 
 the viscera. Its significance is greatest when it 
 arises in consequence of exhaustion of the heart ; 
 coming on in consequence of bodily exertion, it 
 is often btie first sign of exhaustion of the reserve 
 force. When it is thus produced, it forms a valuable 
 sign for estimating the amount of reserve force 
 present in the heart-muscle. It gives no indication 
 
 Q 
 
226 Chapter XX. 
 
 of the conditions that have led to this exhaustion, 
 for it ma}^ occur in a healthy heart after prolonged 
 exertion, as well as in a diseased hea,rt after a very 
 slight exertion. Under these circumstances the 
 heart's action is usually rapid as well as forcible, 
 but in some cases there is not much increase in 
 rate. The consciousness of the heart's action is 
 often spoken of as palpitation. While it may not 
 occasion much suffering, there are individuals of a 
 neurotic type in whom this consciousness of the 
 heart's action causes much distress. In these 
 patients the heart may be quite healthy, and the 
 palpitation is then the action of an undue excita- 
 bility of the sympathetic nerve supply of tlie heart. 
 As other portions of the nervous system are abnor- 
 mally excitable the heart's action may cause con- 
 siderable distress bodily and mentally. In patients 
 with this neurotic temperament, where there is real 
 heart trouble, as in mitral stenosis, palpitation on 
 exertion may be so readily induced that it acts as a 
 protection from over-exertion, because, in order to 
 avoid its occurrence, the patient is perforce kept 
 quiet. 
 
 The occurrence of palpitation should always 
 lead to an examination of the nervous system as well 
 as of the heart's condition. 
 
 Other sensations of the heart's abnormal action 
 may be felt by the patient. A gentle fluttering 
 may be felt within the chest during a period of 
 irregular action. This may be brief and transient, 
 or, as in certain cases of paroxysmal tachycardia, it 
 may continue during an attack of many hours. 
 Accompanying the latter condition there is often a 
 feeling of exhaustion wliich leads the patient to 
 
Affections of the Circulatory System. 227 
 
 rest, or to go about carefully and quietty. When 
 the heart resumes its normal action the patient is 
 at once conscious of a change and of a sense of 
 relief. A more common sensation is that when 
 the heart is felt to stand still, in what is called 
 intermittent action of the heart. This sensation is 
 usually felt in cases of extra-systole, which is so 
 frequent in advanced life though occasionally 
 present in the young. Here the ventricle con- 
 tracts prematurely, and often before the auricle ; 
 the individual is not conscious of this premature 
 beat or extra-sj^stole which is followed by a long- 
 pause, and it is this pause which often alarms the 
 patient. After the long pause the next beat is 
 frequent!}^ big and powerful, and the patient 
 may be conscious of the shock due to this. In 
 nervous people this big beat often causes much 
 mental anxiety. 
 
 Another curious reflex is sometimes met with 
 in these extra-systoles, the patient giving a little 
 gasp or cough when the extra-systole occurs. 
 
 121. Breathlessness. — Breathlessness is so fre- 
 quently associated with affections of the heart that 
 its occurrence under any circumstance necessitates 
 a consideration of the heart's condition. It is so 
 common a sign of exhaustion of the reserve force 
 that in an inquiry into a patient's cardiac symptoms 
 the amount of exertion that can be undertaken 
 before breathlessness occurs should be carefully 
 inquired into. In many cases the breathlessness 
 may occur independently of any bodily exertion, 
 coming on when the patient is in bed, and persisting 
 till the patient has to sit up and breathe in a 
 laboured fashion (orthopnoea). 
 
228 Chapter XX. 
 
 The mechanism by which breathlessness is 
 brought about in heart affections is far from 
 clear, and so many factors are concerned in respira- 
 tion that any endeavour to explain its cause would 
 lead to such vague and indeterminate speculation 
 that, in the present state of our knowledge, little 
 good would result. The great point is to observe 
 the fact, to exclude other possible causes of 
 breathlessness (as affections of the lungs, mechanical 
 obstructions to the breathing, anaemia, and other 
 blood affections), and then from a study of the 
 cardiac conditions to determine the nature of the 
 exhaustion that has been produced. This is seldom 
 a matter of much difficulty when a sufficient experi- 
 ence of the various forms of heart disease has been 
 acquired. The presence of a demonstrable lesion in 
 the heart may be a guide, as shown by modification 
 of the heart sounds, or changes in the size, rate and 
 rhythm of the heart. In the absence of these the 
 age of the patient may be suggestive — if old,, 
 degenerative changes in the myocardium ; if young,, 
 the probability of some general infection, as tuber- 
 culosis ; if middle-aged, the possibility of exhaus- 
 tion of the reserve force from over-work, worry, bad 
 nourishment — in fact, the consideration of the fac- 
 tors that tend to exhaust the reserve force of the 
 heart, breathlessness being often the first sign of 
 such exhaustion. 
 
 Apart from breathlessness brought on by 
 exertion there are som.e definite forms of breath- 
 lessness which are recognised as especially associated 
 with heart affection. The best known of these is 
 the Cheyne-Stokes respiration, where periods of 
 apnoea alternate with periods of laboured 
 
Affections of the Circulatory System. 229 
 
 breathing. Another characteristic form is that in 
 which patients are seized in the night with attacks 
 of breathlessness, and have to sit up and breathe 
 in laboured fashion for periods of varying duration, 
 from half-an-hour to several hours. This form of 
 laboured breathing is sometimes spoken of as 
 cardiac asthma, and its onset is often mistaken for 
 the more common form of asthma. When asthma is 
 found to occur in people of middle or advanced age 
 for the first time, the possibility of its cardiac origin 
 should always be borne in mind. 
 
 In many cases the patient breathes quietly 
 though hurriedly, with no distress, and the respira- 
 tory condition may, in consequence, be overlooked, 
 though the rate of respiration may be from twenty 
 to thirty tim.es per minute. With failing hearts 
 (as in typhoid fever, in conditions in which elderly 
 people are forced to lie in bed, or in valvular disease) 
 this rate tends to increase, and on examination 
 respiration is found to be shallow and limited to the 
 upper portion of the chest. In such cases there will 
 almost always be found evidence of stasis or oedema 
 at the bases of the lungs. The first sign of this 
 condition, apart from the increased rapidity of the 
 respiratory movement, is the detection of fine crepi- 
 tations on deep inspiration heard over the base of the 
 lung, on that side towards which the patient habitu- 
 ally lies. My usual method of detecting this is to 
 ask the patient on which side he has lain, and then to 
 ask him to sit up and to auscultate the base of the 
 lung on the side on which he has lain. This is the 
 first step in the physical examination of the patient. 
 If done at a later stage the movements may have 
 deepened the respiration, so that the crepitations 
 
230 Chapter XX. 
 
 have disappeared. One usually detects the fine 
 crepitations on the first full and deep inspiration. 
 In the early stages of pulmonary stasis, after this 
 thorough ventilation of the bases of the lungs, the 
 crepitations disappear. If measures are not taken 
 to stop this tendency to oedema, or if in spite of all 
 endeavours the oedema increases, the crepitations 
 become more numerous and persistent, and the 
 lung resonance may become impaired. In fatal 
 cases the bases of the lungs becom.e dull, there 
 is an absence of the respiratory sounds, and post- 
 mortem the lungs are found sodden and airless. In 
 suitable cases there can be detected coincident with 
 these lung symptom.s evidences of the dilatation of 
 the right heart, as epigastric pulsation due to the 
 filling and emptying of the dilated right ventricle. 
 
 A sense of suffocation is an occasional symptom 
 in heart affections. It may be the first sign of 
 exhaustion of the reserve force, coming on when the 
 patient exerts himself. It may suddenly seize a 
 patient when he is lying in bed. Its mechanism is 
 obscure. The sensation is usually referred to the 
 upper part of the chest and throat. 
 
 122. Viscero-sensory and Viscero - motor 
 Reflexes. — Under these terms I include such sen- 
 sory phenomena as pain and hyperalgesia of the skin, 
 muscles, mammary glands, and the contraction of the 
 muscles, which gives rise to a sensation described 
 "as if the breast -bone were breaking." After 
 obtaining a full account of the patient's sensations 
 and experiences, if careful inquiry be made in regard 
 to a number of symptoms, as pain, constriction of 
 the chest, soreness of the chest or arms, frequent 
 micturition, increased flow of saliva, bad dreams. 
 
Affections of the Circulatory System. 231 
 
 there will be found a number of phenomena which 
 the patient does not include in his description, 
 because his mind is occupied with the sensations 
 which cause him suffering and discomfort. The 
 accurate noting of these less obtrusive phenomena 
 will often throw a flood of light on many an obscure 
 process and reveal the mechanism by which the 
 more obtrusive phenomena are produced. 
 
 In the physical examination careful testing for 
 hyperalgesia should first be made. The skin of the 
 left chest should be lightly pinched and compared 
 with that of the right. The breasts should be 
 lightly compressed and the resultant sensations 
 compared. The tenderness to pressure of the 
 pectoralis major where it forms the anterior wall of 
 the left axilla should be tested. In the same way the 
 skin of the neck and the sterno-mastoid should be 
 tested. The upper edge of the trapezius muscle 
 where it passes from the scapula to the neck should 
 be lightly compressed along its whole border, and it 
 will sometimes happen that certain areas will be 
 found very tender. These are places where a small 
 nerve trunk- is pressed upon. Special areas of ten- 
 derness may sometimes be found, as under the left 
 breast, and over the second and third ribs in the 
 nipple line. In one patient, where this latter ten- 
 derness was very marked, I found, at the post-mortem 
 examination, on dissection, a small nerve trunk (the 
 internal anterior thoracic nerve). 
 
 Angina pectoris affords an excellent illustration 
 of the application of the principles I have en- 
 deavoured to enunciate, as the symptoms can be 
 with certainty referred to the organ at fault, and 
 because the complex of symptoms that are included 
 
232 Chapter XX. 
 
 in an attack of angina pectoris are capable of being 
 analysed with great precision. This is, in a great 
 measure, due to the peculiar distribution of the sen- 
 sory nerves in whose peripheral distribution the 
 characteristic phenomena are shown, and whose 
 centres in the spinal cord and medulla are in close 
 relationship to the centres of the autonomic nerves 
 of the heart (sympathetic and vagus). The cases I 
 cite dem.onstrate that the term " angina pectoris " 
 includes a number of reflexes, and I give in detail 
 the more conspicuous of these, namely, sensory 
 reflexes, where the pain and hyperalgesia affect the 
 chest, arm, head, and neck ; motor reflexes, resulting 
 in spasm of the intercostal muscles ; secretory 
 reflexes, shown by profuse secretion of saliva and 
 urine. Some cases show other reflexes, as the 
 respiratory, but the discussion of these would lead 
 me beyond the object I had in writing this book. 
 
 Notwithstanding the numerous papers devoted 
 to the consideration of angina pectoris, practically 
 none have dealt adequately with the analysis of the 
 symptoms present during an attack. Angina pec- 
 toris is often surrounded by such tragic circum- 
 stances that it forms a suitable theme for disquisition, 
 and on that account we too often get the lurid 
 description of an impressionist artist instead of 
 the plain, matter-of-fact description of an accurate 
 observer. A careful sifting of all the details brings 
 out the fact that the essential principles underlying 
 the pains associated with affections of the heart 
 differ in no way from those of any other hollow 
 muscular organ. So terrifying is the attack to the 
 patient that his perceptions of the details of his 
 suffering are generally confused, so that often no 
 
Affections of the Circulatory System. 233 
 
 •clear account can be obtained from his description ; 
 but if he is intelhgent and is asked to note particu- 
 lars in subsequent attacks, he may be able to throw 
 a very valuable light on the onset and character 
 of the sensations he experiences. The observations 
 made by the physician of patients during an attack 
 also afford great help in this respect. 
 
 123. The Viscero-sensory Reflexes in Dilata- 
 tion of the Heart and Liver. — Before dealing with 
 the more characteristic attacks of heart pain 
 which go by the name of angina pectoris, I wish 
 first to draw attention to the very distinct sensory 
 evidences that arise from the dilatation of the 
 heart. These sensory symptoms are practically 
 identical with those that arise in cases of distension 
 of any other viscus, as the stomach, bladder or liver. 
 To illustrate this I select cases where the dilatation 
 of the heart occurs rapidly, and is followed by a 
 rapid distension of the liver, such as we find in 
 certain forms of paroxysmal tachycardia. In cer- 
 tain of these cases the rhythm of the heart starts 
 suddenly at some abnormal place in the auricle or 
 ventricle, or at the fibres joining auricle and ven- 
 tricle. The heart at once beats with great rapidity, 
 but fails to maintain the circulation, and in conse- 
 quence we have very rapidly developed great dila- 
 tation of the heart, fullness of the veins, enlargement 
 of the liver, and dropsy. I have seen a number of 
 these cases, and in two particularly T have observed 
 some fifteen to twenty attacks, of which the following 
 is a typical description. 
 
 The patient may be in good health and no 
 abnormality be detected save, in some cases, the 
 •occurrence of an extra-svstole. Suddonlv the 
 
234 
 
 Chapter XX, 
 
 Fig. 16. 
 
 The areas shaded in the neck, chest and upper part of the abdomert 
 represent the distribution of cutaneous hyperalgesia in a patient suffering 
 from acute dilatation of the heart and liver. 
 
 heart's rate becomes greatly accelerated, to 150 beats 
 and more per minute. In a few hours the patient's 
 face becomes duskj^ the lips swollen and livid, and 
 there appears great shortness of breath on exertion, 
 marked increase in the size of the heart, distension 
 and pulsation of the veins of the neck, and enlarge- 
 ment and pulsation of the liver. The j ugular and liver 
 pulsation are of the ventricular type. Pain and 
 oppression may be felt over the chest. The skin and 
 deeper tissues of the left chest become extremely 
 tender on pressure in the area shaded in Fig. 16. If 
 
Affections of the Circulatory System. 235 
 
 the left pectoralis major muscle be grasped where it 
 forms the axillary fold it will be found extremely 
 tender. The skin of the left side of the neck may 
 also be tender, and if the left sterno-mastoid muscle 
 and the left trapezius m.uscle, above the middle of 
 the scapula, are lightly grasped they may be found 
 exquisitely sensitive. The skin and muscles over the 
 liver will also be found extrem.ely sensitive to pres- 
 sure, and the parts hyperalgesic extend over a much 
 larger area than the enlarged liver. If the heart's 
 rate revert to the normal the patient at once experi- 
 ences great relief, and in a few hours all signs of 
 the circulatory disturbances disappear. The hyper- 
 algesia may last with diminishing severity for a few 
 days. The tenderness of the skin and muscles in 
 the regions described above may be found in patients 
 during the early stages of dilatation of the heart 
 from any cause, and is very common in heart failure 
 secondary to mitral disease. Tn some cases one can 
 tell when improvement is taking place by noting the 
 diminution of this tenderness. 
 
 There can be little doubt as to the mechanism 
 by which the- hyperalgesia of the tissues in the 
 three re^jions is brouglit about. The relation of the 
 dilatation of the heart and liver with these sensory 
 phenomena is undoubtedly that of cause and effect. 
 The tenderness to pressure of the tissues in the 
 left chest is due to stimulation of the afferent 
 sympathetic nerves by the dilated heart. These 
 nerves stimulate the sensory centres of the third and 
 fourth thoracic nerves in the spinal cord, so that a 
 stimulus reaching them from their peripheral dis- 
 tribution gives rise to a pninful impression. The 
 tenderness of the left sterno-mastoid and trapezius 
 
236 Chapter XX. 
 
 muscle, and of the skin of the neck, is due to the 
 afferent fibres of the " bulbar autonomic " system — 
 that is the vagus, conveying a stimulus to the sensory 
 roots of the second and third cervical nerves. The 
 hyperalgesia of the tissues covering the liver is 
 due to stimulation of the sensory centres in the 
 spinal cord by the afferent sympathetic fibres from 
 the engorged liver. 
 
 124. The Pain of Angina Pectoris is a 
 Viscero-sensory Reflex. — The usual description given 
 of the pain in angina pectoris is that it is felt in 
 the heart and shoots into the arm, or that there 
 are two pains, a local pain in the heart and a referred 
 pain in the arm. If, however, a careful analysis 
 be made of all the symptoms present, facts will 
 be found that practically demonstrate that in 
 angina pectoris there is but one kind of pain, and 
 that its production is in accordance with the law I 
 have attempted to establish, namely, that it is a 
 viscero-sensory reflex. One is not able in every case 
 to demonstrate the proofs of this hypothesis, but 
 facts derived from suitable cases afford legitimate 
 conclusions applicable to all cases. Shortly, these 
 facts are, that the pain in the very gravest cases 
 may be felt in regions distant from the heart ; that 
 this pain is identical in character with that felt over 
 the heart ; that the pain may originally start in parts 
 distant from the heart, and gradually approach and 
 settle over the heart ; and, lastly, that the tissues 
 of the external body wall, in the exact region in 
 which the pain was felt, may be found extremely 
 hyperalgesic after the pain has passed away. From 
 this last fact it is inferred that, inasmuch as the seat 
 of pain corresponds to the region of hyperalgesia. 
 
Affections of the Circulatory System. 237 
 
 therefore the pain was due to stimulation of the 
 hyperalgesia nerves. To assume otherwise would be 
 to ignore a principle that explains satisfactorily the 
 sensation of pain wherever arising. 
 
 The following observations illustrate this point. 
 They are examples chosen from a large number of 
 cases that demonstrate the same feature. For the 
 sake of brevity only those points bearing upon this 
 argument are referred to. 
 
 Female, aged 30, suffering from stenosis of the 
 aortic, mitral, and tricuspid valves, was seized 
 with a violent pain referred to the outer part of the 
 left side of the chest wall. The pain passed off, but a 
 sense of soreness and smarting remained over the 
 part in which the pain was felt. On examining her 
 I found a portion of the skin of the chest extremely 
 tender to touch, corresponding to the area shaded in 
 Fig. 17. 
 
 A few days later she began to suffer from 
 attacks of pain in the left breast and down the 
 inside of the left arm, and on examination I found 
 that the hyperalgesia had extended and occupied an 
 area similar to that shaded in Fig. 18. 
 
 These attacks of pain became so severe on the 
 slightest exertion that she was obliged to keep to 
 her bed. She partially recovered from these attacks, 
 but they recurred with increased severity. When 
 suffering the most severe attacks the hyperalgesia 
 embraced nearly the whole of the left chest and 
 inside of the left arm, and also a portion of the right 
 chest. The left sterno-mastoid muscle and trapezius 
 also became very tender, and the patient would 
 sometimes complain of pain on the inner surface of 
 the right arm, at the elbow, where also I found a 
 
238 
 
 Chapter XX, 
 
 Fig. 17. 
 
 The shaded area shows the distribu- 
 tion of the cutaneous hyperalgesia after 
 the first attack of angina pectoris (com- 
 pare with fig. 18). 
 
 Ftg. 18. 
 
 After repeated attacks of angina 
 pectoris the pain and hyperalgesia ex- 
 tended to the regions shaded here. 
 Note the areas in the neck and inner side 
 of right elbow (compare with figs. 6 and 7). 
 
Affections of the Circulatory System. 239 
 
 ^atch of cutaneous hyperalgesia. Two j^ears and a 
 half after the first attack of pain she was recovering 
 from a series of violent attacks, when, on getting out 
 of bed, she fell forward and died immediately. 
 
 The fact that in this case the attacks of pain 
 were followed by a h^^peralgesia of the skin in the 
 region where the pain was felt, and the further fact 
 iihat the pain started at a distance from the cardiac 
 region, and was often felt most severely at a distance 
 from the heart, proves that the cardiac pain in this 
 case was a viscero-sensory reflex, and that the pain 
 felt over the precordia was presumably of the same 
 nature. 
 
 Female, aged 56, with high blood pressure, 
 suffers from pain in the foot (gout), and has had 
 several severe attacks of true angina pectoris, in 
 which the pain is referred over the left chest and 
 through to the shoulder. After the attack she 
 passes a large quantity of clear urine, and the 
 skin and deeper tissues of the left breast and the 
 left sterno-mastoid and trapezius muscles become 
 very tender on pressure. In one attack the pain 
 was felt in a limited area over the second left inter- 
 space, and next morning I found the skin and 
 deeper tissues at this place extremely tender to the 
 slightest pressure. 
 
 In this instance, also, the hyperalgesia of the 
 skin corresponded to the region where pain was 
 felt, and is presumptive evidence in favour of the 
 view that the pain as well as the hyperalgesia is the 
 result of the viscero-sensory reflex. 
 
 Male, aged 42, consulted me on October 18th, 
 1 905, complaining of pain in the left little finger and 
 ulnar border of the left ami and forearm, coming 
 
240 Chapter XX. 
 
 on when he exerted himself at his work and on going- 
 up hill. For some months he suffered from a dull 
 aching pain at the back over his shoulder blades. 
 I found dilatation of the aorta, slight incompetence 
 of the aortic valves, and slight enlargement of the 
 heart (verified at the subsequent post-mortem 
 examination). The blood pressure was 150 mm. Hg. 
 During the following weeks the pain in the left arm 
 increased in severity, gradually extended up the 
 arm till it was felt in the axilla, and finally invaded 
 the left chest. At first the pain was wont to start 
 at the little finger and to pass rapidly up the arm, 
 but latterly it seized him with such severity and 
 suddenness that he could not tell where it began. 
 It usually held him with the greatest severity either 
 over the heart or in the inner surface of the left arm 
 immediately above the internal condyle. I par- 
 ticularly asked him to note in his frequent attacks- 
 if there was a difference between the arm pain and 
 the chest pain, and his reply was that there was no- 
 difference in the character of the pain, but, if any- 
 thing, the arm pain was the worse. Sometimes the 
 pain was very severe up the left side of the neck and 
 behind the left ear. Under treatment he seemed to 
 make considerable improvement. During January, 
 1906, these attacks recurred. During some of them 
 the pain was so agonising that he felt he was djdng, 
 and wished to die. The pain was equally severe in 
 chest and arm, and saliva sometimes dribbled 
 from his mouth. On February 12th the least 
 exertion was sufficient to induce a severe attack of 
 pain ; from three p.m. to seven p.m. he was- 
 scarcely free from pain, and ultimately became 
 unconscious. When I saw him next day he was. 
 
Affections of the Cnculatory System. 241 
 
 having another series of attacks. He was keeping 
 his left arm very still, and helping himself to food 
 entirely with his right hand. He told me he dare not 
 move his left arm, as even the act of lifting the left 
 hand to his month was sufficient to induce an 
 attack. His pulse was extremeh'^ soft and weak. 
 His blood pressure had fallen to 95 mm. Hg. 
 During the following night he had another series of 
 attacks, became unconscious and expired. 
 
 I omit man}^ details in this case on purpose to 
 emphasise the regions in which the pain was felt in 
 a case of the most severe form of angina pectoris. 
 It seems to me that no other explanation save 
 that of the viscero-sensory reflex can satisfactority 
 account for the pains in this case, and to attempt 
 to distinguish the chest pain as a heart pain and 
 the pain in the arm as a referred pain would be 
 arbitrary, illogical, and opposed to the evidence. 
 The radiation of the pain from the hand to the 
 chest was practically of the same nature as the 
 more common radiation of the pain from the chest 
 to the hand. The pain in the neck and behind the 
 ear, on the same hypothesis, would be induced b}^ 
 the stimulus passing from the heart by the vagus, 
 a view that would also explain the increased flow of 
 saliva during some of the attacks, points to which 
 I shall afterwards revert. 
 
 It is interesting to note here that the movement 
 of the left arm would induce an attack of angina 
 pectoris. I have already pointed out (page 89) 
 that a stimulus from any source reaching an irritable 
 focus in the cord will cause the characteristic pain 
 to arise. In the next observation the stimulus 
 reached the cord from the skin of the chest. 
 
242 Cha'pter XX. 
 
 The two following observations of attacks of 
 angina pectoris which I witnessed illustrate true 
 heart pain of the most severe tj^pe at places remote 
 from the heart. 
 
 Male, aged 14, suffering from adhesive medias- 
 tinitis, with enormous enlargement of the heart. 
 The patient lay propped up in bed. As I was gently 
 testing the sensibility of the skin outside and under 
 the left nipple the patient was suddenly attacked 
 with severe pain. He gave a great sob, and leant 
 forward with his left upper arm across his chest, 
 and his right hand pressing it gently. He rocked 
 backwards and forwards with deep sobs, while tears 
 streamed down his cheeks. His pulse became very 
 soft and his face pale, with beads of perspiration 
 on his forehead. In a few minutes the pain sub- 
 sided and he lay back exhausted. Afterwards he 
 said that, on my touching a certain spot, a pain shot 
 from his chest to his arm, and during the whole 
 time the awful pain remained in his arm, and he put 
 his hand over the fleshy part of the upper arm. His 
 doctor told me he had given up examining him by 
 auscultation, because on a few occasions, on applying 
 the stethoscope, attacks similar to those I had wit- 
 nessed were induced. 
 
 Female, aged 60, complained of pain of agon- 
 ising severity limited to the ulnar border of the 
 left forearm. Coming to see me one day she hurried 
 to catch the train, and when she reached my con- 
 sulting room she sat down. In a few minutes the 
 pain seized her, and she took up her left arm and 
 nursed it across her breast with evidences of 
 great suffering. The pain subsided in a few moments, 
 and she said she felt as if she would have died. 
 
Affections of the Circulatory System. 243 
 
 The pain was felt nowhere but in the left forearm. 
 Three months afterwards the patient died from 
 heart failure. At the post-mortem examination 
 there was found marked atheroma, calcification of 
 the coronary arteries and extensive chronic fibrous 
 myocarditis. 
 
 In this last case the pain was doubtless limited 
 to the highest sensory nerve centre (first thoracic), 
 whose fibres are associated with the sympathetic 
 supply of the heart. 
 
 125. Evidences of the Viscero-motor Reflex. — 
 So far I have dealt with the viscero-sensor}^ reflex, 
 and evidence no less striking can be found of the 
 viscero-motor reflex among the group of s^^mp- 
 toms included in the term " angina pectoris." Some 
 would limit the term " angina pectoris " to that class 
 of cases where, in addition to the pain, there is a 
 sense of constriction in the chest, amounting at times 
 to a sensation as if the chest were gripped in a 
 vice, or as if the breast-bone would break. I am 
 convinced that these sensations arise from spasm 
 of the intercostal muscles, and correspond to the 
 hard contraction of the flat abdominal muscles in 
 affections of the abdominal viscera. If one watches 
 a case of what is called " muscular rheumatism " 
 where the intercostal muscles are affected, and 
 where these muscles are stimulated by the slightest 
 movement to violent cramp-like contractions, one 
 cannot but be struck by the resemblance to the 
 description given of the " gripping " sensation 
 experienced by patients suffering from certain 
 affections of the heart. I have watched the attacks 
 in such cases and could find no difference between 
 them and those where the sense of constriction was 
 
244 Chapter XX. 
 
 the chief symptom in heart disease. The 
 viscero-motor reflex may be present alone, or, as is 
 more commonly the case, it may be associated with 
 pain. The pm^ely viscero-motor reflex is seen best 
 in the elderly, where it may be considered as a 
 symptom of one form of the terminal affections of 
 the heart due to arterio-sclerosis or old age. I have 
 fomid it a precursor of steadily advancing cardiac 
 weakness, and although for a time considerable 
 relief may be afforded, the changes in the heart are so 
 advanced that, in the nature of things, only one end 
 can be looked for. The three following observations 
 illustrate these views. 
 
 Male, aged 82, with large tortuous arteries, 
 was seized while walking with a sense of constriction 
 across the chest that compelled him to stand still. 
 These attacks became so frequent and so severe 
 that he could scarcely walk fifty yards before he had 
 to stop and lean against the wall. He described 
 the sensation as one not of pain, but as if somebody 
 gripped the upper part of the chest with a strong 
 hand. With rest and suitable treatment these 
 attacks gradually disappeared. Three months later 
 the heart suddenly became irregular (auricular 
 fibrillation), dropsy set in, and he died seven weeks 
 later from heart failure. 
 
 Male, aged 56, was seized with a spasm which 
 held his chest as in a vice when he walked up a hill. 
 There was no pain but the sense of constriction and a 
 sense of suffocation produced such discomfort that he 
 was forced to stand still. Within a few minutes the 
 chest would feel free, but the sensation would at once 
 recur if he attempted further effort of the same 
 kind. Thus, in going to business, he had to go up 
 
Affections of the Circulatory System. 245 
 
 a steep hill, but frequenth^ found it impossible to do 
 so, and then had to go downhill and reach his des- 
 tination by another and less steep road. 
 
 Female, aged 78. Two years before her death 
 she experienced attacks of breathlessness with a 
 sensation of constriction across the chest. This 
 feeling of tightness was so readily set up that she 
 was obliged to stay in bed. The attacks dis- 
 appeared, but recurred again shortly before her 
 death. These latter attacks were accompanied b}" 
 slight precordial pain. She became gradually weaker 
 and died. At the post-mortem examination the 
 coronary arteries were found markedl}^ thickened, 
 with calcareous patches in their walls. 
 
 The following experience illustrates the fact 
 that the viscero-motor reflex is a symptom distinct 
 from the pain. 
 
 Male, aged 48, consulted me on November 25th, 
 1905, for a pain he felt across the middle of his 
 chest. He had felt a slight pain here for some 
 months on walking up a hill. He was a master-builder, 
 and on this day, while watching his men at work, 
 feeling cold, he began to help them to dig up som.e 
 earth, to warm himself. He did this for a quarter of 
 an hour with a good deal of energy. He then 
 examined a few partially built houses, running up 
 and down a great many steps. On his way home he 
 became conscious of pain in his chest, and as it con- 
 tinued to increase in severity he called on me. I 
 examined him carefully, and found a slight dilata- 
 tion of the heart with an impure first sound. The 
 blood pressure was 1.30 mm. Hg. On liis way home 
 tlie pain increased in severity, and after he reached 
 liome it became very violent. A colleague saw him 
 
246 Chapter XX. 
 
 and prescribed opium, which reheved him. When 1 
 saw him next morning he gave a graphic account of 
 his sufferings. He said : "In the tram coming home 
 the pain got worse, and after getting home it became 
 so severe that I felt I was going to die. The pain 
 spread from, my chest down my left arm to my little 
 finger. You asked me, when I saw you yesterday, if 
 I felt any gripping sensation, and I did not know 
 what you meant ; but, by George ! I know now. When 
 the pain was at its worst, I felt my chest suddenly 
 seized as in a vice, and I rolled on the floor in agon}^ 
 The pain and the gripping eased off for a time and 
 then came on again. This continued till I got the 
 opium. This morning I awoke all right, but at 10.30 
 that gripping sensation came on and held me tight 
 for ten minutes. I dare not move for fear 
 the awful pain should come on, and I felt 
 every moment it was about to come, and I 
 was in such terror of it that the sweat poured 
 off me." 
 
 With rest and treatment these attacks grew less, 
 till he only felt a slight pain when he over-exerted 
 himself. 
 
 So far the symptoms I have dealt with have 
 been mainly concerned with the reflexes connected 
 with the sympathetic nerve supply. Equally 
 instructive symptom.s, though less frequent, can be 
 shown to arise from stimulation of the vagus. At 
 its centre in the medulla this nerve is in near rela- 
 tionship to the upper cervical nerves, and, it would 
 seem, more particularly the sensory nerves supplying 
 the sterno-mastoid and trapezius muscles. Not only 
 may these muscles become extreme^ tender in various 
 heart affections, but the pain from heart affections 
 
Affections of the Circulatory System. 247 
 
 ma}' be felt in the region of distribution of the cer- 
 vical nerves as alreach' noted. The following obser- 
 vations also show the same thing. 
 
 ]Male, aged 62, complained of great pain striking 
 into his chest and behind his ears when . walking. 
 Thus, in going to his work, he allowed seven or 
 eight minutes to walk to the station, but now it took 
 him over half an hour, as he had to stop on account 
 of the pain ever}' fifty yards. After accurately 
 noting the pain he described it as arising in the left 
 breast, extending across to the right breast, seizing 
 him in the neck, and extending up behind the ears, 
 where it held him with great severity. In showing 
 me the situation, he laid the fingers of both hands 
 over the insertion of the sterno-mastoid muscle into 
 the mastoid process. On one occasion the pain ex- 
 tended from the breasts to the armpits, and down 
 the side of each arm to the elbow. 
 
 This patient dropped dead while at his 
 work, and on post-mortem examination I found 
 extreme calcareous degeneration of the coronary 
 arteries. 
 
 126. Organic Reflexes occurring during an 
 Attack of Angina Pectoris. — Other very striking 
 plienomena are sometimes met with during an 
 attack of angina pectoris. During or after an 
 attack an abundant flow of saliva and the secretion 
 of large quantities of pale urine may occur ; both 
 symptoms I suggest are due to reflex stimulation of 
 nuclei in the floor of the fourth ventricle. Possibly 
 the polyuria may be of the same character as that 
 in diabetes insipidus, which, as is well known, may 
 be induced in animals by puncture of the floor of 
 the fourth ventricle. 
 
248 Chapter XX. 
 
 Male, aged 58, of gouty diathesis, complained 
 of pain, induced b}^ the slightest exertion, which 
 arose in the left breast, passed up the armpit, and 
 extended down the inner surface of the left arm to 
 the little finger. During an attack an abundant flow 
 of saliva took place into the left side of the mouth. 
 These attacks became so frequent that he could only 
 walk a ver}^ short distance without inducing an 
 attack. He died while sitting at his desk, and at 
 the post-mortem examination I found that the heart 
 had ruptured, and the coronary artery was very 
 atheromatous. Where the rupture had taken place 
 the myocardium had nearly disappeared. 
 
 Male, aged 46, whose work entailed periods 
 of great muscular exertion, complained of pain 
 striking into the chest when walking up a hill. 
 If he stopped as soon as he felt the pain coming on, 
 it passed off, but if he persisted the pain increased 
 to an agonising severity and radiated into both 
 arms, but worse into the left, as far down as the 
 little finger. At the same time the chest was gripped, 
 so that he was forced to straighten himself and to 
 breathe deeply, and at the same time his mouth filled 
 with saliva, and an aching pain was felt in the 
 throat. A few minutes after each attack he had to 
 pass urine, which was always abundant and ver}^ 
 clear. These details I had from him after he had 
 carefully noted a number of attacks. 
 
 127. Summation of Stimuli as a Cause of 
 Angina Pectoris. — The fundamental functions of 
 the heart muscle correspond to those of other in- 
 voluntary muscles that form the walls of hollow 
 organs ; these functions being modified to suit its 
 special work. Like the other viscera the heart is 
 
Affections of the Circulatory System. 249 
 
 insensitive when stimulated in a manner that pro- 
 vokes pain when applied to the tissues of the exter- 
 nal body wall. I have pointed out that a long strong 
 contraction of a hollow organ can produce pain, and 
 that this is undoubtedly the cause of the severe pain 
 associated with renal calculus, gall-stones, spasm of 
 the bowel, and uterine contractions. Can the heart 
 ^ive rise to pain in a similar manner ? On account 
 of the modification of its functions, the heart cannot 
 pass into a prolonged state of contraction. Imme- 
 diately it contracts, the function of contractility is 
 abolished and the muscle passes at once into a state 
 of relaxation, and for this reason the pain cannot be 
 produced by a " spasm of the heart." But I suggest 
 that the heart muscle may produce pain when it is 
 confronted with work greater than it can readily 
 overcome, a condition which produces strong peri- 
 stalsis and pain in other hollow viscera. But the pain 
 in the heart arises by a slightl}^ different mechanism. 
 A skeletal muscle will contract in obedience to 
 stimulation of a sensory nerve going to the spinal 
 centre of its nerve, if a stimulus of sufficient strength 
 be applied. If the stimulus be too weak, no contrac- 
 tion follows, but if this weak stimulus be frequently 
 and rapidly repeated, then the muscle contracts in 
 accordance with the law of the summation of stimuli. 
 I suggest that the heart muscle induces pain on the 
 principle of summation of stimuli. If we minutely 
 study our cases we shall find that the pain rarely 
 arises at the first exposure of the heart to the effort 
 that induces the pain. Sometimes effort has been 
 undertaken a few niinutes before the pain comes on, 
 and in certain cases it may not come on for hours 
 after the casual exertion has ceased. 
 
250 Chapter XX. 
 
 From such observations we can infer that th& 
 heart muscle was exhausted by the exertion, and sa 
 great was the exhaustion of the reserve force that 
 it was unable to regain its reserve on cessation 
 of effort ; thus the exhaustion persisted till it 
 culminated in an attack of angina pectoris. 
 
( 251 ) 
 
 Chapter XXL 
 
 ESTIMATION OF THE VALUE OF 
 SYMPTOMS. 
 
 128. The Relation of the Symptoms to the General 
 
 State. 
 
 129. Remote Effects of the Lesion. 
 
 130. Relation of Symptoms arising from different 
 
 Causes. 
 
 131. The Bearing of Symptoms on Prognosis. 
 
 132. The Bearing of Symptoms on Treatment. 
 
 In this chapter I endeavour to sum up the 
 general principles which have been applied in more 
 detail in the earlier chapters. That the interpre- 
 tation of symptoms should be imperfect can readily 
 be recognised, for not only is the subject too vast 
 to be dealt with in a few pages, but the knowledge 
 to deal with it efficientl}^ is lacking. I confine myself, 
 therefore, to a few general principles that have 
 been of service to me in my endeavours to estimate 
 the value of symptoms in individual cases. 
 
 128. The Relation of the Symptoms to the 
 General State. — Before a hnal opinion is form.ed 
 of the value of any symptom, the physician must 
 consider the patient as a whole, and the relation 
 of any abnormal sign to the general health. The 
 patient's complaint may be of a trivial nature, and 
 the examination of the different organs may reveal 
 
252 Chapter XXI. 
 
 no abnormality ; nevertheless the contemplation 
 of the patient's whole economy may help one not 
 to dismiss the symptoms too hastily because of their 
 seeming triviality. Malignant disease of the stomach 
 may cause the symptoms of a simple indigestion, but 
 a slight loss in weight and a slight change in the 
 patient's colour may ultim.ately be found to indicate 
 the grave nature of the illness. The description of 
 the patient's complaint may be given in such term.s 
 that the physician may fancy it is exaggerated and 
 due to the patient being of a neurotic habit. This 
 may be true, yet the com.plaint from which the 
 patient suffers may have so undermined his strength 
 that the neurotic habit has been induced by his 
 prolonged suffering. It is necessary to state this 
 because the presence of many reflex phenomena is 
 apt to be pooh-poohed, because of the manifest 
 hypersensitiveness of the patient's nervous system.. 
 There is no doubt that in people of a neurotic habit 
 there is a greater tendency for reflex phenomena to 
 be readily produced, yet the phenomena should not 
 on that account be ignored, but should be utilised for 
 the purpose of discovering the lesion if possible, and 
 the neurotic tendency being duly discounted, their 
 true value should be estim.ated. However widespread 
 such symptoms as pain and hyperalgesia may be, 
 there is always som.e irritation in the cord, induced, 
 as a rule, by some trouble in the viscera or external 
 body wall. This was well illustrated in the following 
 case, which was under m,y observation for many 
 years. I attended the patient during several attacks 
 of rheumatic fever from. 1880 to 1884. She 
 developed well-marked symptom,s of aortic, mitral, 
 and tricuspid valvular disease, and was for years 
 
Estimation of the Value of Symptoms. 253 
 
 very short of breath occasionally, but had no pain 
 or h3^peralgesia. In 1895 she began to complain of 
 pain, particularly after meals, referred to the lower 
 part of the epigastric region, with a limited area of 
 hyperalgesia. The pain becam.e very severe, so that 
 I came to the opinion that she had a gastric ulcer 
 near the p3doric orifice. The hyperalgesia spread 
 widely round to the left chest. She kept in bed for 
 a few weeks, but began to go about her household 
 duties before the pain and hyperalgesia had dis- 
 appeared. She then began to have attacks of pain 
 in the chest on exertion, slight at first, but gradually 
 becoming more severe, until they resembled in every 
 respect attacks of angina pectoris. Coincident with 
 the pain, hyperalgesia appeared in the chest and 
 arm.. The distribution of this h3^peralgesia, due 
 manifestl}" to the heart lesion, coalesced with that 
 due to the gastric ulcer, so that there was an exten- 
 sive field of h}' peralgesia em.bracing the left chest 
 and abdomen, from the level of the second rib to 
 below the umbilicus. At the patient's death there 
 were found the lesions of the three valves mentioned, 
 and an ulcer at the pyloric orifice. Anyone seeing 
 the patient after the development of the extreme 
 field of liyperalgesia might have attributed the whole 
 condition to some such vague complaint as " neuras- 
 thenia," particularly if the nature of the cardiac 
 lesions were not detected. I have seen another case 
 with very severe attacks of angina pectoris and wide- 
 spread hyperalgesia where no cardiac abnormality 
 could be detected. The extraordinary acuteness and 
 extent of the sensory phenomena might have led to 
 the surmise that there was only a neurasthenic con- 
 dition, yet at the post-mortem examination the 
 
254 Chapter XXI. 
 
 coronary artery was found almost impermeable, and 
 the muscle of the heart greatly degenerated. The 
 rule I make in these cases is to recognise the fact 
 that, however exaggerated the reflex symptoms, and 
 however neurotic the patient may be, the symptoms 
 are nevertheless due to actual affection of some 
 viscus, and a careful consideration of all the other 
 features of the case will lead one to an approxim.ately 
 correct estimation of the value of the symptom,s. 
 
 129. Remote Effects of the Lesion. — Not 
 only may the continuance of a visceral lesion and 
 prolongation of suffering lead to the exhaustion of 
 the patient's nervous system (which is probably the 
 reason for the ease with which the reflex phenomena 
 are produced in m.any people), but the original 
 ailment, in consequence of persistent suffering, may 
 alter the whole m.ental balance of the patient. 
 Previous to an illness he may be sensible, unselfish, 
 and considerate of his relatives and dependents, 
 but during illness he may become utterly selfish, 
 wear out the patience of his children and dependents 
 with his peevishness and want of consideration, 
 in order that his own requirements and comforts may 
 be satisfied. Patients in this condition are extrem.ely 
 difficult subjects for diagnosis, for it is to their 
 interest to m.agnify their complaints, and it is 
 difficult to estimate the value of their symptoms. 
 This is particularly the case if one searches for 
 hyperalgesia of skin or m,uscle, for they readily 
 complain of pain and tenderness. To discriminate 
 the sym.ptoms in such people the distribution of the 
 sensory phenomena (pain and hyperalgesia) affords a 
 very good guide. Thus if one tests for hyperalgesia . 
 of a heart affection, and the symptoms are found to 
 
Estimation of the Value of Symptoms. 255 
 
 •extend up the chest and over the clavicle, one 
 might reject the synaptoms, for the skin over the 
 clavicle as low as the second rib is supplied by the 
 fourth cervical nerve, while below it is supplied 
 by the second thoracic, so that the extension of 
 the hyperalgesia from the second thoracic to the 
 fourth cervical is not conceivable. So it is in 
 other complaints ; the peculiar distribution of 
 the sensory phenomena in affections of any given 
 organ being unknown to the patient, one can test 
 his reliability by noting the distribution of his 
 pain and hyperalgesia. 
 
 This method of discrimination is also to be used 
 in distinguishing true visceral sensory phenomena 
 in cases of suspected hysteria and malingering. If 
 the svmptoms are found to follow the distribution 
 peculiar to one organ, even if the patient be evidently 
 hysterical, then it may be concluded that there is an 
 affection of the viscus, and it remains to make care- 
 ful consideration of the other factors in the diagnosis 
 in order to estimate what value the symptoms 
 possess. 
 
 The intensification of reflex phenomena is par- 
 ticularly noticeable where the conditions of living 
 have reduced the bodily strength, through worry, 
 sleeplessness, or improper nourishment. I have been 
 particularly struck, for instance, with the symptoms 
 of angina pectoris that may be induced in young 
 people who have had a long and trying period of 
 strain. Women who work hard for their living, or 
 who look after household duties during the day, and 
 have to attend an invalid parent or ailing child 
 during the night, who are frequently disturbed in 
 sleep, or who pass the greater part of the night in 
 
256 Cha'pter XXI, 
 
 constant attendance, become gradually exhausted, 
 and the struggle may go on until an attack of pain 
 in the chest imperatively calls attention to the 
 exhausted heart. In such people the attacks of 
 angina pectoris may be extremely severe, and the 
 hyperalgesia may be widespread, affecting both 
 sides of the chest (the left breast particularly often 
 becoming extremely tender), and, it may be, the 
 neck, particularly the left sterno-mastoid and 
 trapezius muscles. 
 
 In estimating the value of the symptoms in such 
 cases the history of the patient's life gives an 
 indication, and one can then recognise, with assur- 
 ance, the condition of the heart that has provoked 
 these manifestations. 
 
 Similar exaggerated symptoms, having a 
 peculiar distribution, may arise should any other 
 organ be affected ; as in stomach affections, a slight 
 indigestion may give rise to such symptoms as to 
 make it difficult to tell whether some more serious 
 condition, as gastric ulcer, may not be present. 
 
 In doubtful cases one feature when present 
 may be taken as a rule to distinguish an 
 affection of an organ from some general nervous 
 manifestation, that is the viscero-motor reflex. Un- 
 fortunately this sym.pt cm. is practically limited to 
 affections of the abdominal organs, and needs to be 
 sought for with care, lest a too susceptible super- 
 ficial reflex be started. But when detected it may 
 be looked upon as dem.onstrating the presence of 
 some visceral trouble. 
 
 130. Relation of Symptoms arising from 
 different Causes. — When a patient presents him.- 
 self one may be able, on physical examination, ta 
 
Estimation of the Value of Symptoms. 257 
 
 detect some abnormal condition to Avhich one can 
 refer with certainty the cause of the patient's 
 suffering. It ma}^ happen, however, that w^e detect 
 an abnormahtv^ having no direct bearing upon the 
 complaint of the patient, and in the absence of one 
 having sucli a direct bearing, there is too often a 
 tendency to refer the patient's complaint to the pres- 
 ence of the recognisable abnormality. There is no 
 doubt that symptoms may be provoked by lesions 
 remote from the place where they are ex- 
 perienced, as in referred pain, and there is no doubt 
 that many other symptoms may be produced by 
 lesions of remote organs, as in the widespread effects 
 of kidney disease. But keeping all this in view, there 
 is still need of a wise discretion in estimating the 
 influence of lesions in which there is no recognisable 
 connection with the symptoms. Thus epileptic 
 attacks may be brought on by affections of the heart 
 as in heart-block (Adams-Stokes syndrome), where 
 the left ventricle becomes so slow in its action that 
 the brain does not receive a sufficient supply of blood. 
 In consequence of this anaemia the patient may faint 
 or have an epileptic seizure. The well-recognised 
 connection between a heart abnorniality and an 
 epileptic attack in this particular instance has led 
 to the assumption that, if a patient has epilepsy 
 and at the same time has some affection of the heart 
 such as irregular action, there is a connection 
 between the two. Under such circunistances it is 
 necessary to recognise the nature of the irregularity, 
 and as it is now possible to demonstrate with pre- 
 cision the different forms of heart irregularity, 
 the recognition of the particular form of irregular 
 heart action at once permits of determining the 
 
258 Chapter XXL 
 
 probabilities of the heart being the cause of the 
 epileptic attack in any given condition. Irregular 
 action of the heart being so common, the occurrence 
 of epilepsy is in the majorit}^ of cases due to an 
 independent affection, and there is no casual 
 relation necessarily present between the two 
 conditions. 
 
 I have already referred to errors arising from 
 attributing the cause of symptoms to some demon- 
 strable structural affection which may be merely 
 coincident or independent. 
 
 It is impossible to lay down rules applicable to 
 all cases, and I write this in order that the subject 
 should in every case receive consideration, since the 
 recognition of the possibility of error may prevent 
 the error being made. 
 
 131. The Bearing of Symptoms on Prognosis. — 
 Of all branches of medicine there is none which 
 has received so little real consideration as the matter 
 of prognosis. The subject itself is one which has to 
 be considered in nearly every case that comes under 
 the notice of a medical man. Its importance is 
 a,ppreciated in all stages of life, and the just con- 
 sideration of the meaning of symptoms is of cardinal 
 importance in regard to the patient's future. 
 
 In addition to recognising the meaning of any 
 abnormal sign or symptom, we should endeavour to 
 acquire a knowledge of what bearing it has upon the 
 future history of the patient. This knowledge can 
 only be obtained by watching how patients exhibit- 
 ing the abnormality withstand the storm and stress 
 of life. This should be a special object of every 
 general practitioner, for it is he who has the oppor- 
 tunity of watching individual cases over a long 
 
Estimation of the Value of Symptoms. 259 
 
 period of years, and of estimating the bearing of 
 any abnormality on the patient's future hfe. 
 
 I am afraid that our profession as a body does 
 not sufficiently recognise its responsibility in regard 
 to prognosis. When an individual submits himself for 
 an opinion, he does so with such implicit confidence 
 that the verdict given m.ay alter the whole tenor of 
 his life. He may, for instance, be seeking to enter 
 some profession, when a preliminary medical exam- 
 ination reveals what the medical man takes to be an 
 abnormality. An imperfect knowledge of its nature 
 may, and unfortunately often does, lead to its being 
 regarded as presaging possibly grave consequences, 
 and the candidate is rejected. He is thus shut off 
 from the prospect of his chosen calling, and, know- 
 ing the reason of his rejection, passes through life 
 uneasily apprehensive of some impending disaster, 
 whilst all the time the supposed abnormality may be 
 a sign of little or no consequence. 
 
 If we look at an insurance form we realise the 
 hardships to which applicants are exposed. " Is the 
 pulse regular ? " " Are the sounds of the heart 
 pure ? " "Is the urine free from albumen ? " When 
 such questions are answered in the negative the 
 applicant may nevertheless be perfectly healthy, yet 
 is either rejected or is penalised for life by having 
 to paj^ a higher premium, and, in addition, he is 
 burdened with the consciousness of infirmity. 
 
 I dwell on this matter with some insistence, 
 because I have known of so many instances in 
 which gross injustice has been done to individuals, 
 not only from a pecuniary aspect, but in having 
 imposed upon them great expense, unnecessary 
 treatment, and mental disquiet, because the meaning 
 
260 Chapter XXI. 
 
 and prognostic significance of some simple symptom 
 had not been recognised. 
 
 A serious responsibility is thrown upon every 
 practitioner at times in advising upon other ques- 
 tions. Should a man give up his business ? is a 
 question upon which advice is constantly sought ; and 
 whether the individual be a statesman or a labourer, 
 the greatest care is necessary in formulating the 
 answer. " Should a wom.an with som.e heart affection 
 m.arry ? " or, " If she be pregnant, should the preg- 
 nancy be allowed to proceed ? " are problems that 
 every general practitioner at one time or another will 
 have to m.eet ; and if he seeks for guidance in the 
 text-books, he finds merely vague views which he 
 cannot apply to the individual case. This fact alone 
 should arrest the attention of the profession, and 
 make it conscious how insufficient are the indications 
 for an intelligent prognosis. 
 
 In estimating the value of any abnorm.al sign, 
 or in determining the condition of the patient, a 
 clear idea must be obtained of the mechanism by 
 which any given sym.ptom is produced, and of the 
 effects that the underlying lesion has upon the 
 economy. It is impossible to give here indications 
 that would be of value, partly because the subject 
 traverses the whole field of clinical medicine and 
 partly because I am not com.petent to deal with the 
 m.atter, being only impressed with the importance 
 of the subject and the necessity for its further con- 
 sideration. So far as my experience goes, I can only 
 say that one should never base a prognosis upon the 
 presence of a single sym.ptom, but should carefully 
 investigate the effect of any abnorm.al sign on the 
 functional efficiency of the organ and upon the 
 
Estimation of the Value of Symptoms. 261 
 
 economy as a whole. The presence of albumen in 
 the urine is often a sign of variable import. In 
 many cases it is a sign of great gravity, and this 
 being recognised, it is too often regarded as being 
 invariably a serious matter. It is now recognised 
 that its significance depends on the conditions induc- 
 ing it, and it may appear when there is no serious 
 affection of the kidney, or when the kidney affection 
 is of such a nature that it may have little effect 
 upon the system. Cases of albuminuria should not 
 therefore be hastily condemned until a complete 
 review of the whole circumstances of the case, such 
 as the history of the illness, tlie condition of the 
 other constituents in the urine and their effect upon 
 the circulator}" system, has been made. In the same 
 waj^ the presence of a cardiac murmur or irregu- 
 larity, or even an attack of angina pectoris, should 
 never be considered as affording grounds for a grave 
 prognosis until the whole circumstances of the case 
 are taken into consideration. I mention these in- 
 stances merely as indications as to what course to 
 pursue when doubts arise as to the significance of 
 any abnormal sign. 
 
 The symptoms which arise reflexly in like 
 manner have to be carefull}^ weighed. Intensity of 
 suffering may have no relation to the gravity of the 
 complaint. Toothache causes no anxiety as to the 
 prognosis, though the immediate suffering is severe. 
 Were the cause of the pain not so easily recognised 
 the agonising distress would at times be viewed 
 with the gravest anxiety. Extreme suffering from 
 some trivial disease may be found among the 
 symptoms of many organs. When it is recognised 
 that the most agonising pains are associated with the 
 
262 Cha'pter XXI. 
 
 contraction of non-striped muscular fibres, it will 
 be realised that the cause inducing a contraction 
 capable of calling forth violent pain may be of the 
 most varied kinds, trivial as well as im,portant. 
 Even in the matter of angina pectoris the violence of 
 the pain bears no necessary relation to the gravity 
 of the heart complaint. In many cases the only 
 sensation brought on by exhaustion of the heart 
 muscle may be limited to a mere sense of constriction, 
 and this, if properly appreciated, may indeed be 
 the one sign which calls attention to the serious 
 condition of the heart. I have repeatedly been con- 
 sulted by elderly people for this sense of constric- 
 tion across the chest when they exerted themselves, 
 and in many cases it was the earliest symptom that 
 heralded the termination of the patient's life. On 
 the other hand, some of the most violent attacks of 
 angina pectoris have occurred in people in whom the 
 exhaustion of the heart was but temporary, and the 
 restoration of reserve force resulted in a complete 
 cessation of pain and in permanent recover}^ 
 Between these extremes there are many intermediate 
 forms, and it needs a careful inquiry into all the 
 circumstances before a definite prognosis can be 
 given. 
 
 In regard to the reflex phenomena the tendency 
 to the exaggeration of symptoms by people with a 
 hypersensitive nervous system must always be 
 borne in mind. 
 
 132. The Bearing of Symptoms on Treatment. — 
 The due appreciation of the mechanism by which 
 sym.ptoms are produced has a profound influence on 
 treatment. It is often stated that treatment has to 
 be symptomatic, that is, the symptoms are to be 
 
Estimation of the Value of Sympto7ns. 263 
 
 treated because the nature of the affection inducing 
 those symptoms cannot be detected. Whole sj^stems 
 of treatment are based upon this idea, and though 
 at times we may be forced to accept this hne, it 
 should always be done with regret at our incapacity 
 to recognise the underlying cause of the suffering. A 
 constant endeavour to make out the meaning of these 
 symptoms, which have perforce to be treated 
 without knowledge of their cause, will gradually 
 diminish the number of patients who have to be 
 treated symptomatically. 
 
 As pain is the most common complaint from 
 which so many suffer, its relief is an aim of our 
 treatment. But it should never be supposed that the 
 assuagement of pain is the only object. It has 
 become stereotyped to say " remove the cause," and 
 if this advice had not become so much of a platitude 
 more attention might be given to the " search for the 
 cause." The recognition of the cause can only be 
 attained in the majority of sufferers by a recognition 
 of the mechanism by which the suffering is produced. 
 Recognising, for instance, that contraction of non- 
 striped muscle produces a referred pain, the know- 
 ledge of how the pain is produced leads to the recog- 
 nition of the hollow viscus producing it. There must 
 be an abnormal stimulus exciting the muscle to con- 
 traction, and experience leads us to conclude what 
 is the most common cause likely to produce the stimu- 
 lation in a particular viscus. A pain with accom- 
 panying phenomena located in a certain region in- 
 forms us that the stimulus arises from the gall-duct 
 or the ureter. Experience tells us that a gall-stone or 
 renal calculus is the most frequent cause. The 
 absence of symptoms indicative of any other lesion 
 
264 Chapter XXI. 
 
 confirms this view. On recognising that this is the 
 cause the question arises : can we remove it ? In 
 the vast majority of cases this is only possible b}^ 
 surgical operation, and the question of the propriety 
 of this procedure has to be considered. If, as is often 
 the case, this proves inadvisable, then the treatment 
 must proceed on other lines, and the recognition of 
 the mechanism by which the pain arises again gives 
 indications. As it is manifestly due to the strong 
 contraction of non-striped muscle, measures that will 
 relax the contraction of the muscle will naturally be 
 the remedy in this particular case for the time being. 
 
 On the other hand, if the pain be aroused by 
 some hollow muscular organ, where it is possible by 
 simple means to remove the cause that stimulates 
 the contraction, to this end treatment should 
 be primarily directed. If, for instance, the 
 indications point to the pain arising from painful 
 peristalsis of the bowel, the inquiry will proceed to 
 find out the probable nature of the stimulus. If 
 there has been a history of constipation, or incom- 
 plete evacuation of the bowel, the retention of 
 scybalous masses is suggested as the cause of the 
 peristalsis, and the treatment will be guided to 
 measures that will lead to evacuation. So also with 
 regard to any other viscus that can be emptied, the 
 recognition of the nature of the symptom.s affording 
 the best guide for a rational and effective treatment. 
 
 In an organ, such as the heart, that cannot have 
 the cause of the sufi^ering removed by some mechani- 
 cal process, the consideration of the conditions that 
 induce the sym.ptoms leads to a rational guide in 
 treatment. As I have pointed out, any symptom 
 of suffering points to an exhaustion of the reserve 
 
Estimation of the Value of Symptoms. 265 
 
 iorce, whatever be the nature of the functional 
 exhaustion or structural lesion. The recognition of 
 this indicates tliat treatment in the first instance 
 must be directed to the restoration of this reserve 
 force, and this can be done when consideration of 
 the factors inducing the exhaustion are appreciated, 
 such as over-work, worry, sleeplessness, or the ham- 
 pering effect of some organic lesion. This demands 
 careful investigation into the special features of each 
 individual case. 
 
 These remarks may seem so evident as to be 
 altogether unnecessary, as everyone recognises them. 
 But though as a matter of theory they are the 
 commonest of platitudes, as a matter of practice 
 they are often neglected. If we consider the 
 matter in relation to the treatment of heart 
 affections, for instance, it would be found that, what- 
 ever the nature of the heart failure, a routine method 
 of treatment is, with few exceptions, invariably 
 adopted. Thus heart failure is supposed to demand 
 what are called " heart tonics," and the usual 
 treatment is to prescribe the tonic which is dictated 
 by the fancy of the physician or by the fashion of 
 tlie day. In our inquiries into systems of treatment, 
 such as are elaborated at phxces hke Nauheim, it 
 will be found that routine methods are employed, 
 after few or no discriminating inquiries into the 
 pecuhar features of each case. One could indefinitely 
 extend ilkistrations, drawn from other systems, where 
 rule of tluimb treatment is followed, to the neglect 
 of the simple and obvious methods suggested by the 
 careful appreciation of the meaning of symptoms. 
 
 I have already pointed out that treatment may 
 be a factor in diagnosis— so-called diagnosis " ex 
 
266 Chaj)ter XXI. 
 
 juvantibus " — the manner in which symptoms react 
 to treatment being often a useful help, as, for in- 
 stance, the use of mercury or iodide of potassium in 
 suspected cases of syphilis. But it is necessary also 
 to appreciate when possible the manner in which the 
 treatment acts. It must be the experience of every- 
 one who has seen a large number of cases of stomach 
 affections, that many cases of great suffering, where 
 there is manifest structural lesion, obtain relief by 
 some simple remedy or change in diet. Thus in 
 pyloric stenosis with dilatation of the stomach the 
 patient may have suffered for a long period, and 
 some simple remedj^, as bicarbonate of soda, may 
 give instant relief and freedom from suffering for a 
 long time. So also a change in the diet may have 
 the same result. Too often such remarkable experi- 
 ences are mistaken by physician and patient as 
 evidences of the curative value and potency of the 
 drug or system of diet, and so we get the exaggerated 
 praises of different drugs and systems so common 
 nowadays. If it be recognised that some constituent 
 was present in the stom.ach which occasioned the 
 sufferings of the patient, and that the drug had 
 neutralised its effects, or the change of diet had pre- 
 vented its formation, it would have led to a truer 
 appreciation of the benefits obtained by the 
 treatment. It cannot be too strongly insisted 
 upon that the reflex symptoms, which are those that 
 are thus " cured," may arise, not from, the actual 
 lesion, but from, a susceptibility to stimulation, 
 or from some agent capable of inducing an adequate 
 stim,ulation, and that the symptoms give no clue 
 to the nature of the stimulation or to the agent 
 causing it. 
 
Estimation of the Value of Symptoms. 267 
 
 The recognition of the meaning of the reflex 
 phenomena is of much use in so many ways that it 
 is scarcely possible to do more than indicate certain 
 phases of their value. The muscular contractions 
 and hyperalgesia are always indications that some 
 active process is going on. In cases of gastric ulcer, 
 for instance, the treatm.ent may have been so success- 
 ful that the patient's sufferings are relieved and a 
 " cure " is said to have resulted. But a careful 
 examination of the left rectus muscle may reveal 
 tenderness of its upper division with increased tone ; 
 and these symptoms indicate that the stom.ach lesion 
 is still so active that it keeps up an irritable focus in 
 the cord, and give indication that the treatment 
 should be continued if a permanent recovery is to be 
 attained. Occasionally one meets Avith cases where 
 this viscero-motor reflex has been recognised and 
 taken as the factor needing treatment. In gall-stone 
 disease, when there is present the tell-tale sign of 
 contracted muscles in the epigastrium, energetic 
 means, as b^-ths, electricity, massage, are frequently 
 employed to reduce the " hardness " of the belly wall! 
 
 The conception of the nature of the reflex 
 phenomena may give a more direct aim to our 
 therapeutic endeavours. I have already pointed 
 out how the suffering in stom.ach affections may be 
 due to the accidental presence of an agent that is 
 capable of producing pain, and that remedies may 
 neutralise the effect of the agent without modifying 
 the disease process. It is conceivable that an effect 
 may be produced in other ways, whereby treatment 
 may influence the reflex symptoms at some portion 
 of the chain between the lesion and the mental 
 conception of tlie suffering. Thus a drug may act 
 
268 Chapter XXI. 
 
 upon the muscular spasm when it causes pain, or it 
 may act upon the spinal cord at the level where the 
 visceral nerve stimulates the sensory nerve. It is 
 just possible that it is here the relief is obtained in 
 certain forms of counter-irritation. Thus I have seen 
 a patient with a pyloric ulcer of the stomach obtain 
 relief by a blister on the epigastrium over the limited 
 area in which the pain was felt. This blister did not 
 directly affect the ulcer, because the ulcer did not 
 lie at the same level {see Fig. 11). Nor could one 
 imagine that any reflex effect was produced in the 
 ulcer itself. It seems more probable that the 
 stimulus from the skin affecting directly the peri- 
 pheral distribution of the sensory nerve prevented 
 by some inhibiting process the stimulus from the 
 viscus passing to the sensory cells in the spinal cord. 
 This seems the m.ore reasonable, because it was 
 found that on the healing of the blister the old pain 
 from the ulcer returned, but if the blistered skin 
 were kept raw by the application of some ointment 
 the pain from the ulcer was subdued.. This view 
 receives support from the result of recent researches 
 of Sherrington, by which it has been shown that 
 nerve paths may be stimulated from a variety of 
 sources, but that of several contemporaneous stimuli 
 one stimulus may be received and the others 
 inhibited. 
 
( 269 
 
 APPENDIX T. 
 
 MR. LIGAT ON HYPERALGESIA IN 
 ABDOMINAL DISEASES. 
 
 It has long been to me a matter of surprise that 
 surgeons should have failed to grasp the significance 
 of the symptoms provoked by visceral disease, 
 because they have had unrivalled opportunities for 
 observation, and for verifying the relations between 
 symptoms and disease. The comparative safety of 
 an exploratory operation has led surgeons to employ 
 this method for diagnostic purposes, and they have, 
 in consequence, neglected the information to be 
 derived from the stud}^ of symptoms. In a case of 
 doubt, and doubtful cases are not infrequent, the 
 surgeon, in place of minutely investigating aU the 
 phenomena, opens up the patient and looks inside. 
 It is for this reason that the s^^mptoms so plainly 
 perceptible on the external bod}^ wall are overlooked 
 or described in language so vague that it is evident 
 that the surgeon has never really grasped their 
 significance. 
 
 It was tlierefore a pleasant surprise when I read 
 the results of one surgeon wlio conducted an in- 
 vestigation on the lines indicated in this book, and 
 it was gratifying for me to find liow completely 
 he verified tlie results I liad obtained in the rehitively 
 few opportunities I had of demonstrating the relation 
 
270 Appendix I. 
 
 between the symptoms and the disease. Mr. Ligat's 
 paper was published in " The Practitioner " for 
 August, 1916, and I would refer my readers to that 
 article for a detailed account of one of the most 
 convincing and helpful clinical studies — too rare, 
 unfortunately, in medicine or surgery. 
 
 In this article Ligat deals mainly with the 
 hyperalgesia of the skin of the abdominal wall. 
 His method of exploration in any given case is to 
 " grasp the skin and subcutaneous tissue firmly 
 between finger and thumb, and draw them away 
 from the deeper layers of the abdominal wall. If 
 a hyperalgesic area be present, the patient winces, 
 and one can tell, by the patient's expression, when 
 such an area is being stimulated." The facial 
 expression should be watched, as when a tender 
 area is thus treated, a sudden expression of pain 
 passes over the face, " converting a subjective 
 symptom virtually into an objective sign." 
 
 In attacks of bihary or renal colic or in a 
 perforating gastric ulcer or appendix the pain is so 
 great and the hyperalgesia may be so severe and 
 widespread that a precise and definite result cannot 
 always be obtained. It is in less acute cases and in 
 clironic cases that instructive hyperalgesic areas, 
 their maximum points, spread, and limitation can 
 best be perceived. 
 
 The following diagram, showing definite areas of 
 hyperalgesia (Fig. 19), from Ligat's paper gives the 
 results of his observations. The areas are based on 
 operations in 54 cases of choli cystitis, of which 41 
 give the characteristic area in the figure. In 243 
 consecutive cases of appendicitis, 195 give the 
 definite area. In 39 cases of tubal disease, 20 give 
 
Appendix I. 
 
 271 
 
 Fig. 19. 
 
 Diagrammatic illustration of the hyperalgesic points, with tj^pical 
 spread. The length of the line denotes the intensity of the hyperalgesia, 
 xiot hxteral spread. Note there is more downward than u[)ward spread. 
 
 1. Shows hyperalgesic area when present in gall-bladder lesions. 
 
 2. Shows hyperalgesic area when present in appendix lesions. 
 
 3. Shows hyperalgesic area when present in right Fallopian tube lesions. 
 
 4. Shows hyperalgesic area when present in gastric and duodenal ulcers. 
 
 5. Shows hyperalgesic area when present in small-gut lesions. 
 
 6. Shows hyperalgesic area when i)resent in great-gut lesions. 
 
 7. Shows hyperalgesic area whtn present in left Fallopian tube lesions. 
 
272 Appendix I. 
 
 the area. In 80 cases of gastric ulcer, 50 give the 
 characteristic area. 
 
 In his recorded cases of intestinal operations 
 the symptoms are not so clear and simple as in the 
 lateral organs, nevertheless they bear out in a 
 remarka,ble manner the region of pain and hyperal- 
 gesia shown in my Figure 8, as will be seen by 
 comparing that figure with the areas 4, 5, and 6 in 
 Fig. 19. 
 
( 273 ) 
 
 APPENDIX II 
 
 CLINICAL INVESTIGATION. 
 
 A great many medical men desire to investigate 
 fields of medicine that are obscure. This desire 
 sensibly diminishes with advancing years. This 
 diminution is not due to the successful accomplish- 
 ment of investigation, but rather to the sense of 
 comparative failure and ineffectiveness that has come 
 after years spent in this work. 
 
 If we inquire into the reason for this dis- 
 appointment we shall find it is due to a wrong 
 conception of what constitutes medical research. 
 During the last half centur}^ the great discoveries 
 have come mainly from researches carried on in 
 laboratories, and to a lesser degree in hospital 
 wards. In consequence there has arisen the idea 
 that it is only in such places that research work can 
 be carried on. When the ardent youth desires to do 
 what is called " orginal research " he naturally 
 seeks the guidance of some one who is himself 
 engaged in research work. The advice he receives 
 is coloured by the experience of the adviser, and 
 as this is again limited by the adviser's somewhat 
 narrow horizon, the enquiring youth has suggested 
 to him some academic problem that has little 
 bearing on practical medicine, and unlikely to yield 
 an}^ fruitful result. Had it been of much promise 
 the adviser himself would long ago have undertaken 
 
274 Appendix II. 
 
 it. Many youths full of hope who enter on a course 
 of research find, after a few j^ears, how profitless 
 has been the time thus spent, and are discouraged 
 for undertaking research work in their later years. 
 
 Unless he merely wants to learn methods or to 
 assist an experienced observer no young man should 
 start out with the idea of undertaking research. 
 He must wait till he has studied disease processes 
 so far as to be able of himself to recognise where 
 knowledge is deficient. In being guided by another's 
 experience he fails to grasp the need for the work. 
 I have been struck over and over again by the failure 
 of research workers to obtain any satisfactory 
 result after long periods of patient labour, and I have 
 frequently observed this failure in men whom I 
 m3^self have advised. The reason for this is that the 
 experienced observer recognises a certain field that 
 needs exploring. He has come to this conclusion 
 because of a great number of experiences which have 
 forced the need upon him. When then he advises 
 an inexperienced individual to follow a certain line 
 he fails to convey to that individual the reasons 
 that govern his advice. Failing to grasp the full 
 significance of the suggested work he, the young 
 student, does not realise its importance, nor does he 
 see the goal, and hence he lacks the incentive to 
 pursue it with that intensity of mind which the true 
 research student requires. 
 
 Hitherto a far too restricted view has been taken 
 of the opportunities and methods of research in 
 medicine. The workman's laboratory and the hos- 
 pital wards have hitherto dominated all conceptions 
 of research, and this has led to a deplorable narrow- 
 ness of outlook ; indeed, so restricted is this view 
 
Appendix II. 275 
 
 that al] the teaching exponents of medicine go so 
 far as to say that research in cHnical medicine has 
 almost reached its hmit until some new mechanical 
 device is discovered, or that it is only in the labora- 
 tory that true research can be achieved. This 
 foolish conception accounts for the sudden and 
 universal popularity of any new instrument or 
 method — a popularity which, however, is evanescent, 
 because sooner or later its field of usefulness is found 
 to be very restricted. This erroneous conception of 
 medical research accounts greatly for the barrenness 
 which has characterised modern medicine. That 
 there are great fields unexplored, which need nothing 
 but the ordinary methods possessed by everj^ doctor, 
 has not yet reached the consciousness of the pro- 
 fession. To recognise these fields which are essential 
 to medical progress, we have but to consider how 
 investigation has been pursued in the past, and is 
 still being pursued. Looking at the matter broadl}^ 
 the prosecution of research in wards and laboratories 
 deals mainly with disease after it has invaded the 
 body and caused such alteration or destruction of 
 tissue as to have produced a physical sign, or the 
 disease is studied after death. Attention has been 
 devoted to finding out all about these physical signs 
 during life and a close investigation into them after 
 death. Thus the later stage of disease, and the 
 post-mortem appearances, have been the main object 
 of investigation, and this restricted outlook on 
 disease has shaped the course of medical study. 
 Thus we see, for instance, all the experienced 
 physicians at a hospital devoting their time to the 
 study of disease in the wards, where patients liave 
 the disease so far advanced as to show ph\'8ical 
 
276 Appendix II. 
 
 signs, many of them dying of their disease. Here 
 all the energies of research are concentrated — the 
 experienced physician, his assistants, his laboratories, 
 and so forth. Thus disease in its later stage has 
 absorbed the attention of investigation in the past. 
 What of the earlier stages ? Surely it is here that 
 the physician's energies should be exerted to the full, 
 for if disease cannot be prevented, the next best 
 thing is to recognise it at its earliest stage, before 
 it has irreparably damaged the tissues, and while 
 yet it is amenable to treatment. The early stage of 
 disease has never yet formed the subject of accurate 
 and painstaking observation. Such opportunities 
 as the hospital physician has for its study are in the 
 out-patient department, and then the conditions 
 are so unfavourable that no real attempt at the 
 carrying on of research work here is made. The 
 sj^mptoms of the early stages of disease are so subtle 
 and elusive that what little is known of them can 
 only come through years of patient investigation. 
 Yet this phase of disease, found mainly in out- 
 patients, is handed over to the least experienced 
 members of a hospital staff at a time when their 
 conception of disease is based on physical signs. 
 
 We must bear in mind that when the body is 
 invaded by disease the earliest sign of its presence 
 is invariably a subjective one, and that long before 
 any physical sign is perceptible the patient himself is 
 conscious that something is amiss. To bring these 
 sensations to light and to estimate their value is one 
 of the most difficult tasks for the physician. The 
 knowledge can only be acquired by careful noting of 
 the different sensations, and all attendant signs and 
 circumstances. Then the patient may have to be 
 
Appendix II. 211 
 
 watched for long periods to see what is the outcome 
 of his complaints. In this way the physician may 
 in the course of years acquire a knowledge which he 
 can apply to other patients. Now as tlie out- 
 patient department of a hospital contains the 
 patients with disease in its earliest stage, how can 
 the symptoms ever be understood by the young 
 inexperienced physician ? The result we see in the 
 fact that no progress whatever is made in this 
 subject. The difficulties are no doubt great — the 
 observer is himself untrained, the number of patients 
 may be too great, and the patients are so migratory 
 that they cannot be kept closely under observation 
 for a sufficient length of time. 
 
 The need for studying the earliest stages of 
 disease is a crying one and should be realised b}^ all 
 classes. The opportunities of hospital and labora- 
 tory workers are so limited as to render it impossible 
 for them to do but a small portion of this work, and 
 without opportunity all effort is vain. The man who 
 has the opportunity is the general practitioner — the 
 man to whom the ailing individual first turns, and 
 the man who' can watch the progress of the disease. 
 But he is the last individual from whom investigation 
 is expected. He has received no instructions likely 
 to be of help and his whole education has impressed 
 liim with the idea that only in hospital wards and 
 laboratories can investigation be carried out. 
 
 One reason why he has been restrained is that 
 he has never been taught how to recognise and 
 appreciate the symptoms that confront him in his 
 daily practice. The majority of the patients who 
 consult hin^ have no physical siorns to cnide him in 
 his diagnosis — the symptoms being subjective. The 
 
278 Appendix II. 
 
 reason he has never been taught the meaning of 
 subjective symptoms is very simple — his teachers 
 are ignorant of them. 
 
 Here then is a field for exploration unlimited in 
 extent. The fact was dimly realised by me some 
 thirty years ago, and as an experiment 1 said to 
 m3^self, "I'll try and find the meaning of every 
 symptom of which the patient complains, and of 
 every sign which I can detect." In a few months' 
 time I found such a large number of signs and 
 symptoms to be investigated that I had to restrict 
 myself to a few. One of the sensations that arrested 
 my attention was that of pain. This sensation is so 
 universal and so informative that one would expect 
 it to have been the subject of the prof oundest study. 
 So far from this being the case, the elementary 
 information necessary for its consideration had 
 never even been elucidated. Thus the tissues capable 
 of producing the sensation had not even been 
 described, while the mechanism of its production 
 had never received any serious consideration. My 
 attempts to solve the question are shown in this 
 book, but it will be seen that my knowledge is still 
 very imperfect and much requires to be done. 
 
 Other signs arrested my attention, such as the 
 irregular action of the heart. The result of that 
 investigation has thrown a light upon the heart's 
 varied action in health and disease, as to give a new 
 conception of heart failure and its treatment. 
 Others indeed had studied this subject, and added 
 greatly to our knowledge, but what nearl}^ all 
 contented themselves with was the elucidation of 
 how a given irregularit}^ was produced, whereas I 
 concerned myself with the question of what happened 
 
Appendix II. 279 
 
 to people who showed dA\y form of irregularity. 
 Xow the last question is one of prime necessity to 
 the physician, yet it is one which the profession up 
 till now has never really appreciated. What use is 
 it to tell a man that he has got a murmur or an 
 irregularity or any other abnormal or supposed 
 abnormal sign, unless you can tell him at the same 
 time, with a knowledge drawn from experience, 
 what is to happen if the condition is untreated, or 
 if it is susceptible to treatment, or if it needs treat- 
 ment at all ? 
 
 If an3^one wishes to realise how unexplored tliis 
 essential field of knowledge is, let him take any 
 striking or abnormal sign which the practitioner 
 recognises, let him turn to a library of medical 
 treatises in any language, and seek to get the 
 knowledge essential to him as a practitioner, and 
 he will discover that what he wants to know is not 
 there, or the description is so vague as to be useless 
 where it is not misleading. Sometimes he may find 
 a sort of reply, but if he inquires into the reasons 
 the author has for his opinion he will only get for 
 proof an " impression." 
 
 If the enquiring practitioner should wish for a 
 line of treatment he will usually be overwhelmed 
 with the multitude of drugs and methods ; but if 
 he again seeks to inquire into the reasons for the 
 recommendation of any one treatment he will 
 discover no detailed and accurate account anywhere 
 — only an " impression." I question if there is a 
 single drug in the whole pharmacopoeia whose 
 effect on the human system in health and disease 
 has ever been carefully studied. So far as I have 
 gone into the question tlio vast majority of these 
 
280 Appendix II. 
 
 drugs are without value, while the really useful 
 drugs have never been so studied as to enable them 
 to be employed with the greatest benefit. Nor must 
 we look to the pharmacological laboratory for the 
 solving of this question, for in my researches, small 
 as they are, I have found that disease modifies the 
 action of remedies in a most marvellous manner, a 
 fact which any one would surmise, but one which is 
 ignored in the use of remedies. 
 
 Another great field has yet to be explored. 
 We all recognise the great advance that has been 
 made in the bacteriological study of disease, and 
 we all realise that a great many obscure diseases 
 are probably microbic in origin, and that the 
 bacteriological investigation of disease is yet in its 
 infancy. The advance in this field will be greatly 
 imperilled unless it goes hand in hand with clinical 
 observation. Not only must the germ producing the 
 disease be recognised but the symptoms it provokes 
 must be ascertained. If this is not done the results 
 of bacteriology will be restricted in two waj^s. It 
 is manifest that it is impossible for the great majorit}^ 
 of patients ever to have the benefit of a bacterio- 
 logical examination. These patients are mostly 
 under the care of general practitioners, and the 
 opportunity for such examination is rare. It is, 
 however, certain that the symptoms provoked bj^ 
 each microbe differ, and the physician, by noting 
 the sj'mptoms in cases verified by bacteriological 
 examination, will by and bye be able to recognise 
 the specific disease from clinical signs. We already 
 recognise a great man}^ of these germs produced 
 diseases, as scarlet fever, measles, influenza, typhoid 
 fever. The characteristic reaction to the toxins 
 
Appe7idix II. 281 
 
 produced by a microbe is well illustrated by ^Marris's 
 discover}^ in typhoid fever, and he has shown that 
 the reaction of the toxin in the heart modifies its 
 action in a striking manner, rendering it less liable 
 to stimulation. Thus effort, or the administration 
 of atropin, which in normal hearts increases the rate 
 of the heart, does not increase the rate, or only very 
 slightly, in typhoid fever. So far tj^phoid fever is the 
 only infectious state in which this peculiarity is 
 present, and in case of doubt, by gi^^ng an injection 
 of atropin and noting its effect on the heart, the 
 diagnosis can be made. We all know the difficulty 
 in diagnosing such a disease in its early stage, and 
 the bacteriological test is not alwa3^s available ; and 
 when available it is late before it is effective, and 
 needs special apparatus and specialh^ trained men 
 for its accomplishment. Here any practitioner can 
 apply the test and get the result in half an hour. 
 
 Another most valuable field remains to be 
 explored. A large number of people suffer from 
 infirmities which limit their activities, yet they may 
 live many years. Many are under present conditions 
 unable to earn a livelihood, or in their attempts to 
 do so injure themselves. The suitable employment 
 of people with chronic diseases and of the manage- 
 ment of their daily life has never been studied with 
 that care that the subject needs. All general 
 practitioners have this subject forced upon them, 
 and some have acquired in the course of many years' 
 experience of success and failure, a dim perception 
 of its handling. But no accurate knowledge is to 
 be found anywhere, and here again the man with the 
 opportunity is the only man that can undertake its 
 study. 
 
282 Appendix II. 
 
 We see therefore that these great fields of 
 research need attention — the early stage of disease, 
 the progress of disease, the action of remedies, and 
 the management of the lives of individuals with 
 impaired health. There are many fields unharvested 
 and waiting only for the reaper. The question may 
 be asked, how is one to set about this work ? As I 
 have said, it is of no use for a young man, just 
 qualified, to undertake research work. These 
 scholarships given to encourage research usually 
 end in a waste of time. If a young man wishes to 
 work in a laboratory he may do so in order to acquire 
 a knowledge of methods, but he will never do much 
 to advance medical science until he has acquired 
 experience. It would be better if research in 
 medicine were delayed until the investigator had 
 realised exactly where knowledge was deficient from 
 personal experience. Let him devote some years to 
 the study of disease as manifested in patients ; let 
 him analyse each symptom, subjective and objective;, 
 let him try to understand the mechanism by which 
 each sign and symptom is produced ; let him under- 
 stand its bearing on the efficiency of the organism, 
 taking into consideration all associated phenomena, 
 and how it becomes modified as the disease pursues 
 its course. Simple as these suggestions are, if they 
 are followed, I have no doubt but that the lines to be 
 pursued will become evident to anyone who seriously 
 undertakes to investigate disease. 
 
INDE 
 
INDEX. 
 
 ABDOMINAL 
 
 respiration, 206. 
 
 tumour, 55, 72, 177, 202. 
 
 wall, 10, 33, 52, 71, 267. 
 
 wall, increased sensibility, 63, 199. 
 
 See " Hyperalgesia. 
 
 ADAMS-STOKES 
 
 syndrome, 257. ' 
 
 ADHESIONS 
 
 after operation, 201. 
 peritoneal, 174, 198. 
 
 parietal, 200. 
 
 visceral 202. 
 
 ADHESIVE MEDIASTINITIS 
 
 case, 242. 
 
 AEEATION 
 
 of blood, 211. 
 
 tissues in heart disease, 208. 
 
Index. 285 
 
 AFFECTIONS 
 of anus, 174. 
 bladder, 189. 
 
 cerebro-spinal nerves, 110. 
 circulatory system, 219. 
 digestive organs, 115. 
 female pelvic organs, 193. 
 intestines, 167. 
 kidney, 178. 
 liver, etc., 156. 
 lungs, 204. 
 
 pelvis of kidney, 180. 
 perineum, 174. 
 pleura, 214. 
 stomach, 132. 
 ureter, 180. 
 urinary system, 178. 
 
 AIR-HUNGER, 205. 
 
 AIR-SUCTION 
 
 in stomach, 142. 
 
 ALBUMINURIA, 178, 179, 259. 
 
 ALCOHOLIC 
 
 gastric catarrh, 123. 
 morning sickness, 140. 
 
 AMPHIOXUS, 94. 
 
 ANGINA PECTORIS, 47, 56, 74, 80, 95 (fig.), 124, 231, 236, 
 238 (figs.), 261. 
 cause, 248. 
 
 ANOREXIA, 120. 
 
 ANUS 
 
 affections of, 174. 
 nerve-supply, 116. 
 
286 Index. 
 
 AOKTIC 
 
 dilatation, case, 240. 
 disease, facial aspect, 102. 
 
 APOPLEXY 
 
 pvilmonary, expectoration in, 209. 
 
 APPEARANCE OF PATIENTS. 99. 
 APPENDICITIS, 43, 73, 74, 81, 171. 
 
 APPETITE, 119. 
 perverted, 121. 
 
 AREAS 
 
 of cutaneous hyperalgesia, 65. 
 
 in angina pectoris, 95, 236. 
 dilatation of heart and 
 
 liver, 233. 
 diaphragmatic pleurisy, 216. 
 gall-stone colic, 157, 200. 
 peritonitis, 198. 
 renal colic, 181, 188. 
 eruption in herpes zoster, 98. 
 muscular hyperalgesia, 68. 
 pain in angina pectoris, 95. 
 bowels, 117, 169. 
 diaphragmatic pleurisy, 216. 
 digestive tube, 117 
 gastric ulcer, 150, 152, 154. 
 intestines, 117, 169. 
 oesophagus, 117. 
 pleurisy, diaphragmatic, 216. 
 renal calculus, 187. 
 stomach, 117. 
 over vertebral spines, 69. 
 
 ARTERIOSCLEROSIS, 244. 
 
 ASTHMA, 80, 207. 
 cardiac, 80, 229. 
 
Index. 28" 
 
 ATHEROMA 
 
 of coronary arteries, 243, 245, 247, 248. 
 
 ATONIC DYSPEPSIA, 145. 
 
 AUTONOMIC 
 
 nerves, diagram, 27. 
 nervous system, 25. 
 
 B 
 
 BACKACHE, 178. 
 
 BILE-DUCTS, 156. 
 in fseces, 176. 
 
 BISMUTH 
 
 in intestines, 168. 
 
 BLADDER 
 
 affections of, 189. 
 calculus in, 76, 185, 188. 
 development, 189. 
 functional symptoms, 191. 
 irritation of, 190. 
 nerve-supply, 189. 
 over-distension, 189. 
 pain iui 118. 
 secretion, 191. 
 structural symptoms, 192. 
 
 BLISTER 
 
 on epigastrium, 153, 268. 
 
 BLOOD 
 
 aeration of, 211. 
 in f feces, 176. 
 
 heart disease, 208. 
 
 BODY WALL 
 
 sensitive tissues, 33. 
 
 See " Abdominal." 
 
288 Index. 
 
 BOULIMIA, 121. 
 BOWELS. See " Intestines.' 
 
 BRAIN MEMBRANES 
 
 sensitiveness, 110. 
 
 BREATHERS 
 
 mouth-, 127. 
 
 BREATHLESSNESS, 227. 
 
 BRONCHITIS 
 
 expectoration in, 213. 
 
 CALCULUS 
 
 in bladder, 76, 184, 188. 
 renal. See " Colic, Renal." 
 ureteral, site of, 182, 184. 
 
 CAMPBELL 
 
 on herpes zoster, 60, 67, 128. 
 
 CANCER 
 
 of liver, 165. 
 
 stomach, 70, 143. 
 
 CARDIAC 
 
 asthma, 80, 229. 
 
 condition, facial aspect, 102. 
 
 murmur, 108. 
 
 reflexes, 81. 
 
 valvular imperfection, 222, 237, 252. 
 
 CASE REPORTED 
 
 of adhesive mediastinitis, 242. 
 
 angina pectoris, 237, 239, 242, 244, 245, 247, 248, 253. 
 aortic dilatation, 240. 
 appendicitis, 42, 74. 
 atheroma, 243, 245, 247, 248. 
 
Index. 289 
 
 CASE REPORTED— roniwwfrf. 
 
 of blood-pressure, high, 240, 2-45. 
 
 calculus, renal, 44, 76, 184, 186, 188. 
 
 cardiac rupture, 248. 
 
 cardiac valvular disease, 237, 253. 
 
 cholecystotomy (Lennauder), 51. 
 
 colic, gall-stone, 90. 
 
 renal. See " Calculus." 
 
 dilatation of aorta, 239. 
 
 enlargement of heart, 242, 245. 
 
 fibrous myocarditis, 242. 
 
 gall-stone colic, 90. 
 
 gastric ulcer, 91, 148, 149, 151, 153, 155, 253. 
 
 high blood pressure, 239. 
 
 Lennander's cholecystotomy, 51. 
 
 mediastinitis, adhesive, 242. 
 
 nodal, rhythm of heart, 244. 
 
 operation for umbilical fistula without anajsthetic, 39. 
 
 perforation of gastric ulcer, 148, 149, 151, 199. 
 
 peritonitis, 199. 
 
 pyloric stenosis, 202. 
 
 renal calculus. 
 
 colic. See " Calculus." 
 rupture of heart, 248. 
 stomach affections, series, 136. 
 ulcer, gastric. See " Gastric." 
 
 CEREBRO-SPINAL 
 
 nerves, affections of, 109. 
 
 pain in, 28. 
 nervous system, 25 
 
 CHEYNE-STOKES 
 
 respiration, 228 
 
 CHLOROFORM 
 
 effects of, in joint disease. 111. 
 parturition, 175. 
 on contracted muscle, 74. 
 
 CHLOROSIS 
 
 facial usp(;ct, 1()L'. 
 
290 Index. 
 
 CHOLANGITIS, 162. 
 
 CHOLECYSTOTOMY 
 
 pain in, 51. 
 
 CHOLERA 
 
 stools, 177. 
 
 CIRCULATION 
 
 affections of, 219. 
 condition of, 106. 
 
 CIRRHOSIS 
 
 of liver, 165. 
 
 atrophic, 166. 
 
 COLD 
 
 in stomach, sensation of, 9. 
 
 COLIC 
 
 appendicular. 172. 
 
 gall-stone, 63, 90, 134, 137, 157. 
 
 intestinal, 39. 
 
 -like pains, 118. 
 
 renal, 44, 46, 58, 74, 75, 92, 119, 180, 183, 185, 187, 188. 
 
 COMPLEXION, 102, 164, 208. 
 
 CONDITION 
 
 of organs, 106. 
 
 patient, general, 105. 
 
 CONSCIOUSNESS 
 
 of heart's action, 225, 
 
 CONSTRICTION 
 
 of stomach, 145. 
 
 CONTRACTION 
 
 of heart- muscle, 249. 
 muscles, 72, 88, 92. 
 non-striped muscle, 181, 262, 263. 
 stomach, hourglass, 145. 
 uterus, 194. 
 
Index. 291 
 
 COOK 
 
 on swallowing fluids, 129. 
 
 CORD 
 
 spinal, irritable foci in, 89, 92. 
 
 COUGH, 209. 
 
 in extra-systole of heart, 210. 
 
 CRAMP 
 
 of muscles, 112. 
 stomach, 137, 160. 
 
 CREMASTER 
 
 muscle, 181. 
 
 CREPITATIONS 
 
 at base of lung, 229. 
 
 CURES 
 
 value of, 267. 
 
 CUSHNY 
 
 experiments on mammalian heart, 11. 
 
 CUTANEOUS 
 
 hyperalgesia, 64, 87 (fig.), 90. 
 areas, 67. 
 
 (figs.) 95, 158, 183, 187, 216, 231, 238. 
 reflex, 86, 139. 
 segments, 67. 
 
 DEEP PAIN, 58. 
 
 DEVELOPMENT 
 
 of appendix, 173 
 l)ladder, 188. 
 liver, etc., 156. 
 nervous system, 19, 96. 
 
292 Index. 
 
 DIAGNOSIS 
 
 differential, 113. 
 
 of intestinal affections, 167. 
 
 stomach affections, 145. 
 treatment as a factor in, 265. 
 
 DIAPHRAGMATIC PLEURISY, 216 (tig.), 217. 
 
 DIARRHOEA 
 
 facial aspect, 103. 
 
 DIARRHCEIC 
 
 stools, 177. 
 
 DIETS, 146. 
 
 DIGESTIVE 
 
 organs, affections of, 115. 
 system, inquiry into, 106. 
 tract, areas of pain, 117 (fig.). 
 
 functional symptoms, 176. 
 
 nerve-supply, 115. 
 
 sensory symptoms, 116. 
 
 DILATATION 
 
 of aorta, case, 239. 
 
 heart and liver, 233, 234 (fig.). 
 stomach, 107, 143, 147. 
 
 DIRECT PAIN, 84. 
 
 DISEASE, 17. 
 
 Graves', facial aspect, 103. 
 
 of organs. See under Organs affected. 
 
 DISTRIBUTION 
 
 of herpes zoster, 97 (fig.), 98. 
 thoracic nerves, 94 (fig.), 96. 
 
 DUCTS 
 
 bile-, 156 
 
Index 293 
 
 DUSKI>^ESS 
 
 of skill, 102, 211. 
 
 DYSPEPSIA, 159. 
 atonic, 145. 
 
 DYSPXCEA, 79, 207. 
 
 EAR 
 
 herpes zoster on, 128. 
 
 EMPHYSEMA 
 liver ill, 166. 
 
 ENDOMETRITIS, 91, 92. 
 
 ENEMA 
 
 pain of, 39. 
 
 ENGELMANN 
 
 experiment on frog's heart, 11. 
 
 EPIGASTRIC 
 
 blister, 153, 268. 
 pain, 136. 
 reflex, 139. 
 symptoms. 135. 
 
 EPILEPSY, 257. 
 
 EUSTACHIAN TUBE 
 
 sensation in, 126. 
 
 EXAMINATION 
 of patient, 99. 
 
 EXHAUSTION 
 
 effect on symptoms, 255. 
 of lieart, 220, 225, 228, 262. 
 
294 Index, 
 
 EXPECTORATION, 212. 
 
 EXTRA-PERITONEAL TISSUE 
 
 sensitiveness of, 34, 66. 
 
 EXTRA-SYSTOLE 
 
 of heart, 136, 224, 227, 233. 
 cough in, 210. 
 
 FACIAL ASPECT 
 
 in. liver aSections, 164. 
 of patients, 99. 
 
 FiECES 
 
 examination of, 176. 
 • impacted, 171. 
 
 FAUCES 
 
 affections of, 123. 
 in swallowing, 128. 
 nerve supplj^, 116. 
 
 FEBRILE STATES 
 tongue in, 127. 
 
 FEMALE 
 
 pelvic organs, 193. 
 
 FEVER 
 
 in gall-stone disease, 162. 
 
 FISSURE 
 
 of arus, 175. 
 
 FLATULENCE, 141. 
 
 FOCI 
 
 in spinal cord, irritable, 89, 92, 133. 
 
Index, 295 
 
 FOOD 
 
 pain after, 134, 138. 
 retention in stomach, 144. 
 
 FUNCTIONAL SYMPTOMS, 20. 
 of bladder, 191. 
 
 digestive tube, 176. 
 
 gall-stone disease, 161. 
 
 kidney, 178. 
 
 liver, 164. 
 
 respiratory affections, 211. 
 
 stomach, 143. 
 
 FUNCTIONS 
 
 of stomach, 132. 
 heart muscle, 249. 
 
 FURRED TONGUE, 126. 
 
 GALL-BLADDER, 156. 
 sensation in, 50. 
 
 GALL-STONE 
 
 colic, 63, 90, 134, 137, 157 
 pain, 47, 48, 101, 119, 157. 
 in shoulder, 159. 
 
 GALL-STONE DISEASE, 147. 
 facial aspect, 102. 
 fever in, 162. 
 functional symptoms, 161. 
 gastric symptoms, 137, 159. 
 reflex symptoms, 157, 267. 
 structural symptoms, 161. 
 taken for pleurisy, 160. 
 
 GASTRIC 
 
 catarrh of alcoholics, 123. 
 
 symptoms in gall-stone disease, 137 159. 
 
296 Index, 
 
 Gk^T^lC—contwiml 
 
 ulcer, 73, 75, 91, 133, 145, 253, 267. 
 perforation, 148, 149, 151, 199. 
 paiii ill, 5, 91, 138, 147. 
 
 site of pain, 147, 150 (fig,), 152 (fig.), 154 (fig.), 199, 
 vomitinjz in, 140. 
 
 GASTKITIS, 133, 140, 160. 
 
 GENEEAL CONDITION 
 of patient, 104. 
 
 GENITO-CRURAL 
 
 nerve, 184. 
 
 GEOPHAGY, 121 
 GOOSE-SKIN, 82. 
 
 GRAVES' DISEASE 
 
 facial aspect, 103. 
 
 H 
 
 HAEMORRHOIDS, 92, 174. 
 
 HALDANE 
 
 on air-hunger, 205. 
 
 respiratory trouble, 208. 
 
 HALLER 
 
 on insensitiveness of viscera, 33. 
 
 HARVEY 
 
 on insensitiveness of heart, 33. 
 
 HAST 
 
 on Lennander's observations, 50. 
 
 HEAD 
 
 on cutaneous hyperalgesia, 64. 
 herpes zoster, 60, 67, 128. 
 muscle pain, 68. 
 
Index. 297 
 
 HEADACHE, 109. 
 
 HEALTH 
 
 definition, etc., 17. 
 
 HEART 
 
 action, consciousness of, 225. 
 affections, 219. 
 
 area of pain, 69 (fig.), 
 -block, 136, 257. 
 dilatation, 233, 234 (fig.), 
 -disease, respiration in, 208. 
 enlargement, 242. 
 exhaustion, 221, 225, 228, 262. 
 extra-systole, 136, 210, 224, 227, 233. 
 failure, 220, 265. 
 
 facial aspect, 102. 
 
 enlartied liver, 163, 165. 
 frog's, Engelmann on, 11. 
 inquiry into condition, 106. 
 irregularities, 11, 108, 257. 
 mammalian, Cushny on, 11. 
 -muscle, 248. 
 nodal rhythm, 163. 
 reflexes, 81. 
 rupture, 248. 
 spasm, 249. 
 treatment, 265. 
 valvulaf imperfection, 222, 237, 253. 
 
 HEART-BURN, 129, 135, 141. 
 HEPATOPTOSIS, 166. 
 
 HERNIA 
 
 pain in radical cure, 35. 
 strangulated, 170. 
 
 HERPES ZOSTER. 60, 67, 97 (fig.). 98. 
 iu tonsilitis. 128. 
 
298 Index. 
 
 HIRST 
 
 on swallowino- fluids, 129. 
 
 HILTON 
 
 on joint affections, 111 
 
 HIP-JOINT DISEASE 
 pain in, 111 
 
 HUNGER, 122. 
 Air-, 205. 
 
 HYDATIDS 
 
 of liver, 165. 
 
 HYPERALGESIA, 63. 
 
 cutaneous, 64, 87 (fig.), 89. 
 areas of. 67. 
 
 (figs.) 95, 158, 183, 187, 216, 234, 238. 
 in affections of respiration, 231. 
 
 stomach, 138, 200. 
 angma pectoris, 236, 238 (figs.), 
 obstruction of bowel, 170. 
 peritonitis, 199. 
 muscular, 34, 65, 87 (fig.), 90. 
 areas of, 68. 
 effect of exercise, 66. 
 of extra-peritoneal tissue, 66. 
 mammae, 66. 
 testicle, 66. 
 
 HYPERCHLORYDRIA, 138, 141, 
 
 HYPOTHESES 
 
 law of parsimony of, 12. 
 value of, 6. 
 
 HYSTERIA, 255. 
 
Index, 299 
 
 I 
 
 ICE 
 
 pain of swallowing, 136. 
 
 INDIGESTION, 134. 
 
 INFANTILE DIARRHCEA 
 stools, 177. 
 
 INSEN8ITIVENESS 
 
 of viscera, 33, 193, 198, 2U. 
 
 See " Sensibility or Sensitiveness." 
 
 INSURANCE 
 
 examination for, 259. 
 
 INTERCOSTAL MUSCLES, 215, 243. 
 
 INTESTINES 
 
 affections of, 167. 
 obstruction, 169, 186. 
 pain in, 117 (figr.), 118. 
 peristalsis of, 40, 118, 168, 169. 
 
 IRREGULARITIES 
 
 of heart, 11, 108, 257. 
 
 IRRITABLE FOCI 
 
 in spinal cord, 89, 92, 133. 
 
 JAUNDICE, 103, 161, 164. 
 
 JOINT 
 
 inflamed, 71. 
 
 knee-. 111. 
 
 nerve-supplv, 112. 
 
 shoulder-, 71, 111. 
 
 stiffness, 112. 
 
 under chloroform. 111. 
 
300 Index. 
 
 K 
 
 KIDNEY 
 
 affections of, 178. 
 -disease, 13, 22. 
 movable, 55, 179. 
 -pelvis and ureter, 180. 
 
 KNEE 
 
 -joint, pain from. 111. 
 in hip-joint disease, 111. 
 
 LABOUR 
 
 uterus during, 194. 
 
 LANGLEY 
 
 on dilatation of pupil, 83. 
 
 's diagram of autonomic nerves, 27, 115. 
 
 LARYNGEAL NERVE, 209. 
 LARYNX, 209. 
 
 LENNANDER'S OBSERVATIONS 
 
 on pain, 49. 
 
 LIVER, 156. 
 
 area of pain in affections of, 69 (fig.), 
 enlarged, 2, 161, 164, 165. 
 
 in heart failure, 163, 165, 233, 23-1 (fia.l 
 facial aspect in affections of, 102, 164. 
 symptoms, functional, 164. 
 reflex, 163. 
 structural, 165. 
 
Index. 30 1 
 
 LOCALISATION 
 of lesion, 93. 
 
 pain, 28, 41, 55, 59, 88, 101, 136, US, 168, 170. 
 renal calculus, 183. 
 
 LUMBAGO, 92, 113. 
 
 LUNG 
 
 affection of, 204. 
 condition, inquiry into, 106. 
 crepitations at base, 229. 
 stasis or oedema, 230. 
 
 M 
 
 MALARIAL CACHEXIA 
 
 facial aspect, 102. 
 
 MALIGNANT DISEASE 
 
 facial aspect, 102. 
 
 of stomach, 70, 142, 147, 252. 
 
 MALINGERING, 255. 
 
 MAMMiE 
 
 hyperalgesia of, 66. 
 
 MAYLARD 
 
 on peritoneal adhesions, 201. 
 
 McBURNEY'S 
 
 point, 68. 
 
 MEDIASTINITIS 
 adhesive, 242. 
 
 MELTZER 
 
 on Lcuuiinder's observations, 50. 
 
 MEMBRANES 
 
 oi brain, scnsitivciu'ss of, 110. 
 
302 Index. 
 
 MEEYCISM, 141. 
 
 MICTURITION, 106, 175, 179, 190, 191. 
 
 MISCARRIAGE, 195. 
 
 MORNING SICKNESS 
 alcoholic, 140. 
 
 MOTOR 
 
 nerves, stimulation of, 72, 92. 
 symptoms, 110. 
 
 MOUTH 
 
 afEections of, 123. 
 -breathers, 127. 
 nerve-supply, 116. 
 
 MUCUS 
 
 in fseces, 176. 
 
 MUSCLES 
 
 abdominal, bard contracted, 10, 71. 
 
 simulating tumour, 72, 202. 
 contraction of, 73, 88, 92. 
 cremaster, 181. 
 
 effects of stimulation of motor nerves, 72. 
 heart-, 249. 
 
 in joint affections. 111. 
 mtercostal, 215, 243. 
 levator palati, 127. 
 non-striped, 181, 262, 263. 
 of respiration, 206. 
 rectus, 135, 139. 
 
 MUSCULAR 
 
 cramp, 112. 
 
 hyperalgesia, 34, 65, 87 (fig.), 90. 
 
 areas of, 68. 
 
 effect of exercise, 66. 
 layer of body wall, sensitiveness of, 34, 51, 199. 
 rheumatism,"^ 113, 215, 243. 
 
Index. .'JO.'i 
 
 N 
 
 NAUHEIM TREATMENT, 265. 
 
 NAUSEA, 122. 
 
 NERVES 
 
 cerebro-spinal, affections of, 109. 
 
 pain in, 28. 
 
 to digestive tract, 115. 
 chorda tvmpani, 116. 
 cranial, fifth, 116, 123. 
 genito-crural, 184. 
 glosso-pharyngeal, 116. 
 lar\nigeal, 209. 
 
 motor, stimulation of, 72, 92. 
 of taste, 116. 
 olfactory, 116. 
 
 phrenic, 48, 157, 216 (fig.), 218. 
 sensory, 4. 
 
 stimulation of, 72, 92, 268. 
 sympathetic to stomach, 134. 
 thoracic, 94 (fig.), 96, 135. 
 vagus, 134, 157, 246. 
 
 NERVE-SUPPLY 
 of anus, 174. 
 bladder, 189. 
 digestive tract, 115. 
 gall-bladder, 156. 
 joints, etc., 112. 
 liver, etc., 156. 
 ovaries, 195. 
 perineum, 175. 
 pleura, 215, 
 
 respiratory muscles, 206. 
 stomach, 134. 
 ureter, 180. 
 
304 Index. 
 
 NERVOUS SYSTEM 
 
 autonomic, 25, 27 (fig.)- 
 cerebro-spiiial, 25. 
 constitution, 25. 
 development, 19. 
 
 NEURALGIA 
 
 trigeminal, 124, 
 
 NEURASTHENIA. See '^ Neurotic." 
 NEURITIS, 48, 114, 159. 
 
 NEUROTIC 
 
 temperament, etc., 104, 142, 180, 226, 252, 253. 
 
 NODAL RHYTHM 
 
 of heart, 163. 
 
 NOMENCLATURE, 13. 
 
 OBSERVATION 
 accuracy of, 2. 
 method of. 6. 
 
 OBSTRUCTION 
 
 of intestines, 169, 186. 
 pyloric, 140, 144, 202. 
 
 (EDEMA 
 
 pulmonary, 229. 
 
 (ESOPHAGEAL PAIN, 61, 116, 11{<. 
 area of, 117. 
 
 OESOPHAGUS, 128. 
 nerve-supply, 116. 
 stricture of, 130. 
 
Index. 305 
 
 OPERATION 
 
 adhesions after, 201. 
 
 ou ovary, 107. 
 
 for appendicitis, paiji in, 4.3. 
 
 gall-stone, pain in, 50. 
 
 umbilical fistula, pain in, 40. 
 
 ORAL ORIFICE 
 
 nerve-supply, 116. 
 
 ORGANIC REFLEXES, 78, 87 (fig.), 88, 247. 
 
 ORGANS 
 
 digestive, affections of, 115. 
 female pelvic, affections of, 193. 
 review of, 105. 
 
 ORTHOPNCEA, 227. 
 
 OVARIES, 195. 
 
 OVARIAN TUMOURS, 203. 
 
 OVARY 
 
 operation on, 107. 
 
 PAIN 
 
 after food, 133, 137. 
 
 colic-like, 118. 
 deep, 58. 
 definition of, 24. 
 differential diagnosis, 113. 
 direct, 84. 
 in abdominal tumour, 55. 
 
 angina pectoris, 47, 56, 95, 236, 238. 
 
 appendicitis, 43. 
 
 cerebro-spinal nerves, 28. 
 
 digestive tract, 117 (fig.). 
 
 gall-stone disease, 47, 48, 157. 
 
306 Index. 
 
 PAIN — continued. 
 
 ill gastric ulcer, 5, 147. See " Gastric Ulcer." 
 
 hip-joint disease, 111. 
 
 knee-joint, 111. 
 
 movable kidney, 55. 
 
 muscles, 68. 
 
 CESophagus, 61, 116, 118, 128. 
 
 ovarian trouble, 195. 
 
 peristalsis of intestine, 39, 118, 169. 
 
 pleurisy, 215, 216 (fig.). 
 
 pneumonia, 217. 
 
 radical cure of hernia, 35. 
 
 renal colic, 44, 46, 58. Sec " Colic, Kenal." 
 
 shoulder, 101, 111, 159, 217. 
 
 stomach, 69, 118, 135, 138, 140. 
 
 testicle, 36. 
 
 tunica vaginalis, 37. 
 
 ureter, 182, 184. 
 
 uterine labour, 194. 
 
 vagma, 196. 
 
 vertebral spines, 69 (fig.). 
 
 visceral disease, 41, 114. 
 localisation of, 29, 41, 55, 59, 85, 101, 150 (fig.), 168. 
 radiation of, 29, 46. 
 referred, 46, 84. 
 sensitiveness of tissues to, 26. 
 somatic, 8, 46. 
 splanchnic, 8, 46, 54. 
 visceral, 4, 8, 26, 32, 46. 
 
 artificial production, 38. 
 mechanism, 41, 85, 87 (fig.). 
 radiation, 47. 
 
 PALATAL MUSCLES, 127. 
 
 PALLOR 
 
 of face, 102. 
 
 PALPITATION, 226. 
 
 PARSIMONY OF HYPOTHESES 
 law of, 12. 
 
Index. :i07 
 
 PAKTURITION 
 
 perineal reflex, 175. 
 
 PATIENT 
 
 appearance, 99. 
 examination, 99. 
 facial aspect, 102. 
 general condition, 104. 
 sensations, 100, 204. 
 
 PELVIC ORGANS 
 female, 193. 
 
 PELVIS OF KIDNEY 
 
 affections of, 180. 
 
 PERFORATION 
 
 of stomach, 148, 149, 150, 199. 
 
 PERINEUM, 175. 
 
 PERISTALSIS 
 
 of intestine, 39, 118, 168, 169. 
 oesophagus, 130. 
 
 PERITONEAL ADHESIONS, 174, 198. 
 parietal^ 200. 
 visceral, 202. 
 
 PERITONEUM 
 
 sensitiveness of, 35, 50, 198. 
 sensitive layer outside, 34, 66. 
 
 PERITONITIS, 35, 75, 171, 198. 
 
 PERITYPHLITIS, 73. 
 
 PERNICIOUS AN^.MIA 
 facial aspect, 102. 
 
 PHRENIC NERVE, 48, 157, 216, 218. 
 
308 Index. 
 
 PILES, 92, 174. 
 PILO-MOTOR REFLEX, 82. 
 
 PLEURA 
 
 aflections of, 204, 214. 
 
 PLEURISY, 215. 
 
 and gall-stone disease, 160. 
 diaphragmatic, area of pain, 216 (fig.). 
 
 PLEURODYNIA, 113. 
 
 PNEUMONIA 
 
 expectoration, 213. 
 facial aspect, 103. 
 pain, 217. 
 stools, 177. 
 
 PREGNANCY 
 
 vomiting in, 196. 
 
 PREGNANT UTERUS, 194. 
 PRIMITIVE VERTEBRATE, 93. 
 PROGNOSIS, 258. 
 
 PULMONARY 
 
 apoplexy, expectoration, 213. 
 condition, facial aspect, 102, 211. 
 stasis, 229. 
 
 PULSE 
 
 irregular, 224. 
 
 PYLORIC STENOSIS, 140, 144, 202. 
 PYROSIS, 140. 
 
Index. 309 
 
 R 
 
 KADIATION 
 
 of pain, 29, 46. 
 
 EAMSTROM 
 
 on histology of abdominal wall, 35, 139, 200. 
 
 RECTUM 
 
 area of pain in affections of, 69 (fig.), 
 ulceration of, 175. 
 
 RECTUS MUSCLE, 135, 139. 
 
 REFERRED PAIN, 46, 84. 
 
 REFLEX 
 
 cardiac, 81. 
 
 exaggerated, 92. 
 
 organic, 78, 87 (fig.), 88, 247. 
 
 perineal, 175. 
 
 pilo-niotor, 82. 
 
 purpose of, 19. 
 
 secretory, 80. 
 
 skin or superficial, 85, 139. 
 
 symptoms, 17, 84. 
 
 vaso-motor, 82. 
 
 viscero-motor, 10, 42, 71, 87 (fig.), 88, 139, 230, 24.3- 
 
 viscero-sensory, 42, 230, 233, 236. 
 
 REFLEXES 
 
 in angina pectoris, 232. 
 gall-.stone disease, 157. 
 kidney affections, 178. 
 liver affections, 163. 
 parturition, 175. 
 respiratory affections, 209. 
 stomach affections, 137. 
 visceral disease, 49. 
 
 REGURGITATION 
 
 from stomach, 135, 138, 141. 
 
310 Inde^. 
 
 EEMOTE EFFECTS 
 of lesion, 254. 
 
 RENAL 
 
 calculus 
 colic 
 
 See " Colic, Renal." 
 
 RESPIRATION, 206. 
 
 Cheyne-Stokes, 228. 
 with failing heart, 229. 
 
 RETENTION 
 
 of food in stomach, 144. 
 urine, 189. 
 
 RHEUMATISM 
 
 muscular, 113, 215, 243. 
 
 ROSS 
 
 on visceral pain, 8, 46. 
 
 RUPTURE 
 
 of heart, 248. 
 
 SALIVA 
 
 flow in angina pectoris, 247. 
 
 SCHLESINGER 
 
 on swallowing fluids, 129. 
 
 SCYBALiE 
 
 in intestine, 171. 
 
 SECRETIONS 
 
 of bladder, 191. 
 stomach, 143. 
 
 SECRETORY REFLEXES, 80. 
 
Index. 3 
 
 SEGMENTS 
 
 of cutaneous surface, 67. 
 
 SENSATION 
 
 of cold ill stomach, 9. 
 
 SENSATIONS 
 
 in affections of lungs and pleura, 204. 
 
 viscera, 9. 
 of patient, 100. 
 
 SENSIBILITY OR SENSITIVENESS 
 
 of brain membranes, 110. 
 
 extra-peritoneal connective tissue, 34, 66. 
 female pelvic organs, 193. 
 membranes of brain, 110. 
 synovial, 112. 
 muscular layer of body-wall, 34, 63. 
 peritoneum, 35, 198. 
 pleura, 214. 
 
 synovial membrane, 112. 
 tissues, 26, 33, 63. 
 
 SENSORY 
 nerves, 2. 
 symptoms, 110. 
 
 in digestive tract, 116. 
 
 SHERRINGTON, PROFESSOR 
 
 on areas of cutaneous nerve supply, 67. 
 muscular response to stimulation, 72. 
 radiation of pain, 29. 
 stimulation of nerves, 76, 83, 268. 
 visceral nerves, 10. 
 
 SHOULDER-JOINT, 71. 113. 
 
 pain, 101, 159, 216 (fig.), 217. 
 
 SICKNESS 
 
 morning, alcoholic, 140. 
 
 SITE OF PAIN. See " Area," and " Localisation." 
 
312 Index, 
 
 SKIN 
 
 duskiuess, 102, 211. 
 goose-, 82. 
 -reflex, 85, 139. 
 sensibility, in, 33. 
 
 See " Cutaneous." 
 
 SNEEZING, 210. 
 SOMATIC PAIN, 8, 46. 
 
 SPASM 
 
 in swallowing, 130. 
 of the heart, 249. 
 
 SPINAL 
 
 column disease, 70. 
 
 tenderness, 68. 
 cord, irritable foci, 89, 92. 
 
 SPLANCHNIC PAIN, 8, 46, 54. 
 
 STASIS 
 
 pulmonary, 229. 
 
 STENOSIS 
 
 of cardiac valves, 237. 
 pyloric, 140, 141, 202. 
 
 STIFF-NECK, 113. 
 
 STIFFNESS 
 
 in joints, 112. 
 
 STIMULI 
 
 summation of, as cause of angina pectoris, 248. 
 
 STOMACH 
 
 aiTectious of, 131. 
 
 areas of pain, 69 (fig.), 117 (fig.), 118, 136. 
 cold in, sensation, 9. 
 constriction of, 145. 
 
Index. 313 
 
 STOMACH— con^inwerf. 
 
 contents in oesophagus, 128, 135, 138, 141. 
 
 cramp, 13-1, 160. 
 
 derangement, 22, 132. 
 
 diagnosis, 145. 
 
 dilatation of, 107, 143, 147. 
 
 functions, 132. 
 
 functional symptoms, 143. 
 
 hyperalgesia from, 138. 
 
 malignant disease, 70, 143, 147, 252. 
 
 nerve suppW, 134. 
 
 pain, areas, "69 (fig.), 117 (fig.), 118, 136. 
 
 pain with gall-stone colic, 90. 
 
 perforation, 148, 149, 151. 
 
 peristalsis, 135, 138, 141. 
 
 pyloric stenosis, 141, 144, 202. 
 
 regurgitation from, 129, 135, 138, 141. 
 
 retention of food, 144. 
 
 secretion, 143. 
 
 stenosis, 140, 144, 202. 
 
 treatment, 146, 266. 
 
 tumour, 145, 
 
 ulcer. See " Gastric Ulcer." 
 
 STONE 
 
 in bladder 
 kidney 
 See " Calculus," 
 
 STOOLS • 
 
 character of, 176. 
 
 STKANGULATED HERNIA, 170. 
 
 STRICTURE 
 
 of oesophagus, 130. 
 
 STRUCTURAL SYMPTOMS, 21, 
 of bladder, 192. 
 
 digestive tube, 177. 
 pall-stone disease, 161. 
 kidneys, 179. 
 
314 Index. 
 
 STRUCTURAL SYMPTOMS— cowftwwetZ. 
 of liver afiections, 165. 
 
 respiratory affections, 213. 
 stomach affections, 145. 
 
 SUFFOCATION 
 
 sense in heart affections, 226. 
 
 SUPERFICIAL REFLEX, 86 (fig.), 139. 
 
 SWALLOWING, 127. 
 
 hot and cold fluids, 129. 
 
 ice, pain in, 135. 
 
 in angina pectoris, 124. 
 
 painful, 125. 
 
 spasm in, 130. 
 
 SYMPATHETIC NERVES. See " Autonomic." 
 to stomach, 134. 
 
 SYMPTOMS 
 
 bearing on prognosis, 258. 
 treatment, 262. 
 functional, 20. See " Functional." 
 motor, 110. 
 of affections of bladder, 189. 
 
 cerebro-spinal nerves, 109. 
 
 heart, 222. 
 
 intestines, 167. 
 
 liver, gall-bladder and ducts, 156. 
 
 limgs and pleura, 209. 
 
 peritoneum, 199. 
 
 stomach, 131. 
 
 urinary system, 178. 
 peritoneal adhesions, parietal, 200. 
 visceral, 202. 
 reflex, 17, 84. 
 relation of, 1, 251, 256. 
 relative importance of, 21. 
 sensory, 110. 
 
 in digestive tract, 116. 
 structural. See " Structural." 
 value of, 251. 
 
Index. 
 
 SYNOVIAL MEMBRANE 
 sensitiveness of, 112. 
 
 SYSTEM, NERVOUS 
 constitution of, 25. 
 development of, 19. 
 
 T 
 
 TACHYCARDIA, 163, 226, 233. 
 
 TEETH 
 
 false, inflammation from, 125. 
 
 TEMPERAMENTS, 104. 
 
 neurotic, 104, 142, 226, 252. 
 
 TENDER 
 
 ovary, 195, 
 vertebrae, 68. 
 
 TESTICULAR PAIN, 36, 66. 
 
 in renal colic, 46, 101, 181, 184. 
 
 THORACIC NERVES 
 
 distribution, 94 (fig.), 96, 135. 
 
 TIC DOULOUREUX, 124. 
 
 TONGUE, 126. 
 
 TONSILITIS, 128. 
 
 TONSILS 
 
 inflamed, 125. 
 
 in svvallowuig, 127. 
 
 TOOTHACHE, 30, 123, 261. 
 
316 Index. 
 
 TREATMENT 
 
 as factor iu diagnosis, 265. 
 bearing on symptoms on, 262. 
 of affections of heart, 265. 
 
 stomach, 146, 267. 
 
 TRIGEMINAL NEURALGIA, 124. 
 
 TUBERCULOUS ULCER 
 of colon, 75. 
 
 TUMOUR 
 
 abdominal, 55, 72, 177, 202. 
 in stomach, 145. 
 ovarian, 203. 
 
 TUNICA VAGINALIS, 38. 
 
 TYPHOID FEVER 
 
 facial aspect, 103. 
 stools, 177. 
 
 U 
 
 ULCER 
 
 gastric. See '* Gastric." 
 tubercular, of colon, 75. 
 
 ULCERATION 
 
 of pelvis of kidney, 181. 
 rectum, 175. 
 ureter, 181. 
 
 UMBILICAL FISTULA 
 
 pain in operation for, 39. 
 
 URETHRAL CARUNCLE, 196. 
 
 URETER 
 
 affections of, 180. 
 nerve-supply, 180. 
 peristalsis, 182, 184. 
 site of stone in, 182, 184. 
 
Index. 317 
 
 UEINAEY SYSTEM 
 
 affections of, 179. 
 inquiry into, 106. 
 
 UKINE 
 
 albumen in, 178, 179, 261. 
 
 retention of, 189. 
 
 secretion, in angina pectoris, 247. 
 
 UTERUS, 194. 
 
 areas of pain in affections of, 69 (fig.), 
 paiia in, 119, 193. 
 
 V 
 
 VAGINA, 196. 
 
 VAGUS NERVE, 134, 157, 246. 
 
 VALUE 
 
 of symptoms, 251. 
 
 VALVULAR IMPERFECTION 
 
 of heart, 222, 237, 252. 
 
 VASOMOTOR REFLEXES, 82. 
 
 VERTEBRAE 
 
 diseased, 70. 
 tender, 68. 
 
 VERTEBRATE ANIMAL 
 
 primitive, 94 (fig.). 
 
 VISCERA 
 
 hollow, pain in, 119. 
 insensitiveness of, 33. 
 sensation in, 8. 
 
318 Index. 
 
 VISCERAL 
 
 disease, cutaneous hyperalgesia, 64. 
 pain in, 41, 114. 
 reflex in, 48. 
 lesion, localisation of, 93. 
 pain, 26, 32, 39, 46, 87 (fig.), 118. 
 artificial production, 38. 
 radiation of, 46. 
 
 VISCERO-MOTOR REFLEX, 10, 42, 71, 87 (fig.), 88, 139, 
 230, 243. 
 
 VISCERO-SENSORY REFLEX, 42, 230, 233, 236. 
 
 VOMITING, 78, 140, 164, 196. 
 
 W 
 
 WATER-BRASH, 141. 
 
 WHITLOW 
 
 pain in, 29. 
 
 X-RAYS 
 
 in examination of digestive tract, 144, 168, 
 
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6 EOEBEB'S MEDICAL MONOGRAPHS 
 
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EOEBEE'S MEDICAL MONOGBAPHS 7 
 
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8 HOEBEB'S MEDICAL MONOGBAPHS 
 
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HOEBEB'S MEDICAL MONOGBAPES 9 
 
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10 HOEBEB'S MEDICAL MONOGRAPHS 
 
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HOEBER'S MEDICAL MONOGEAPHS 11 
 
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12 HOEBEE'S MEDICAL MONOGRAPHS 
 
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EOEBEB'S MEDICAL MONOGEAPES 13 
 
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14 BOEBEB'S MEDICAL ilOXOGBAPHS 
 
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HOEBEB'S MEDICAL MONOGRAPHS 15 
 
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