RC7/
ma
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Columbia Sfrr/ Corf ft-
P. Occip> tnl
THE DATA OBTAINED BY OBSERVATION. 103
of hemianopsia is the loss of the temporal field in one eye and of the
nasal field in the other, this condition being known as lateral homony-
mous hemianopsia. If the temporal portions of both fields are lost,
the defect is known as bitemporal hemianopsia ; binasal hemianopsia,
indicating; a loss in the nasal fields of both eyes. Superior and inferior
hemianopsia are very rare.
It is often possible by studying the changes in the visual fields to locate
quite definitely the seat of the cerebral lesion. By a reference to the
diagram (Fig. 12) it will be at once evident that a lesion of the
h f % R
Diagram showing the course of the optic fibres in the chiasm. (Hirt.)
chiasm would necessarily comprise the crossed fibres of the optic nerve,
and would occasion bitemporal hemianopsia. Such a lesion may be due
to basilar meningitis, periostitis, hyperostitis, fracture of the body of
the sphenoid, distentions of the infundibulum, and of the third ven-
tricle, or to tumors, especially those of the pituitary body, and finally
syphilitic gumma. If due to the latter cause, there may be transient
recurrent attacks of the hemianopsia. Bitemporal hemianopsia is also
an early symptom of acromegalia. The lesion in superior and inferior
hemianopsia is usually in the chiasm also, affecting its superior or in-
ferior portions ; these defects in the fields may, however, be caused by
symmetrical cortical lesions and by optic neuritis. (See Plate I.)
If the lesion affects the outer angle of the chiasm, then monocular
nasal hemianopsia is the result.
Lesions of the Tract and Centres. As shown in Plate I.,
the optic tract after crossing the cms to the hinder part of the optic
thalamus divides into two branches, one going to the thalamus and the
external geniculate bodies and to the anterior quadrigeminal bodies
from which fibres pass into the hinder part of the internal capsule, and
entering the occipital lobe, form the fibres of the optic radiations termi-
nating in the cuneus, the perceptive visual centres ; while the fibres of
the other branch pass to the internal geniculate bodies and the posterior
(juadrigeminal bodies.
A lesion affecting the optic fibres anywhere posterior to the optic
chiasm will produce lateral hemianopsia, so that this symptom of itself
is of little value in localizations. There are, however, certain accessory
symptoms which, when taken in conjunction with it, will often serve to
establish the seat of the lesion in most instances. Tims, in hemian-
opsia from lesions of the optic tract there is an absence of the symptoms
which occur when the cortex is affected — as mind-blindness, word-
104 GENERAL DIAGNOSIS.
blindness, etc. — while other symptoms indicating a basal lesion are apt
to be present, as, for example, implication of the cranial nerves, espe-
cially those supplying the ocular muscles. Lesions of the optic tract
are also frequently associated with a disease of the crus cerebri, so that
hemianesthesia or hemiplegia of the opposite side of the body would
be associated with the hemianopsia. There is, however, a sign which
enables us at once to say definitely whether the lesion be in the optic
tract or not, and this is known as the Wernicke or pupillary inaction
sign. This is elicited as follows : The patient is seated in a darkened
room with one eye blindfolded, and is directed to look straight ahead
into the darkness. The eye being slightly illuminated by an assistant
by means of the diffuse light from a plane mirror, which is reflected
into the eye from a light placed behind the patient's head, the examiner
slowly throws a small beam of concentrated light from a concave mirror
upon the blind half of the retina. If the pupil fails to react, the lesion
is then in the geniculate bodies or in the tract, inasmuch as the failure
in the pupillary activity indicates that the lesion must have involved
the sensory motor arc of the pupil as well as the visual fibres.
Although when present the Wernicke sign is of great value, recent
observations have shown that its absence is not conclusive. Lesions
of the optic tract may be due either to neoplasms or to tubercular or
gummatous meningitis, or more rarely they may be the result of cere-
bral softening and hemorrhage. As yet clinical evidence is too meagre
to permit of a diagnosis of lesions of the primary optic ganglia (pulvi-
nar anterior corpora quadrigemina and external geniculate bodies),
although in lesions of the pulvinar two typical symptoms occur — viz.,
hemianopsia and athetosis — and sometimes hemianesthesia may be
present. In like manner, also, while it is generally believed that
lesions of the optic radiations cause homonymous hemianopsia, it has
not been definitely proven that these fibres have solely to do with
vision.
The hemianopsia is usually thought to depend upon cortical lesions
in the occipital lobe, when it is unaccompanied by any of the accessory
symptoms which have just been detailed. The chief diagnostic symp-
tom of a central lesion, however, is what is designated as negative
vision, " vision nulle," for in these cases the patient has no subjective
sensations of the defect in his visual field. Cortical hemianopsia may
also be incomplete, but a quadrant of the field being lost.
Transitory hemianopsia, or scintillating scotoma, is the occurrence of
symmetrical defects in the field of vision which usually conform to the
hemianopic type, and in which a play of lights frequently appears as a
precursor of an attack of migraine. (See Migraine.)
Visual hallucinations may also be hemianopic in character, and are
due to irritation of the visual memory centre.
Hysterical amblyopia may manifest itself either in complete blindness
or central scotoma, but more commonly as defective central vision with
concentric contraction and reversal of the visual fields.
Paralysis of the Motor Nerves of the Eyeball. Although in the
section which dealt with the diseases of the ocular muscles the vari-
ous forms of ocular deviation and the different varieties of diplopia
THE DATA OBTAINED BY OBSERVATION. 105
which resulted therefrom were mentioned at length, it is necessary to
refer still further to their causes and to point out their connection with
cerebral diseases.
Paralysis of the orbital muscles may be due to orbital lesions or to
those at the base of the brain ; they may indicate pontine lesions, or
they may be originated by causes operating higher up in the cerebrum
above the nuclei. In making the differential diagnosis between central
and peripheral palsies, it must be remembered that those of central
origin are frequently associated with other symptoms which denote
intracranial involvement, while peripheral palsies are generally isolated
and often complete.
Peripheral paralyses of the orbital muscles are generally the
result of either rheumatism or syphilis. When due to the latter
disease they are usually tertiary manifestations, and especially is this
apt to be the case if the third nerve is involved, which seems to be
singularly prone to be attacked by gumma of the base. Paralysis of
the sixth nerve is frequently of rheumatic origin.
Syphilis causes fully one-half the cases of central paralysis, affecting
either the nuclei of the nerves or the neighboring brain structure, the
third and fourth ventricles, or the aqueduct of Sylvius.
Diphtheria usually causes a paralysis of the ciliary muscle ; it may,
however, affect one or more of the external muscles. Diabetes is com-
plicated at times by paralysis of the external rectus. Influenza, herpes
zoster, and whooping-cough are also rare causes of ocular palsies.
Paralysis of the eye muscles is seen in paretic dementia, bulbar paraly-
sis, and in multiple and posterior sclerosis. In locomotor ataxia they
may be transient and appear at an early stage of the disease. Ocular
palsies have also been caused by poisoning by lead, nicotine, sulphuric
acid, carbonic oxide, and tainted meat.
Complete' paralysis of the third nerve causes the following
symptoms : The upper lid droops, the pupil is partially dilated and
immovable, and the power of accommodation is lost. The globe is
slightly protruded and strongly diverged externally by the two unaf-
fected muscles (the external rectus and the superior oblique). In in-
complete paralyse of the third nerve, as well as in paralysis of the fourth
and sixth nerves, the diagnosis is made by a study of the deviations and
by the character of the diplopia, which has been already referred to.
There is a peculiar form of intermitting paralysis of the third nerve,
known as ophthalmoplegic migraine, which occurs in the young and is
associated with headache and at times with vomiting.
Paralysis of the ciliary muscle, or cycloplegia, follows a lesion of the
trunk of the oculomotor nerve or of the anterior part of its nucleus.
It is quite common as a sequel of diphtheria, and occurs, though rarely,
in connection with spinal disease.
Ophthalmoplegia externa and interna refer to paralyses of all or nearly
all of the external and internal muscles. As the lesion in this affec-
tion is central, it is frequently known also as nuclear paralysis. In its
acute form it is due either to an acute inflammatory process in the
nuclei or to hemorrhage, while the chronic depends upon a degenerate
atrophy of the nerve nuclei, similar to that which is seen in progressive
106 GENERAL DIAGNOSIS.
muscular atrophy and in chronic bulbar paralysis, with which they
may become associated.
In conjugate lateral deviations of the eyes, although the axes of vision
of both eyes are deviated from the middle Hue, yet they remain parallel
with one another. This condition is generally the result of a cortical
lesion which involves the movements of the eyes to the right or to the
left, and is usually the result of apoplexy. A spasm deviation of the
eyes in the same direction occurs as the result of irritative lesions of the
brain, involving the association centres or tracts, and also in hysteria.
The Localizing Value of Paralysis of the Orbital Muscles.'
Paralysis of the Third Nerve. Ptosis, the most frequent symptom
of diseases of this nerve, may be present as a focal symptom in cortical
lesions without paralysis of any other branch of the third nerve. This
would seem to indicate a special centre for the elevator of the lids, and
though not definitely ascertained, such a centre is believed to exist in
front of the upper extremity of the ascending frontal convolution close
to the centre. Ptosis on the side of the lesion, without paralysis of the
other branches of the third nerve, has been seen in disease of the pons,
and again by forming a factor of a crossed paralysis may seem to
localize a lesion in the crus cerebri, although when the third nerve is
paralyzed by a lesion in this situation it is usually involved as a whole.
Grossed hemiplegia is a term used to express a disease of the crus
cerebri when there is paralysis of the third nerve on the side of the
lesion, with hemiplegia, hemiansesthesia, and often facial and sometimes
hypoglossal paralysis of the opposite side of the body.
Complete paralysis of every branch of the third nerve without any
other paralysis is almost always basal ; so, also, are those cases in
which when there is hemiplegia it is slight as compared with the degree
of the third-nerve paralysis. Lesion of the interpeduncular space and
thrombosis of the cavernous sinus also indicate third-nerve palsies ; but
in the latter the other orbital nerves, as well as the fifth and the optic
nerve, may be involved as well Third-nerve symptoms may also be
distant symptoms of tumors of the cerebral hemispheres, more particu-
larly if accompanied by violent general head symptoms.
As a symptom of cerebral lesion solitary paralysis of the fourth nerve
is rare. AVhen present it is apt to be produced by a basal lesion. In
combination with paralysis of the third nerve it speaks for a lesion in
the cerebral peduncle extending back to the valve of Vieussens.
When paralysis of the sixth nerve occurs as the only focal sign it is
probably due to disease of the base as a distinct symptom. On account
of the lengthened course these nerves take over the most prominent
part of the pons, which renders them readily affected by distant press-
ure ; they are more liable to provide a distant symptom than any other
cranial nerve. Thus paralysis of this nerve is not infrequently a dis-
tant symptom of tumor of the cerebellum, whereas paralysis of the
1 This section has been epitomized from the excellent article on the subject in
Swanzy's Hand Book of Diseases of the Eye.
THE DATA OBTAINED BY OBSERVATION. 107
third nerve is more apt to be a distant symptom in a lesion of the cere-
bral hemisphere.
Paralysis of the sixth nerve, simultaneous in its onset with hemi-
plegia of the opposite side of the body, indicates a lesion in the pons,
usually a hemorrhage, on the side corresponding to the paralyzed nerve.
Basal paralysis of the nerve is frequently double, especially in syphilis.
In combination with paralysis of the facial, paralysis of the sixth
nerve is referable to a pontine lesion.
The Ear.
Subjective Symptoms. Buzzing, roaring, hissing, singing, and
other sounds in the ear — tinnitus aurium — are symptoms which may
or may not be due to disease of the ear. If associated with vertigo, it
may be due to Meniere 's disease. They may be the aura preceding an
epileptic attack or the subjective phenomena attending syncope. Many
drugs when pushed to physiological effects cause tinnitus.
The External Ear. The external ear should always be examined.
The thin ear may show the anaemic or chlorotic hue more strikingly
than other portions of the body, or the opposite condition may be
more vividly shown. Hcematoma auris is seen in general paralysis of
the insane and in other forms of insanity. It is a trophoneurosis.
The ear is thickened and deformed, on account of effusion of blood
between the- cartilages and the perichondrium. It is discolored, and
simulates the subcutaneous effusion due to injury. Tophi are observed
in the external ears of patients with a gouty diathesis. They are
small, hard, gritty accretions, seen in the external ear along the margin
or in the depressions. They consist of urate of soda.
The Discharge. When cerebral symptoms or symptoms of infec-
tion (pyaemia) are present the presence or absence of ear discharge must
be ascertained. Middle-ear disease very frequently results in inflam-
mation of the mastoid, and from thence the sinuses and adjacent mem-
branes of the brain become inflamed ; or the ear suppuration may be
the primary focus from which general infection has taken place. It
may not be possible in all cases to observe a discharge. It may have
diminished or disappeared on account of the fever. Tenderness and
oedema over the mastoid, perforation or bulging of the ear-drum, as
well as other inflammatory signs, point to the occurrence of suppura-
tion of the middle ear and mastoid cells. It must not be forgotten
that a bloody discharge from the ear may take place in fractures of the
skull. The ears must also be examined in cases of coma from injury,
or if the origin of coma is obscure.
The Auditory Nerve. The Hearing. The power and acuteness of
hearing must be tested. This may be done with the voice, a watch, or
a tuning-fork. Normally, the instrument should be heard at an equal
distance from either ear. If both sides are equally affected the hear-
ing of a patient must be compared with that of a healthy person. The
ticking of a watch should be heard at a distance of about three feet.
The tuning-fork is used by placing it on the skull. In some cases the
voice may be easily heard, while the ticking of a watch can be distin-
108 GENERAL DIAGNOSIS.
guishecl only with great difficulty. The tuning-fork is used to deter-
mine by bone conduction whether deafness is due to obstruction or
disease of the auditory nerve. If it is due to obstruction the vibrating
tuning fork placed on the vortex is heard better on the deaf side on
contact with the skull than when held close to the ear (Rhine's test).
Obstructive deafness, is always due to disease of (1) the external meatus,
(2) the tympanic membrane and middle ear, or (3) the Eustachian tube.
Deafness from internal ear disease may be due to affections of the
labyrinth — as inflammation, caries, and necrosis — or of the auditory
nerve. The tuning-fork is not heard on contact with the skull. The
auditory nerve may be diseased in its course, or the auditory centre
may be affected. (See Nervous Diseases, Part II., Chapter VIII.)
It must not be forgotten that certain drugs, as quinine and the sali-
cylates, may cause deafness. It may be an early and premonitory
symptom of typhoid fever, or cerebro-spinal meningitis, and may occur
early or late in the course of mumps. Deafness due to occupation is
worthy of mention. It is not uncommon in blacksmiths, boiler-makers,
locomotive engineers, and firemen. In some instances the patients can
hear better in the noise incident to their work than when the surround-
ings are absolutely quiet.
Hyperesthesia or the Auditory Nerve. Very rarely in cer-
tain cases of facial paralysis, and not seldom in hysteria, there is abnor-
mal acuteness of hearing (oxyacoia). In some individuals suffering
from hemicrania or tic douloureux, and in meningitis, the hearing of
certain sounds — for example, high musical notes and whistling — is
accompanied by pain. Nervous patients often complain of subjective
noises, buzzing, roaring, hissing, and singing — the so-called tinnitus
aurium.
Paralysis of the Auditory Nerve. No case of absolute uni-
lateral deafness, due to a focal lesion in a hemisphere, has as yet been
observed. Deafness from disease of the auditory nucleus is very rare.
That due to disease of the peripheral nerve is much more common.
We may have a rheumatic auditory paralysis similar to that of the
facial nerve, or the deafness may be due to pressure from a tumor or
inflammatory exudate at the base of the brain, or disease of the mas-
toid process of the temporal bone. The localization of the lesion is
often extremely difficult. The only positive point is, that labyrinthine
disease is apt to be accompanied by vertigo while in disease of the
nerve-trunk vertigo is absent.
Meniere's Disease. Aural Vertigo. We may define vertigo as a
subjective feeling of motion referred by the patient either to his own
body or to surrounding objects, with loss of equilibrium and without
unconsciousness.
In this disease, first described by P. Meniere in 1861, there is
paroxysmal vertigo (sometimes so sudden and intense as to throw the
patient to the ground), tinnitus aurium, nausea, pallor, clammy sweat,
and vomiting. The severity of the attacks varies greatly. There may
be momentary unconsciousness. There is sometimes jerking of the
eyeballs, nystagmus, or diplopia. The disease is paroxysmal in char-
acter, but slight vertigo and tinnitus are apt to persist between the
THE DA TA OB TA [NED B Y OBSER VA TION. 109
attacks. Some deafness is present. The attacks may vary in frequency
from several in a day to only one in several months.
Paralyzing Vertigo. Gerlier describes a remarkable form of parox-
ysmal vertigo accompanied by weakness, paresis in the extremities,
drooping of the eyelids, marked lassitude, and depression without un-
consciousness. It occurs only in men, and is epidemic in the Canton
of Geneva.
Hysterical or functional deafness is recognized by (1) its association
with undoubted symptoms of hysteria ; (2) its sudden occurrence
after shock, emotional disturbance, or trauma ; (3) the absence of a
cause in the auditory apparatus for the deafness ; (4) impairment of
bone-conduction and aerial conduction to the same degree ; (5) the
frequent coexistence of anaesthesia of the pinna and external meatus ;
(6) frequently recovery takes place suddenly.
Hysterical deaf-mutism is a rare condition, characterized by (1) sudden
origin ; (2) absolute aphasia and aphonia ; (3) absence of signs of paralysis
of the lips and tongue and of any paralytic phenomena except hysterical
hemiplegia ; (4) preservation of intellectual faculties and power of
writing ; (5) frequent coexistence of hysterical stigmata ; (6) usually
rapid recovery.
CHAPTER IX.
THE DATA OBTAINED BY OBSERVATION— (Continued),
The extremities — hands The shape — temperament — occupation — "claw-hands" —
"seal-fin hands" — rheumatoid arthritis — nervous affections — "spade" hands
— large bones of acromegalia — osteo arthropathy — wrist-drop. The movements
— spasm — tremor. The skin — color — moisture. Fingers. Heberden's nodosities
— contraction of fascia — Dupuytren's contraction — deviations in shape. The
nails. Trophoneuroses— cold hands and feet. Raynaud's disease — erythro
melalgia.
THE EXTREMITIES.
The Hands.
The Shape. We bear in mind the variation in the form of the
hand in different types of individuals — the broad and heavy hand of
the sanguine, the slender, dexterous hand of an individual of the nervous
temperament (see Chapter VI.), the large joints of the hand of so-
called strumous persons, and the effeminate hand of the one who is
inclined to tuberculosis, present sharp contrasts. Then, too, the ' ' occu-
pation " hand indicates in a general sense the disease the patient is
liable to — none more striking than the hand of the miner, the blue-
black dottings of which sharply indicate the possibility of anthracosis.
Finally, we note the broad hand and clubbed fingers that are seen in
congenital heart disease. The withered hand of age and wasting of the
hands, as in phthisis or malignant disease, need not be referred to, as*
they are part of the general process.
Fig. 13.
Pseudo-muscular atrophy. Claw-hand. (Geay.)
Presenting more striking changes in shape are the peculiarly de-
formed hands seen in affections of the muscles and joints. These
deformities will be described in the respective sections (Chapters XII..
THE DATA OBTAINED BY OBSERVATION.
Ill
and XIII.), although in passing they may be grouped together. First
we have the " claw-hand " of progressive muscular atrophy, of inflam-
Fig. 14.
Rheumatoid arthritis. The tapering fingers are seen. The phalangeal joints are swollen ; many
are anchylosed. The wrist is stiff. The muscles are atrophied ; the forearm-muscles much
wasted.
Fig. 15.
Photograph of a case of lead-paralysis affecting the extensor muscles. (Gray. )
mation of the ulnar and median nerve, and of chronic poliomyelitis;
the " seal-fin" hand of chronic gout and rheumatoid arthritis, spasm
of the extensor muscles causing deflection to the ulnar side. The
112
GENERAL DIAGNOSIS.
gnarled hand of rheumatoid arthritis and the knotted hand of gout are
characteristic. In the former the tapering, shining fingers, the bulbous
phalangeal joints, the pallid, clammy surface, dotted with freckles, the
locked joints, the atrophied muscles, combined with exquisite tender-
ness of the involved parts, make a picture never to be forgotten. The
Fig. 16.
Examples of the positions of the fingers in the movements of athetosis. (StrOjipell.)
peculiar deformity occurring in scleroderma is described in the chapter
devoted to the skin. Then we have the deformity resulting from
flexion of the hand on the forearm, the forearm on the arm as seen in
cerebral palsies of children and in the hemiplegias.
THE DA TA OB TAIN ED B Y OBSER VA TION. 1 1 3
The ' ' spade-like " hands of myxoedema and the enlarged bones of
the hands of acromegalia and pulmonary osteo-arthropathy are described
in other sections.
Deformities of the hand from other causes than the ones just men-
tioned are often observed. Temporary contractures occur in tetany,
in temporary hemiplegia or monoplegia, and in paralysis of the exten-
sors. Dropping of the hand from the radius toward the ulna occurs in
acute poliomyelitis from paralysis of the extensors. Then we have
paralysis of the median, ulnar, and other nerves, with their character-
istic deformity. (See Nervous Diseases.) So-called wrist-drop is seen
in peripheral neuritis (musculo-spiral nerve), and may be unilateral or
bilateral. The hand hangs from the wrist on account of paralysis of the
extensor muscles. Both hands may drop, although it sometimes happens
that one is affected from a few days to a few weeks before the other.
Movements. One can infer the limitation of movements of the hands
in the affections described above. The stiffened and immobile hand
of chronic rheumatism, in which enlarged joints are prominent, contrast
with the painfully locked hand of rheumatoid arthritis. Involuntary
movements, as tremors and spasms, are also observed. The tremor of
age, of hysteria, of paralysis agitans, of exophthalmic goitre, of mer-
curial and other intoxications, and of disseminated sclerosis, is most
marked in the hands. It is in the hands and arms we see that most
significant tremor or twitching with aimless picking at the bedclothes,
described in an account of the typhoid state (Chapter XIV.), known
as subsultus tendinum. Twitching and spasm of the hand or arm are
seen in convulsive disorders, and may be unilateral or bilateral, as in
hysteria, chorea, epilepsy, true and Jacksonian, tetanus, and tetany.
When permanent, it is seen as an expression of a chronic cerebral
j)rocess, as hydrocephalus. Alternating spasm and relaxation of the
lingers, hand, and arm are seen in athetosis.
Having noted the shape and movement of the hand, we direct atten-
tion to the skin, the nails, and the fingers.
The Skin.
The skin of the hand need not be considered apart from the skin of
the rest of the body. It is smooth or rough, dry and harsh, moist and
warm, under the same circumstances that affect the skin generally. In
rheumatoid arthritis it has been described as peculiar. Both the dorsal
surface and the palm are moist and very soft, and the former is dotted
with freckles. In progressive muscular atrophy and exophthalmic goitre
the skin is moist. The cold, clammy skin of one laboring under excite-
ment, as may be caused by the first visit to the physician, is well known.
Color. The color of the hands is significant of the state of the cir-
culation and the condition of the blood. The blue finger-tips and the
pallid hand accompany similar color changes in the lips, and are early
signs of cyanosis and of anseinia.
The swelling* of the hand, inflammatory or (Edematous, do not differ
from swellings of the joints or the subcutaneous connective tissues in
other portions of the body. Several exceptions are to be noted. First,
114
GENERAL DIAGNOSIS.
Fig. 17.
the swelling that attends articular rheumatism with involvement of
the wrist-joint extends over the dorsum of the hand frequently, while
the fingers are free from the process. Second, a localized swelling on
the dorsum of the hand is often due to a ganglion from a local affection
of the tendons. Third, Gubler's tumor is a swelling that is seen in
wrist-drop from displacement backward of the carpal bones. Fourth,
long-continued inflammatory swelling, with subsequent rupture of the
skin, is seen in mycetoma. Finally, traumatic injuries produce tendo-
synovitis, bone affections, and palmar abscess. Syphilis and gonorrhoea
may be causal factors in the production of such processes, it is impor-
tant to remember. (See Chapters X. and XIII.)
The Fingers.
In gout and rheumatism the joints of the fingers are enlarged and
painful. The swellings of the joints of each condition cannot well be
distinguished. In gout, tophi, hard, white, sometimes glistening
masses are likely to be present hi the joints or along the tendons, on
account of great accumulation of
urate of soda. They are more promi-
nent on the dorsal surface of the
joints, and sometimes break through
the skin, so that the " chalk-like "
concretion exudes. It was said by
Sir Thomas Watson that a gouty sub-
ject under his care used his joints to
keep tally while playing cards.
Heberden's Nodes. Haygarttis
nodosities. The term " end -joint
arthritis " is also applied to this con-
dition. This node belongs to the
first of the three divisions Charcot
makes of rheumatoid arthritis. The
nodules develop gradually at the
sides of the distal phalanges. The
subject may be in good health, or
may have had attacks of gout, or
have suffered from acid dyspepsia.
At first the joints may be a little
swollen and tender. The swelling
and tenderness may be periodical,
and the size may be increased with
each fresh paroxysm. The tubercles
are seen at the side of the dorsal
surface of the second phalanx, the
corresponding cartilage becomes soft,
the ends of the bone may be ebur-
nated. A moderate anchylosis takes place. The nodules are often
considered of good prognostic omen ; it is even said that they are a sign
of longevity. It is certain that the large joints are rarely involved
when these nodules are present.
Heberden's nodes.
THE DATA OBTAINED BY OBSERVATION. 115
The tips of the fingers may be bulbous, or club-shaped, in some cases
of phthisis and of other forms of chronic lung disease, and also of
chronic heart disease. It is most common, however, in bronchitis and
phthisis. The clubbing is associated with changes in the nails (see
below and illustration of pulmonary osteo-arthropathy).
Deviations in Position and Shape. Eversion is characteristic of
rheumatoid arthritis, but deviations due to abnormal flexion or exten-
sion are the most characteristic. Flexion of the first phalanx of the
little finger is due to contraction of the palmar fascia or to paralysis of
the common extensor from disease of the musculo-spiral nerve. Con-
traction of the fascia of the hand, causing more or less flexion of the
little and ring fingers, is frequently seen, and may be an indication of
gouty diathesis. It is certain that these contractions are seen in several
members or generations of a family in which gout is prevalent. It is
called Dupuytren's contraction.
Abnormal extension is usually very marked. Hyper-extension of
the middle phalanx is due to paralysis of the flexor sublimis from
disease of the median nerve ; hyper-extension of the distal phalanges
to paralysis of the flexor profundus muscle from disease of the median
and ulnar nerves. Extension of the proximal phalanx, with extreme
flexion of the two distal phalanges, contributes to form the " claw-
hand." (See Muscles.) Contractions due to chorea or to central
lesions, as post-hemiplegic contractions, will be considered under
special diagnosis. It is thus seen that the peculiar combined exten-
sion and flexion, causing abnormal shape of hands and fingers, is due
to (1) local joint inflammation (subluxations) ; (2) local neuritis and
paralysis ; (3) progressive (spinal) muscular atrophy ; (4) idiopathic
muscular atrophy, rarely.
The Circulation. Raynaud's Disease. Local Asphyxia. The
hands or fingers become pale and intensely cold ; they are the seat of
numbness, and are without sensation. The term "dead fingers"
graphically describes the appearance. The pallor usually comes on
suddenly, and continues for a variable period. As the pallor disap-
pears there is a gradual return of warmth, and the color changes to
a livid red, dark blue, or even blackish hue. The paroxysms of
alternating pallid and livid hue may occur several times in twenty-four
hours. In some cases the lividity becomes so intense that gangrene
ensues in small superficial spots, or even involves the whole finger.
Pain may or may not be present, and does not increase when the hand
hangs down. In my experience it is more frequently present and ex-
cruciating at the time the fingers are " dead." The tip of the nose
and the lobe of the ear may be affected, and occasionally other parts of
the surface. The sensitiveness to touch is markedly lessened. Ray-
naud's disease occurs usually in ill-nourished subjects, or after an acute
disease, as typhoid fever. It may be associated with vascular spasm
in internal organs, giving rise to epilepsy, hemoglobinuria, temporary
aphasia, or hemiplegia. It is usually worse in cold weather.
Erythromelalgia. Local changes in color are often due to neuritis
either of the trunk or of the terminal endings of the nerves. When
such changes are associated with pain we use the term erythromelalgia.
116
GENERAL DIAGNOSIS.
It is characterized by redness of the surface with increased tempera-
ture ; it is usually seen in the extremities and is limited to the distri-
bution of the affected nerve. It is worse in summer, increased by
artificial heat, and aggravated when the extremity is dependent or
pressed upon. The redness is attended by burning and extreme local
discomfort, in which all sorts of sensations are described — tearing of
the finger-nails, pulling or pricking of the skin, twistings of thousands
of needles, and other forms of torture. I know of no peripheral pain
which is the source of greater agony.
Glossy skin is seen after nerve-injuries and neuritis, and in central
affections in which the trophic nerves are involved. The skin is shiny,
smooth, drawn very tightly over the surface, and sometimes atrophied.
Red and pale mottling may be seen. The surface is free from hair.
Burning pain precedes and accompanies the change. (See Nails.)
The Nails.
The Shape. The appearance of the nails enables us to estimate the
duration of certain diseases, or the time when convalescence began ; it
also indicates local interference with the nutrition of the parts. Thus,
curving of the nails, with the club-shape of the finger-ends, occurs only
Fig. 18.
Clubbed fingers with curved nails (middle finger slightly flexed).
in chronic diseases, as phthisis or emphysema, or in chronic cardiac
disease and aneurism. In the latter it is sometimes found on one hand
only. It is sometimes seen in other chronic wasting diseases. The
nails may curve transversely or longitudinally. When transversely
the appearance is like that of a filbert, and when longitudinally they
are said to be incurvated. This change in shape may occur without
clubbing of the fingers. The shape is altered in acromegalia and
pulmonary osteo-arthropathy. (See Chapter XIII.)
THE DATA OBTAINED BY OBSERVATION. 117
Color. White marks on the surface are usually seen after an illness,
and may indicate the date of recovery. The marks develop at the
root of the nail, and as the nail grows the marks approach the tips of
the fingers, and thus their position denotes the time that has elapsed
since convalescence set in. If they are seen half-way up the nails, con-
valescence is probably of three months' standing. We get a good idea
of the condition of the blood in the capillaries from the appearance of
the tissue under the nails. If there is anaemia, pressure on the finger-
tips will drive the blood from the capillaries. Stephen Mackenzie's
rule, that if such pressure completely empties the vessels so that they
become pale, it indicates that the globular richness of the blood is re-
duced one-half, is a fair and rapid test of the degree of the anaemia.
The purplish and bluish-black discoloration of cyanosis previously
referred to is first seen under the nails. Sometimes the capillaries
pulsate, and this pulsation is more visible under the nails than in any
other part of the body except the retina. It may occur in aortic
regurgitation.
Nutritive Changes. The nails undergo chronic inflammation with
destruction in various skin affections, and the matrix is the seat of acute
inflammation in onychia. Onychia may be simple or syphilitic. Its
presence may indicate the organic origin of otherwise obscure nervous
symptoms. It may be only a simple inflammation, or it may result in
the loss of the nail and necrosis of the bone.
Deformity of the nails (toe) occurs in acute and chronic myelitis. In
locomotor ataxia the nails fall out.
In neuritis the trophic change is marked ; the growth is arrested,
and the nail becomes dark and brittle and curved in its long axis, while
lateral arching takes place. The cutis underneath thickens and the
skin at the base retracts. The fingers may be clubbed. When growth
is resumed a distinct roughened line of demarcation is seen. In leprous
neuritis there is destruction of nails and phalanges. Atrophy and ulcer-
ation at the base of the nails, followed by necrosis of the phalanges, is
seen in so-called Morvan's disease, which is not really a disease but a
symptom of neuritis or syringomyelia. Enlargement with thickening
and sometimes twisting occurs after fevers, as typhoid, or in the course
of ' syphilis and in sclerodactyle. The nutrition is changed in Ray-
naud's disease. In some cases the nails become dry, scaly, and cracked,
or hypertrophied entirely. In the hemiplegia from cerebral apoplexy
the growth is arrested on the paralyzed side. This is tested by stain-
ing the nails of the two hands at the same level with nitric acid ; the
relative position of the stain upon corresponding nails of the two hands
will show whether there has been growth or not. The return of func-
tional power is indicated by renewed growth.
The Feet.
Enlargement or deformities of the feet and legs may be due to
changes in the joints, the bones, and the subcutaneous connective
tissue. Hence we would have swelling due to oedema and myxoedema,
and enlargements due to acromegalia and pulmonary osteo-arthropathy.
118 GENERAL DIAGNOSIS.
The chapters so frequently referred to will contain a discussion of these
subjects, and to the Chapter on Joints must be referred all articular
changes. It must be recalled that pain may be due to flat-foot and to
neuralgia of the third interosseous nerve. (See Pain.) Flat-foot must
always be looked for when inability to walk is complained of. Changes
in the shape of the foot from muscular affections will be described,
bearing in mind that " claw-foot " is a prototype of " claw-hand,"
found in progressive muscular atrophy and in Friedreich's ataxia.
Three nutritional changes take place in the feet that are of diagnos-
tic significance : perforating ulcer of the foot, a trophic change occur-
ring in locomotor ataxia ; gangrene, the result of endarteritis (usually
senile), or occurring in the course of diabetes mellitus ; mycetoma, or
" Madura foot." Perforating ulcer usually begins as a blister, then an
abscess, and finally an ulcer.
The nails of the feet are subject to the same changes that take place
in the nails of the fingers.
Cold Hands and Feet. Patients frequently complain of coldness
of the extremities. It is a common and often serious complaint. It
is natural to expect a peripheral coldness when the central organ of
circulation is weakened. Coldness takes place in the final hours pre-
ceding death. It occurs in collapse, in hemorrhage, and in shock.
But we also see it in organic disease of the heart, with impairment of
the circulation. It is a common vasomotor condition in nervousness,
independent of hysteria. It is a marked feature in NothnagePs angina
pectoris vaso motoria, as well as in true and false angina pectoris.
A visit to a physician, or excitement from any cause, is likely to be
attended by coldness of the hands and feet. Under these circum-
stances the extremities are often bathed in a cold and clammy perspi-
ration. In senile endarteritis cold hands and feet frequently occur.
They are an index to the state of the peripheral circulation in other
parts of the body, as the brain.
The poisons of gout, of rheumatism, and of other diseases, which irri-
tate peripheral and vasomotor nerves, may cause cold hands and feet.
In gastric and intestinal dyspepsia, with the absorption of toxic prin-
ciples, as leucomaines, this symptom may be present.
Changes of sensation in the skin of the extremities will not be con-
sidered in this section. They will be taken up in the chapters devoted
to the diseases of the nerves. It is sufficient to state that ancesthesia
in local areas, and due to causes limited to the skin, is seen in morphoea,
in the anaesthetic form of leprosy, and in certain ischseniic states (urti-
caria). It is accompanied by loss of tactile sensibility. Hyperesthesia
and paresthesia occur with various local affections, but they are with-
out diagnostic significance except in nervous diseases.
CHAPTER X,
THE DATA OBTAINED BY OBSERVATION— {Continued).
The skin. The color — redness — pallor — jaundice — cyanosis — the bronzed skin — Addi-
son's disease — hemochromatosis — chloasma — tinea versicolor — vagabond's dis-
ease — argyria — freckles. The nutrition. Moisture and dryness — hyperidrosis
— anhidrosis. Scars Hemorrhages — mode of recognition — cause — significance.
Eruptions — their clinical significance — nature of the lesion — distribution — asso-
ciate morbid phenomena — general symptoms. Table of skin diseases — erythema
— herpes— erythema nodosum — urticaria — medicinal rashes — erythema of infec-
tious diseases — roseola — miliaria or sudamina. General diagnosis.
THE SKIN.
Color. The portions exposed to the air exhibit more varied and
pronounced changes of color than parts that are covered. The changes
in color herein described refer more particularly to the face and hands.
The color of other parts partakes of the same tint as that of the face,
other things being equal, except that the intensity is less. Comparison
of the two should always be made, and the mucous membranes examined,
as control observations. For the latter the conjunctivae, lips, and mouth
are sufficient, always remembering the possibility of hyperemia of the
conjunctiva from other causes.
Local color changes of the face will be particularized in this section.
It is not to be forgotten that the color varies with the type — whether
blonde or brunette — and that variations in the latter at times easily
escape recognition.
The skin in a healthy child is of a faint pink color ; as age advances
it loses its fresh appearance and becomes paler, except in those whose
occupation exposes them to atmospheric influences. In the latter, the
skin becomes weather-stained, and may assume a mahogany or reddish-
brown hue. In old age, the color is apt to deepen and become duller,
while the loss of subcutaneous fat allows the skin to lie in folds, espe-
cially about the jaws and neck, and wrinkles are marked, especially
between the eyebrows, over the nose, and at the angles of the eyes and
mouth.
Apart from these changes, which are physiological or necessarily the
result of occupation, the skin exhibits changes which are the result of
the habits or health of the individual. Some persons, especially if
blondes, retain to old age the fresh, pink skin of childhood. In others
is seen early a dull, muddy complexion. This is common in those
who use coffee to excess and are habitually constipated. In others
digestive derangements, particularly constipation, uterine disorders, or
gouty derangements produce, in addition to a muddy complexion, crops
of acne and comedones, or black-heads. It must be admitted, however,
120 GENERAL DIAGNOSIS.
that some persons preserve a fresh complexion in spite of marked
digestive disturbance. Considerable congestion of the superficial blood-
vessels, giving a person a florid appearance, may be due, especially in
a young person, to alcoholic excesses ; and there is a popular belief
which connects such an appearance, when coupled with a tuberous nose
and a crop of angry-looking pustules, with a prolonged use of spirits.
The sebaceous glands of the skin of the face merit but a passing
notice. Deficiencies or excesses of secretion, or alteration of it, are
usually due to local causes. Excessive secretion of sebaceous matter,
known as seborrhea, or steatorrhoea, is seen in two forms. First, with
oily exudation ; second, with drying of the secretion and the formation
of crusts. It may be more pronounced in strumous subjects. The
opposite condition, or asteatodes, is seen in wasting diseases, particularly
diabetes, and in xeroderma and ichthyosis.
Color Increased. The Abnormally Red Skin. Physiological
hyperemia has been spoken of. The color is intensified when the
capillaries are overfilled or the blood-current is unusually rapid. The
hyperemia may be general or local, and is due to dilatation of the capil-
laries, possibly from nerve-influences. General hyperemia is seen in
fever, in poisoning from atropine, and from organic poisons derived
from food or the result of intestinal putrefaction.
Local hyperemia attends the phenomena of blushing, and comes and
goes in nervous persons with every psychical impression. Rarely in
neurasthenics the hyperemias may be extreme, amounting almost to an
erythromelalgia. Abnormal redness may be diffused over the whole
face or may present the circumscribed flush of phthisis ; the local deep-
red area, on one cheek, of pneumonia ; the evanescent flush of anaemia,
with cardiac palpitation ; and the creeping flush, with raised border, of
erysipelas, appearing on the bridge of the nose or at the nostril. In
phthisis, moderate excitement or exertion, the taking of food, or the
onset of fever, tinges the cheek with the blush of hectic. In migraine,
the burning flesh may be limited to one side. Capillary congestion on
the cheeks or on the tip of the nose occurs with the endarteritis of the
aged, but is seen also in early life in cases of hepatic cirrhosis or of
obstruction of the hepatic circulation from other causes.
Color Lessened. It is caused by diminution of the amount of
blood in the capillaries, or because its richness in haemoglobin has been
reduced.
Pallor. Diminished amount of blood in the capillaries occurs
from active contraction or spasm of the arterioles, from hemorrhage,
or from weak heart. The pallor, therefore, is usually acute or tem-
porary, and may be recurrent. It attends fright, syncope, or nausea
and vomiting. It occurs also in acute poisoning, in acute disease, such
as diphtheria, and in hemorrhage. The pallor due to loss of blood
may be instantaneous if the hemorrhage is sudden and large, or develop
gradually if it is small and continued over a long period. The onset
of sudden pallor is of diagnostic significance in diseases in which hem-
orrhage may occur, as in aneurism, gastric or intestinal ulcer, and
typhoid fever. Symptoms of collapse are seen with this form of
pallor.
THE DATA OBTAINED BY OBSERVATION. 121
Pallor of long duration, or chronic pallor, if we may so term it, is
seen in a number of diseases. In all of them there are diminution in
the amount of red corpuscles and destruction of the haemoglobin. It
is characteristic of blood affections, as the various forms of anaemia. It
does not necessarily occur in leucaemia ; indeed, the cheeks and lips
may be red. It is seen, in a striking form, in chronic Bright' s disease,
in cancer, in chronic poisoning, as from lead or arsenic, in chronic
catarrh of the stomach or of the bowels, and in chronic infectious pro-
cesses, as tuberculosis and syphilis.
While paleness is recognized as the fundamental or prevailing color
of the skin in many of the above-noted affections, a further tinge gives a
characteristic hue to the skin ; thus, in chlorosis there is a greenish
appearance of the face, which is in striking contrast to the pearly col-
ored conjunctivae. In carcinoma the yellowish tinge of the pallor often
causes it to be mistaken for jaundice. In pernicious anosmia a straw-
colored appearance of the skin has been frequently described, which
may cause it to be mistaken for carcinoma. It is worthy of remark
that the cachectic pallor in carcinoma is not likely to occur unless
there are primary or secondary deposits in the gastro-intestinal tract or
the liver, and it is well known that pernicious anaemia is usually sec-
ondary to gastric or hepatic disorder. The peculiar hue of the pallor,
therefore, may be due to a common cause in these affections. The
pallor that attends Bright's disease is usually associated with slight
puffiness under the eyelids, or local dropsical accumulations elsewhere.
In chronic poisoning with lead pallor is associated with a blue line
upon the gums and drop-wrist ; while in arsenical poisoning there are
frequently associated a puffiness of the eyelids and looseness of the
bowels.
It is not well to lay much stress upon the variations in hue of the
pallor. They are not of diagnostic importance in themselves, but only
when associated with the characteristic symptoms and signs of the
respective affections in which this hue occurs.
It must not be forgotten that there are a large number of individuals
in whom pallor is the normal condition. This is particularly the case
with those who lead a sedentary life and are confined within doors.
There are a number of occupations which predispose to pallor.
Abnormal Color. I. The Yellow Skin. Jaundice. The yel-
low coloration is seen not only in the skin but in the sclera? (see the
Eye) and the mucous membranes. The discoloration of the skin is not
difficult of recognition. It varies in shades from a slight yellow hue to
yellow-green or olive-green, and in many forms of jaundice to brownish-
yellow. The yellow hue of the skin in jaundice may be preceded and
is always accompanied by tingeing of the conjunctivae; its presence in
this situation confirms the observation. The mucous membrane under
the tongue early gives evidence of jaundice ; or, if the lips are everted
and a glass slide pressed evenly on the surface, the yellow discoloration
of the mucous membrane will shine through.
The yellow tint of the conjunctivae must not be confounded with the
same color due to subconjunctival fat. The latter is not uniform in the
conjunctivae, but may occupy cone-shaped areas.
122 GENERAL DIAGNOSIS.
The physiological yellow color of the skin that is seen in infants
shortly after birth is not a true jaundice, but in all probability arises
from excessive destruction of red corpuscles in the over-congested
skin. On light pressure with the finger the color changes. It
fades from shades of yellow into the genuine flesh-color. The con-
junctiva? are natural, and the urine is free from bile-pigment.
The faeces are normal. By these symptoms a distinction can be
made.
Jaundice is a symptom due to a number of diseases. In the first
place, it is most frequently due to disease of the liver ; this form is
known as hepatogenous jaundice. It may possibly be due to destruc-
tion of the corpuscles of the blood and liberation of the haemoglobin,
the so-called hcematogenous jaundice. The various causes of the former
will be considered under diseases of the liver. The latter is said, not
without objection, to be due to destructive agencies in the blood, such
as ptomaines, which are absorbed in gastro-intestinal disease, or to
poisons that develop in the course of pyaemia, yellow fever, malarial
and relapsing fevers ; it may also be due to snake-bite or to poisons that
are imported, as in mineral poisonings, or chloroform, ether, or chloral.
In both instances the yellow coloration of the skin is due to coloring-
matter of the bile or of the blood, or bilirubin, which is deposited in
the cells of the rete mucosum.
Other symptoms due to the same cause are associated with hepato-
genous jaundice. Their presence may be of diagnostic value in deter-
mining the nature of the yellow color of the skin in cases of doubt.
These symptoms are : (1) Itching. This symptom is intolerable ; the
surface of the body is often seen to be covered with scratch-marks on
account of the irritation of the peripheral ends of the nerves in the skin
by bile-pigment. (2) Slow pulse. Slowness of the pulse also fre-
quently attends jaundice. (3) Secretions and excretions. The saliva,
or expectoration, if present, is bile-tinged, and the urine is dark col-
ored, due to the presence of the pigment. (See Urine.) While the
excretions are all tinged with bile in the hepatogenous form, the faeces
are free from bile, hence they are pale or of an ashy color. On account
of the absence of bile in the intestines its physiological effects are lost,
and therefore flatulency from fermentation becomes an important
symptom.
II. The Blue Skix. Cyanosis. This peculiar hue is recognized
without difficulty. The bluish or bluish-red appearance of the skin is
first seen at points furthest from the central organ of circulation, as in
the extremities. The mucous membranes, in which the capillary cir-
culation is readily seen, also exhibit the change early. It is early seen
also in the finger-tips, particularly underneath the nails, about the
phalangeal joints, and in the lips. Subsequently the entire surface of
the skin may become dusky or cyanosed, as its cause increases in
degree. Its onset, it is said, can be anticipated by the state of the
veins on the under part of the tongue ; overfilling or extreme disten-
tion of these vessels always occurs in cyanosis. At first the color,
wherever situated, usually disappears on pressure, but as the hue
deepens it remains in spite of pressure.
THE DATA OBTAINED BY OBSERVATION. 123
Causes. Cyanosis is (1) respiratory, due to overfilling of the veins
and capillaries with blood not sufficiently oxygenated, or (2) vascular,
to an excess of venous blood, oxygenation not being interfered with.
1. Respiratory. All conditions which interfere with the aeration
of the blood cause more or less cyanosis. Practically sufficient air
cannot get to the blood, or sufficient blood to the air. Obstruction of
the air-passages, diminution of respiratory area, and diminished or in-
efficient respiratory movements prevent oxygen getting into the blood ;
interference with the circulation in the lungs prevents the blood getting
air. Both causes are often combined.
a. Obstruction of the Air-passages. This may occur in the
upper respiratory tract, or in the capillary bronchi. (1) Fancied ob-
struction, by pharyngeal abscess or tonsillitis, or, in rare cases, by
diphtheria, causes moderate cyanosis. (2) Obstructive laryngeal dis-
eases produce cyanosis varying in degree with the amount of obstruc-
tion and its persistence. The cyanosis is of short duration in spasmodic
croup and in laryngismus stridulus ; it is prolonged in the more per-
sistent inflammatory affections. Its gradual onset, in moderate degree,
as seen by the purple lips or dusky finger-tips, is of serious prognostic
import in the course of tuberculous laryngitis even if symptoms of
grave obstruction have not arisen. (3) Tumors, pressing on the trachea
or bronchi, narrowing the air-channel, cause cyanosis. The tumors
may be situated in the neck, as the thyroid gland, or within the medi-
astinum. (4) Spasm of the bronchi, as in asthma, occlusion of the
bronchioles, as in bronchitis, both acute and chronic, and particularly
the grave forms of capillary bronchitis in childhood, cause cyanosis.
(5) Foreign bodies anywhere in the upper regions of the respiratory
tract are fruitful sources of cyanosis.
b. Diminution of the Respiratory Area. Cyanosis from this
cause occurs in pneumonia, in oedema of the lungs, in tuberculosis, and
in all forms of pleural effusion and of intrathoracic tumors compressing
the lung. It is an important diagnostic feature of acute tuberculosis.
c. Diminished or Insufficient Respiratory Movements. De-
ficient chest-expansion, because the action of the respiratory muscles is
interfered with, lessens the respiratory area. This interference may
be either on account of muscular or pleuritic pain, on account of paraly-
sis, or, in the case of the diaphragm, on account of upward pressure by
accumulations in the abdominal cavity, as large peritoneal effusions, an
enlarged liver or spleen, or an abdominal tumor. In bulbar paralysis
and peripheral neuritis, in paralysis of the diaphragm, and in spasm of
the muscles of respiration (as in tetanus) there is diminished respira-
tory movement. In forms of progressive muscular atrophy and in other
rare affections of the muscles, as trichinosis, cyanosis is also observed
for the same reasons.
d. Obstruction of the Pulmonary Vessels. Interference with
the circulation within the lungs, from pressure on the pulmonary artery
or vein by aneurism or mediastinal tumor, or from disease of the heart
itself, is a most frequent cause of cyanosis. In affections of the heart it is
not seen until — in the case of valvular disease, for instance — compensa-
tion is lost and the right heart is dilated, causing an accumulation of
124 GENERAL DIAGNOSIS.
blood in the lungs. In the latter condition the bronchitis of passive con-
gestion of the mucous membrane is an additional cause for the cyanosis.
2. Cakdio-vasculab. Obstruction to the flow of venous blood
anywhere in the circulation will lead to the development of cyanosis.
This is the cyanosis of passive congestion. Cyanosis due to causes
mentioned above is always general. Cyanosis arising from the causes
indicated in this section may be general or local, depending upon the
seat of obstruction. General cyanosis may occur in (1) congenital
heart disease ; (2) in valvulitis, when compensation is lost and dila-
tation has taken place ; (3) in incompetency of the valves from
dilatation ; (4) in weak heart or enfeebled action from pericardial
effusion. In congenital heart disease the cyanosis is so great and so
persistent that the affection has been termed " blue disease " or " morbus
cceruleus."
Local cyanosis is seen when there is obstruction of the venous trunks
from external pressure, or from disease of the venous wall, causing
thrombosis. It may be limited to the head and upper extremities, in
obstruction of the descending cava by tumor or aneurism, or to the
lower portion of the trunk and the lower extremities in obstruction of
the ascending cava by pressure from tumors within the abdomen and
thorax. One extremity may be the seat of local venous stasis from
pressure upon the veins, or its occlusion by thrombosis ; the arm in
cases of cancer of the breast and axillary glands, the leg in cases of
femoral phlebitis, represent typical forms of venous stasis. A striking
form is due to causes affecting the vasomotor nerves, giving rise to
peripheral capillary spasm. (See under Fingers, Raynaud's Disease.)
III. The Bronzed Skin. Pigmentation. Addison's Disease. The
most marked form of bronzing is seen in Addison's disease — an affec-
tion characterized by a gradual loss of strength without much loss of
flesh ; by gastric uneasiness and occasional vomiting ; feeble circula-
tion, and a bronze hue of the skin.
Social History. The disease occurs most frequently during the active
period of life, from the age of twenty to forty years, and nearly twice
as often in males as in females.
Asthenia. The disease begins insidiously with gradual and progres-
sive loss of strength. It becomes evident from the patient's languor,
weariness on slight exertion, and inaptitude for mental effort that he
is suffering with some exhausting disease. The most characteristic
symptom is the extreme prostration without any obvious cause. Any
exertion requires great effort and may induce fainting.
Gastric Symptoms. The appetite is impaired or lost, there is more
or less discomfort at the epigastrium, and occasional vomiting.
Perhaps at this time a close inspection may show some discoloration
of the skin, but usually this appears later. By degrees the gastric
symptoms become more prominent, and vomiting may be so frequent
as to shorten life materially. Finally, the patient is unable to leave
the bed. Dull pains in the head, back, and abdomen are not uncom-
mon ; neuralgic pains in the limbs may be complained of ; and Osier
states that there is tenderness on pressure in the lumbar region in a
considerable proportion of cases.
PLATE II.
•%- : WB*-
Addison's Disease, Showing Bronzing of Skin, and White
Areas of Atrophy. (Coleman.)
THE DATA OBTAINED BY OBSERVATION. 125
The pulse is extremely small and feeble ; in the later stages it may
be absent at the wrist.
Bronzing. The discoloration of the skin is the most striking symp-
tom of the disease when it is well marked. The external surfaces are
changed in hue, and delicate portions of the skin underneath the cloth-
ing are also bronzed. The discoloration is not removed by pressure.
The areas are irregular in shape. The skin is soft and pliable. The
pigment which causes the discoloration is deposited in the rete Mal-
pighia.
The pigmentation is never seen in the cornea or in the nails. The
axilla, the flexure of joints, the median line, the areola about the nipple
and other normal areas of pigment deposit are the common sites.
Bronzed areas in sharply circumscribed patches are also seen in the
mucous membrane of the lips and cheeks.
Sometimes the whole body becomes of a walnut-juice color, a bronz-
ing which is deeper in exposed surfaces. At times only portions of
the body are discolored, in which case the dark hue shades oft' grad-
ually into the normal hue of the skin. Wilks 1 states that in all the
cases which he has seen the scalp, finger-nails, soles of the feet, and
palms of the hands escaped pigmentation.
Nevertheless, discoloration of the skin is not an essential symptom
of the disease ; in some cases it is entirely absent. These cases, espe-
cially if associated with much vomiting, run a more acute course than
the others, lasting only a few weeks. Such cases have been mistaken
for typhus fever.
On the other hand, diseases of the suprarenal capsules not usually
associated with the Addison symptom-complex, as carcinoma, are
attended by pigmentation. In about an equal proportion of cases it
is absent, however.
The discoloration of the skin in Addison's disease must not be con-
founded with that of sunburn. The latter discoloration is limited to
parts that are exposed to the sun, is more uniform, and the mucous
membranes are free. Moreover, the anaemia and debility of Addison's
disease do not attend it. The pigmented areas in the mucous mem-
brane of the mouth, seen in a certain class of negroes, must not be
mistaken for the pigmentation of Addison's disease. (See Plate II.)
In persons living in filth general discoloration of the skin takes place,
known as " vagabond's disease ;" but because it is so general and the
skin is rough and thickened, and other evidences of filth are seen, it
can easily be recognized. In the latter stages of jaundice the dark-
green, olive, or black hue of the skin might be taken for the general
bronzing of Addison's disease. The appearance of the conjunctiva is
sufficient to indicate the cause of the bronzing. In certain cases of
tuberculous peritonitis, even if the adrenals are not involved, the pecu-
liar brown discoloration which simulates Addison's disease is present.
In scleroderma pigmentation occurs, although rarely.
The pigmentation that occurs in uterine disease or in pregnancy (uterine
chloasma) resembles the bronzing of Addison's disease. It is usually
1 Reynolds' System of Medicine, Philadelphia, 1880, iii. 561.
126 GENERAL DIAGNOSIS.
confined to the forehead and cheeks and the normal pigmentary areas of
the skin. The mucous membranes are not affected, although in pregnancy
there may be the characteristic change of the vaginal mucous membrane.
The vomiting and weakness that attend pregnancy may sometimes lead
to confusion — vomiting is early, pigmentation late in pregnancy.
The affections just described must not be confounded with the dis-
coloration — yellowish-brown in hue — of tinea versicolor, a parasitic skin
disease. The latter is recognized by its color and irregular dissemina-
tion. It especially occupies the chest and spreads to the abdomen. It
rarely ascends above the neck. It does not usually, therefore, occur
in parts exposed to the air, or in parts that are the seat of normal pig-
mentation. Then, again, the surface desquamates in brownish scales.
Examination of the scales in a drop of dilute liquor potassse, under the
microscope, shows both spores and mycelium. The spores are of the
fungus micro-sporon furfur. Another skin affection is attended by
bronzing — leucoderma. In diabetes bronzing is often seen independently
of any parasitic invasion of the skin, and apparently the result of the
cachexia. It is possible that it is due to the cirrhosis of the liver
which causes the glycosuria. But if the pancreas is primarily at
fault the skin change is more likely to occur. In certain forms of
hepatic cirrhosis, as so-called Hanot's, or the hypertrophic form,
bronzing, undoubtedly the result of blood destruction, hoemochroma-
tosis, is seen in rare instances.
At times the bronzing and other characteristic symptoms of Addi-
son's disease are associated with tuberculosis in other organs. Con-
versely, in cases of phthisis in which there is bronzing, tuberculous
disease of the suprarenal capsules may be suspected, and it adds to the
gravity of the prognosis.
Argyria. If nitrate of silver is administered over a long period of
time, fine black particles of the metal or of the albuminate are deposited
in the kidneys, the intestines, and the skin. The corium is the principal
seat of the deposition. The discoloration of the skin is gray or gray-
ish-black. It is not changed by pressure, and is usually limited to the
face and hands. Small specks may also be noted in the mucous mem-
brane of the mouth. The cornea and nails are not affected. Persons
are usually in good health, although the presence of the skin-change, if
seen in a patient with coma, would point to the possible presence of
epilepsy, on account of which the drug had been taken.
Freckles. Freckles are not usually of special diagnostic significance.
Their occurrence in an unusual degree on the back of the hand and
forearm has been observed, however, in cases of rheumatoid arthritis.
Hemorrhages.
Hemorrhages in the skin are called, according to their size, petechia;,
ecchymoses, vibices, and Ivxmatomata. The petechia? and ecchymoses are
apt to appear in the hair follicles, and vary in size from a pin-point to
a split pea.
Mode of Recognition. They must be distinguished from erythe-
matous and other eruptions. They may be raised above the surface of
THE DATA OBTAINED BY OBSERVATION. 127
the skin ; they do not disappear upon pressure, and vary in hue from
deep red to yellow-brown, according to their depth beneath the surface
and to the degree of absorption that has taken place since the hemor-
rhage occurred.
Vierordt advises the following test to distinguish them from erythe-
mas : Press a piece of glass (a microscope slide) upon the suspected
spot. A hemorrhage is rendered more distinct, while the surrounding
part becomes more anaemic. An inflammatory hyperemia, on the
other hand, disappears.
Cause. Hemorrhages may be due to affections of the blood or dis-
ease of the bloodvessels. They occur in the course of blood diseases,
because such change in the quality of the blood takes place that permits
diapedesis more readily. They are more particularly, but not exclu-
sively, seen in dependent parts, especially in the lower extremities.
Significance. While subcutaneous hemorrhages are easily recog-
nized, their diagnostic significance is more difficult to determine, and
must depend upon the phenomena with which they are associated.
Moreover, the situation of the hemorrhage is in a measure an index of
its causal origin ; thus hemorrhages about joints are usually purpuric
or hsemophilic.
1. Hemorrhage with Fever. Subcutaneous hemorrhages in the
infections are due to changes in the quality of the blood, and indicate
the severity of the infection, or to obstruction of the bloodvessels with
emboli. To the former class belong cerebrospinal fever and measles,
variola, and scarlatina. In the exanthemata they precede, develop with,
or even replace the characteristic eruption, the latter being darker in
color than normal. Hemorrhages will probably take place at the same
time from the mucous membranes ; perhaps the nares will be occluded,
and the mouth and fauces filled with clotted blood. In milder infections
sordes collect in the mouth only. They indicate the degree of malignancy
of these affections. To the same class of affections belong epidemic
hemoglobinuria and morbus maculosus neonatorum, diseases of newborn
infants but little understood, although no doubt of an infectious nature.
To these may be added the severe forms of purpura hemorrhagica,
attended by fever, marked visceral disturbances, skin eruptions, and
great oedema.
Hemorrhages due to obstruction of the vessels are known as hemor-
rhagic infarcts, and are seen iajpycemia and ulcerative endocarditis. The
hemorrhages are small, sometimes elevated, more abundant on the
extremities, but distributed over the trunk ; they are seen as small
areas in the mucous membranes, observed in the conjunctivae, and, on
ophthalmoscopic examination, in the retina. The association of chill,
fever, and sweat, the presence of pus in some structures of the body,
and the characteristic joint affections point to pyaemia. On the other
hand, if due to ulcerative endocarditis, the physical signs of this affec-
tion render the recognition of the cause of the hemorrhage clear.
Finally, in rheumatic fever with involvement of the joints we have the
occurrence of purpura. (See Erythema, same chapter.)
2. Hemorrhage with Anaemia. Hemorrhages occur in all forms
of ancemia attended by debility. In idiopathic or pernicious anaemia
128 GENERAL DIAGNOSIS.
they are usually small, but may become extensive. They occur on the
extremities, and, usually, on the dorsum of the feet or hands. There
may also be retinal hemorrhages. They are also seen in the secondary
anaemias that arise in the later stages of tuberculosis and of carcinoma,
particularly of the stomach ; in the later stages of Bright' s disease, and
of cirrhosis of the liver.
Scurvy is an affection characterized by ansemia, debility, and wasting,
in which there are hemorrhages under the skin as well as from the
mucous surfaces. The gums are particularly affected. They bleed
easily. Hemorrhages also occur in the deep lymphatic spaces, in the
muscles, underneath the periosteum, and in the joints. In scurvy-
rickets similar hemorrhages are seen. (See Chapter XIII.)
3. Purpura. Primary purpura occurs without any known cause.
It has been divided, for convenience, into simple and hemorrhagic
purpura, though the two probably differ only in intensity.
Secondary purpur a occurs in connection with a variety of febrile and
constitutional diseases : 1. Scurvy. 2. Haemophilia. 3. Hodgkin's
disease. 4. Splenic leucocythsemia. 5. Pernicious ansemia. 6. Chronic
lesions of the kidney and liver, with or without jaundice. 7. Ulcera-
tive endocarditis. 8. Malignant sarcomata. 9. Infectious diseases.
A. In simple purpura the hemorrhages are limited to the skin.
They consist of : 1. Bright-red spots, varying in size from a pin-
head to a silver three-cent piece. These spots are under the skin
and are unaffected by pressure. They fade gradually from red to
yellow and disappear. 2. Larger spots or streaks called vibices. 3.
Ecchymoses.
The disease is said to be most common about the age of puberty.
It may come on in the midst of apparent health, or it may follow an
illness, as typhoid fever.
Purpura occurs especially upon the legs, the standing position seem-
ing to favor its occurrence. It comes on in successive crops. Some-
times large blebs, filled with thin blood, form under the skin, and
gangrene at times occurs.
B. In the hemorrhagic form 1 hemorrhages occur from the nose,
stomach, bowels, vagina, and bronchi, or into the kidney or other
viscus. Cutaneous and submucous hemorrhages also occur.
The onset of these cases is sudden, though there may be a day or
two of depression, lassitude, headache, and nausea. The first symptom
noticed is generally fever, which is apt to be moderate, then eruption
upon the skin is detected, and for a day or two the patient may seem
to be only slightly ailing. Copious epistaxis may now occur, or a
hsematemesis or hematuria, or all of these and other hemorrhages, may
occur the same day. The temperature may be only moderately raised,
or it may reach 104° to 105°, or even a higher point. The pulse at
first is frequent (120 to 140), but of good volume and tension. Subse-
quently, in unfavorable cases, it becomes thready and very frequent.
Respiration is not affected, and the mind is clear ; the face is pale and
1 See Grave Forms of Purpura Hemorrhagica. Musser : Trans. Association of
American Physicians, vol. vi.
THE DA TA OB TAINED B Y OB SEE VA TION. 129
anxious. Hemorrhage may also occur into the choroid and brain-
substance, with blindness and paralysis as sequels. It may also occur
into the uvula or tonsil.
The subjective symptoms are pains in the loins, limbs, epigastrium, or
chest. Often these pains announce a fresh hemorrhage, as into the
kidney, or a fresh crop of purpuric spots. The degree of anaemia
depends upon the copiousness of the hemorrhage and the length of time
the disease lasts. Sometimes the hemorrhages cause great exhaustion,
with a tendency to collapse.
The urine, in the case of hemorrhage into the kidney, of course
contains blood ; sometimes casts are also found.
C. Another variety of purpura is known as peliosis rheumatica, the
peculiar features of which are tender and swollen joints, oedema of the
subcutaneous cellular tissue, and purpura associated with urticarial
wheals and intense itching (purpura urticans). The subcutaneous
hemorrhages consist of petechia?, vibices, and ecchymoses. There may
be such large hemorrhages into the penis, scrotum, and uvula as to
result in gangrene and slow separation of the dead tissue by ulceration.
Epistaxis may occur, but copious hemorrhages from the stomach, the
bowel, or into the kidney or other organs are rare. Endocarditis and
pericarditis occur as complications in some cases. The duration is
apt to be long, convalescence being delayed by repeated outbreaks of
purpura with multiple arthritic symptoms and oedema.
Diagnosis. It is distinguished from scurvy by the absence of ante-
cedent debility and anaemia, of spongy gums, of brawny induration in
the limbs, and by the fact that the hemorrhages do not usually occur
around a hair follicle. In scurvy there is a history of deprivation of
vegetable food, whereas purpura may occur in the midst of robust
health. As a rule, the cutaneous hemorrhages are larger in scurvy
than in purpura.
It is distinguished from acute infectious diseases, particularly typhus,
cerebro-spinal fever, and smallpox, by the absence of severe constitu-
tional symptoms which characterize the graver forms of these diseases
— in which alone a purpuric eruption is likely to be severe enough to
cause doubt. Hemorrhages from mucous surfaces are rare in the
latter.
Hcemophilia is distinguished by the history the patient gives of being
a bleeder by heredity, and the fact that the bleeding has been started
by some injury, wound, or operation.
It is distinguished from the hemorrhages of leukaemia by the absence
of enlarged spleen and liver, and by the fact that there is no excess of
leucocytes in the blood.
31alif/nant sarcoma causing hemorrhages is recognized by the pre-
vious history of anaemia and cachexia, and by the detection of pri man-
or secondary growths.
It must not be confounded with Raynaud's disease, a vasomotor
affection characterized by local syncope, local asphyxia, and gangrene.
4. Haemophilia. The diagnostic significance of subcutaneous hemor-
rhage is clearer when associated with profuse hemorrhages in other
portions of the body, and when there is also a history of the occur-
9
130 GENERAL DIAGNOSIS.
reuce of such hemorrhages in the family. Hamophilia is a constitu-
tional affection characterized by bleeding, which is spontaneous or
occurs upon slight injury. It is nearly always hereditary, but may
arise de novo.
Males are very much more liable to it than females, the ratio being
about 11 to 1. This curious disposition to bleeding maybe transmitted
for generations, and almost always to the males through the female
members of the family — that is to say, the daughter of a bleeder is not
usually affected, but she transmits the tendency to her sons, who
become bleeders ; so, too, the granddaughters are not bleeders, but they
in turn transmit the disposition to their male offspring. It generally
shows itself early in life, usually before the end of the second year, and
almost invariably by puberty.
The affection usually first declares itself by the occurrence of a hem-
orrhage, either spontaneous or the result of slight injury, the bleeding
being far more profuse than would be natural, and in some cases abso-
lutely uncontrollable.
Legg 1 has divided haemophilia into three degrees, according to the
severity of the symptoms. The first is characterized by external and
internal bleedings of every kind, and by joint-affections ; the second,
by spontaneous hemorrhages from mucous membranes, but no trau-
matic bleeding or ecchymoses, and no joint -affections ; the third, by a
tendency simply to ecchymoses. The first form is seen most fre-
quently in men ; the second most frequently in women ; and the third
in either sex.
The most frequent seat of hemorrhage is the nose, and the next the
gastro-intestinal tract. The bleeding is from the capillaries ; it may
prove fatal in a few hours, or last for days and weeks with final recov-
ery. Intense anaemia follows the prolonged hemorrhage, but the blood
is replaced with remarkable rapidity. All operations, even the most
trivial, are extremely dangerous in bleeders. Circumcision, extraction
of teeth, and leeching are credited Avith the most deaths by Grandidier.
Joint-symptoms are very common. The knees, elbows, ankles, and
shoulders are the ones most frequently involved. The attack may be
marked by pain, redness, swelling, inflammation, and fever ; or fever
may be absent ; or pain alone may be complained of. The attacks are
liable to recur, especially in cold, damp weather, and may result in
stiffened, deformed joints.
The diagnosis is easy when the history of a hereditary tendency to
bleed can be obtained. Osier 2 properly remarks that slight joint-trouble
and petechia? are as much a manifestation of the disease as the more
severe hemorrhages. In cases in which no history can be secured
the diagnosis is made by noting a persistent liability to hemorrhage,
without adequate cause, and associated with joint-affections.
Osier gives the following excellent summary of the affections with
which haemophilia can be confounded :
1. The umbilical hemorrhages of infants, due to jaundice or to syph-
ilis, haemorrhagica neonatorum, etc.
1 Haemophilia. London, 1892.
2 Quoted by Osier, Pepper's System of Medicine, 1885, iii. 932.
THE DATA OBTAINED BY OBSERVATION. 131
2. Purpura simplex, often seen in debilitated, rarely in healthy chil-
dren, usually confined to the legs, and in some cases associated with
rheumatic pains or swellings in the knees and ankles.
3. Peliosis rheumatica.
4. Purpura hemorrhagica, morbus maculosus Werlhofii, a grave
disease, characterized by extensive cutaneous ecchymoses, mucous hem-
orrhages, but not dependent on any local disease, or, as far as known,
on any specific poison.
5. Infective purpura due to the action of some specific poison —
smallpox, measles, scarlet fever, cerebro-spinal fever, etc. The hem-
orrhages may be cutaneous and trivial, or may be in the most aggra-
vated form of interstitial and mucous bleedings, as seen, for example,
in black smallpox.
6. Toxic purpura, as in snake-bites and many poisons, such as phos-
phorus.
7. Simple hemorrhagic diathesis, under which may be included those
cases in which, without any hereditary disposition or previous hemor-
rhagic history, there is a tendency to uncontrollable hemorrhage from a
slight wound.
8. Hsematidrosis, bloody sweats, which occur usually in hysterical
or epileptic females, and are in rare instances accompanied by mucous
hemorrhages.
5. Hemorrhage in Central Nervous Disease. Neuritis. Pur-
pura in some instances is believed by Mitchell to be due to primary
disease of the nervous system ; certainly we do see it in neuritis, in
Raynaud's disease, in myelitis, and in locomotor ataxia. It may occur
in hysteria, when drops of blood ooze through the skin at the time of
the attack (hsematidrosis).
6. Hemorrhage of Toxic Origin. The virus of snakes causes hem-
orrhages under the skin. In jaundice the blood is disintegrated and
hemorrhages take place. In malignant types the mucous membrane
bleeds and sordes collect on the tongue, lips, and gums. To the same
class belong the subcutaneous hemorrhages that follow the adminis-
tration of certain drugs, as copaiba, iodide of potassium, quinine, and
belladonna. (See Medicinal Rashes.)
Eruptions.
Diseases of the skin are usually characterized by eruptions. Now,
such eruptions may be primary and local (from causes operating directly
on the skin) in the sense that they occur independently of any internal
affection ; or secondary, the resultant of an internal morbid process.
The morbid processes are the same, and morbid processes in the skin
do not differ from such processes in other epithelial structures. The
anatomical and physiological peculiarity of the part causes the difference
in the phenomena. Hence anaemias and hyperaemias, inflammations,
acute or chronic, with or without exudation ; hemorrhages-, atrophies, and
hypertrophies, new growths, and parasitic affections are found in both.
But instead of a painless inflammation with transudation of mucus, as in
mucous membrane inflammation, we have a more or less painful infiam-
132 GENERAL DIAGNOSIS.
mation, with itching (nerve-supply), and with sebaceous and sudorifer-
ous gland exudation. Otherwise the same symptoms attend each ; but
ocular examination of the inner mucous membranes is not possible.
While the reader is referred to special works on skin diseases for a
description of the primary or local skin affections, the secondary affec-
tions will be briefly noted. It must not be forgotten that the local
affections — eczemas, parasitic disease, etc. — are modified by the general
conditions or state of health of the patient.
Clinical, Significance. This depends, first, upon the special
character of the eruption, the nature of the lesion ; second, its distribu-
tion (a) in the layers of the skin, (6) over the surface of the body ;
third, its association with other morbid phenomena or various circum-
stances.
I. The Nature of the Lesion. Observation concerning the
nature of the lesion includes (1) its anatomical character, (2) the order
of appearance, (3) its uniformity, and (4) the mode of invasion.
A knowledge of anatomical lesions is essential in order to be able to
define exactly the morbid process and determine the primary cause of
the lesion. For a long period of time the lesions were divided into
primary and secondary. The lesions known as scabs, scale, raw sur-
faces, scratch-marks, and ulcers are always secondary. Scars and
macula? appear latest. The other lesions herein described are primary.
The writer follows Dr. Pye-Smith in the description of them, as well
as in most of the matter appertaining to cutaneous affections.
1. Hyperemia, or congestion.
a. Mere overfulness of the vessels from paralysis of the vasomotor
nerves, with redness and heat, but without the exudation and tissue
changes which accompany inflammation. This hypersemic blush, readily
produced in the physiological laboratory, is rarely seen as an uncompli-
cated morbid condition (e, g., Trousseau's tache-cerebrale).
b. Active, arterial, or inflammatory hypoxemia , varying in color from
brilliant scarlet to rose-pink, and combined with heat, tingling, or other
sensations.
c. Passive, venous, or congestive hyperemia, dependent upon retarded
circulation and distended venules. The color is purple, bluish, or livid,
the surface is cold, and there are no painful sensations.
2. Pimple, or papule. A small, solid elevation of the skin.
a. The acute inflammatory papule.
b. The chronic large inflammatory papule, discrete or confluent.
c. A solid non-inflammatory papule.
d. Solid elevations of the skin, which may be called false papules.
3. Vesicle. A visible cavity in the skin filled with transparent
liquid.
4. Pustule. A cutaneous abscess.
5. Bulla, or bleb. A very large vesicle.
6. Scab, or crust, A dried-up concretion of the contents of a vesi-
cle, pustule, or "bleb.
7. Scale (squama). A dry flake of epidermic cells.
8. Wliecd (pomphos). A flat, solid elevation of the skin, much larger
than a papule, and of ephemeral duration.
THE DATA OBTAINED BY OBSERVATION. 133
9. Scratch-mark. An injury to the skin, of linear form and curved
outline.
10. Raw. A surface which has lost its horny layer of epidermis.
11. Chap (rima). A crack or fissure which goes through the epi-
dermis.
12. Sore (ulcus). The result of destruction by inflammation, which
has reached below the Malpighian layer and has destroyed the papillae.
13. Scar (cicatrix). The result of the healing process after an injury
or disease deep enough to destroy the papilla? of the part.
14. Nodule. A solid elevation of the skin larger than a papule and
seated in its deep layer.
15. Stain (macula). A patch of increased pigmentation of the skin.
16. Hemorrhage (ecchymosis). When a bloodvessel of the cutis vera
gives way a dark-red or purple mark is produced, which (like the
macula) does not disappear on pressure.
The recognition of the exact anatomical lesion is not sufficient for
diagnosis unless the mode of invasion is observed at the same time.
The rash often spreads from a single focus, or numerous foci appear
and coalesce. The lesion is best studied in the most recent part. Not
only is the mode of local invasion to be noted, but also the uniformity of
the anatomical lesion. Often, instead of a simple lesion, various kinds are
present at the same time, or they develop in successive order ; thus, in
smallpox, we have first the papule, then the vesicle, and finally the pustule.
II. Distribution. The location of the lesion in the various layers of
the skin, and the distribution over the surface of the body, must be
observed. The layers of skin : (1) The horny layer of the epidermis
manifests the pathological changes of hypertrophy, atrophy, dryness,
or desquamation of the cuticle. Dead scales result, in addition to the
hypertrophies and atrophies indicated in the outline. (2) The eruption
in a large number of cases is limited to the living Malpighian layer of
the epidermis and to the papillary layer of the cutis. The hyperemias
(erythemata), and inflammations of all kinds, are confined to these
layers. In this situation they never leave scars. (3) The deep layer
of the cutis is so intimately connected with the subcutaneous tissue that
morbid changes in it involve the latter, and even extend more deeply.
The affections are more severe, but less numerous than affections of the
superficial layers, and are always followed by cicatrices. The changes
in the sweat glands, sebaceous glands, hair, and nails, so far as they
refer to internal medicine, have been treated in another section.
Area of distribution : The distribution of the eruption over different
areas of the body is of great importance in the diagnosis of the various
erythemata due to exanthems and to morbid conditions of the gastro-
intestinal tract. It will be noted more in detail when the specific erup-
tions are considered. The student should also bear in mind the rela-
tionship of eruptions or cutaneous changes of nutrition (trophic disor-
ders) to the affected nerve-supplies.
III. Associate Morbid Phenomena. The student of internal
medicine should particularly observe the associated morbid phenomena,
or concomitant circumstances, in order to determine the nature of the
skin affection, which may be the expression of internal disorder. The
134 GENERAL DIAGNOSIS.
associated morbid phenomena of diagnostic significance are fever, jaun-
dice, albuminuria, and the phenomena of past or present syphilitic dis-
ease, tuberculosis, rheumatism, or the rheumatic habit. The presence of
one of these processes or diseases points to particular affections. Thus,
a large number of eruptions is attended with fever ; another group is
of frequent occurrence in the course of rheumatism ; another class
belongs to syphilis, while a fourth class is associated with anaemia, jaun-
dice, or albuminuria. This subdivision is not based on the nature of
the eruption but on its association with other phenomena. It will be
learned later that all the groups belong to the hemorrhages or the ery-
themata. The true relationship of the two classes of phenomena can be
fully ascertained only by inquiry into the history and course of the erup-
tion and, in addition, into the concomitant phenomena. Thus, if the
eruption is thought to be due to the exanthemata, the period of incuba-
tion, mode of infection, symptoms of the invasion, and the progress of
the attack must be inquired into.
General Symptoms. In order to determine accurately the cause of
an eruption and appreciate its diagnostic significance, the general health
must be inquired into, the condition of the stomach and bowels and
the character of the urine must be ascertained. It must be remembered
that local skin disorders are influenced, for good or ill, by the general
health. Functional disorders of the stomach and bowels are a fre-
quent source of many of the erythemas, while in diabetes pruritus and
forms of dermatitis are of common occurrence. The latter are also ob-
served in Bright's disease. The cause for the eruption is the same in
both, in all probability — that is, a perverted secretion of the skin, or,
if oedema is present, impaired nutrition of the surface.
The subjective symptoms are of great importance in the attempt
to ascertain the true nature of an eruption. Pain, itching, burning,
smarting, and tenderness are significant of the inflammations. Pain
due to inflammation is constant and smarting, burning or throbbing in
character. Sometimes, however, pains of a neuralgic character, inter-
mittent and distributed in the course of nerve- trunks, precede the
development of eruption. This is seen in herpes zoster. Itching is an
important symptom in disease of the skin. It is not present in the
eruption due to the exanthemata generally, except in smallpox, chicken-
pox, and rubella. Its absence is a striking peculiarity of the erup-
tions of syphilis ; but in erythema, especially if associated with oedema,
it is a most annoying symptom. In other skin diseases, as eczema,
psoriasis, and the parasitic affections, it is much more common and of
extreme annoyance.
Itching may be present without any anatomical evidence of skin
disease. It is seen in the troublesome pruritus that occurs in the aged,
particularly about the intestinal and genito-urinary orifices, symptom-
atic of affections of the organs related thereto. It is a symptom which
should lead to an examination of the urine, as diabetes is sometimes*
found to be the fundamental source of the complaint. It has been pre-
viously noted that itching occurs to a high degree in jaundice. It is
also due to the internal administration of drugs, as opium and mor-
phine, and sometimes quinine.
THE DA TA OB TAIN ED B Y OBSEB VA TION. \ 35
In addition to the associate pathological phenomena which should be
ascertained in the study of skin eruptions, in order to determine their
relationship to internal affections, other circumstances should be inquired
into, such as the occupation, the character of the clothing, degree of
cleanliness of the patient ; the effects of climate, the season, tempera-
ture, and the state of the air.
The following very concise outline, taken from the work of the above-
named author, to whom the writer is indebted for much of the data
of this section, is here given to enable the student to appreciate more
thoroughly the pathological relations of the various skin diseases. The
table also shows at once the relation of the eruptions to the internal
disorders which concern us more particularly in this work :
Diseases of the Skin Regarded as Physiological Processes.
( Pathological Arrangement. ^
Acute Inflammations. — Diffuse, e. g., scarlatina, morbilli, syphilis, roseola (eruptive
fevers, erythema).
With venous congestion— Erythema nodosum (rheumatism).
With oedema — Urticaria, erythema nodosum (gastro-intestinal disorder and rheu-
matism).
With necrosis — Furunculus, anthrax (diabetes).
Localized in papules — Enterica (erythemata), syphilis, eczema, prurigo.
Localized in vesicles — Eczema, zona, variola, scabies, herpes, varicella (eruptive
fevers, infectious diseases).
Localized in pustules — Impetigo, variola, scabies, syphilis, sycosis, acne.
Localized in blebs — Pemphigus, scabies, rupia.
Desquamating during involution — Scarlatina, etc.
Chronic Inflammations. — With venous congestion — Acne rosacea, pernio.
With over-production of epidermis — Psoriasis, pityriasis rubra.
With oedema — Elephantiasis.
With fatty degeneration — Xanthelasma.
With hypertrophy — Elephantiasis.
With cicatrization — Cheloid.
With ulceration — Lupus, syphilis, lepra.
New growths — Xanthelasma, lupus, lepra, syphilis, cancer.
Atrophy — The senile skin, linae gravidarum.
Hypertrophy — Ichthyosis, cornu cutaneum, clavis, verruca.
Hemorrhage — Traumatic (e. g., flea bites), typhus, scurvy.
Pigmentation — Syphilitic maculae, melasma, chloasma, icterus, ephelis.
Congenital malformations — Ichthyosis, cutaneous nsevus.
Neurosis— Pruritus (diabetes, jaundice).
Anomalies of Secretion. — Increased, diminished, or perverted — Seborrhea, xeroderma,
hyperidrosis, anidrosis, chromidrosis, etc. Obstructed — Comedo, milium, acne,
sudamina.
A glance at the above outline will show that the eruptions which
particularly concern us belong to the class of diseases to which the term
erythema is applied.
Erythema. Classification. Erythemata may be divided, • in
accordance with the classification of Kaposi, into acute, contagious,
exudative dermatoses, represented by measles, scarlatina, rubella, and
136 GENERAL DIAGNOSIS.
smallpox ; and the acute, non-contagious, inflammatory dermatoses,
which may be further subdivided into : (1) typical forms, idiopathic and
toxic, including urticaria, or nettle-rash • (2) varieties of herpes ; (3)
erythemas due to boils, colds, or erysipelas. The first group of the
won-contagious form includes the class which should always be consid-
ered in connection with the diagnosis of fevers. The skin inflamma-
tions closely simulate in their symptoms the eruptive fevers, even to
the affections of the mucous membranes. Besnier has named them the
pseudo-exanthems, and divides them into rubeloids and scarlatinoids.
Both simulate eruptive fevers throughout their course, and hence both
are acute and febrile. The scarlatiniform erythemas are febrile at the
beginning, subacute in course, but of longer duration than the fever
they simulate. They are the most common forms, and arise from in-
fectious diseases, such as puerperal fever, septicaemia, and gonorrhoea,
or from toxaemia due to drugs or articles of food.
Character of eruption in the non-contagious forms. The ery-
themata are characterized by (a) rose rash with injection of the surface,
either (6) with general oedema, or with circumscribed local oedema,
forming wheals or with papules. In rare cases bullae are also formed.
(c) The rash is followed by a branny desquamation, (c?) The exuda-
tion that attends the lesion is always watery, in contradistinction to the
sero-purulent or purulent exudation of eczema and scabies. Sometimes
slight hemorrhages attend the lesion, as in cases of purpura or of urti-
caria, (e) The course of the erythema is of diagnostic significance. It
begins quickly, and is usually attended with febrile symptoms, some-
times mild, again very intense. (/) The duration is short ; at least it
is not indefinite. The erythemas that are recurrent must not be con-
sidered to be one process of long duration, (g) The locality of the
erythema is not of precise diagnostic significance. The eruption is
usually symmetrical, and the favorite localities may be defined as the
extensor surfaces of the forearms and leg, the face, cheeks, neck, and
the chest and abdomen. True erythema does not attack the scalp, the
flexures of the joints, the palms (except erythema multiforme), nor the
soles. (A) The local symptoms that attend erythemata are mild. Local
tenderness is more marked than in eczema. Smarting and tingling
are complained of, but severe pain and excessive itching are rare. Only
when wheals are present do we find pruritus. The rash of erythema
does not spread. Patches occasionally unite, but an affected area never
enlarges its borders.
The etiology of erythema is involved in obscurity. Although
the frequent associate phenomena are not of etiological, they are cer-
tainly of diagnostic significance. We may have them occur under the
following circumstances : 1. In one class the eruption is symptom-
atic, depending upon dyspepsia or upon rheumatic fever. 2. In the
eruptive fevers, especially scarlatina and measles, in enteric fever and
cholera, and in syphilis, there is an early erythema preceding the later
true eruption. 3. The most striking instance of the relationship to
internal disorder is seen in the rash that arises after the administration
of medicine, as copaiba, or after the taking of certain foods. 4. The
erythemata occur most commonly in children and young people.
THE DATA OBTAINED BY OBSERVATION. 137
They are very frequent in men. The age at which they occur coincides
with that of rheumatism.
Varieties of non-contagious erythemata : First, erythema multi-
forme in simple form, with papules or with exudation ; it may disap-
pear in a few hours, or persist for a day or two and form rings (ery-
thema fugax or erythema annulatum). With the fading of the redness
faint desquamation ensues, and there may be a few pigment marks.
The annular form is observed in rheumatic fever. In addition to
rheumatism erythema multiforme may be found associated with the
following affections : Typhoid fever, puerperal fever, gonorrhoea,
cholera, infectious endocarditis and osteomyelitis, syphilis, leprosy,
vaccination, and surgical septicaemia. Osier has called attention to the
visceral complications of erythema exudativa multiforme associated with
the skin lesions — viz., gastro-intestinal crises, endocarditis, pericarditis,
acute nephritis, and hemorrhage from the mucous surfaces. Arthritis
is also seen in some instances. The skin lesions range from simple
purpura to local oedema, and from urticaria to large infiltrating hemor-
rhages of the skin and subcutaneous tissues. The gastro-intestinal
crises are attended by colic, with vomiting and diarrhoea.
Erythema l,eve often appears upon the tense skin of dropsical
parts. It may be the result of acupuncture.
Vesicular and Bullous Erythema. To this class belong the
affections known as herpes and erythema bullosum.
Herpes zoster is seen in the cutaneous distribution of one or more
nerves. It consists of vesicles of flattened form, ranged in clusters of
twenty or thirty, lying on a reddened, slightly swollen bed of skin.
The number of clusters varies from one to ten. The vesicles develop
in quick succession, beginning usually near the roots of the nerve whose
branches they follow. A short papular stage precedes the vesicles, and
some of the vesicles abort. The eruption tends to dry up in five or six
days. The crusts form in yellowish or brownish clusters, which fall
off in the third week, leaving purple stains.
When the disease attacks the face it follows the course of the fifth
nerve. The several twigs of the trifacial are traced out from their
points of emergence from the bony canals. Great swelling of the eye-
lids sometimes takes place on account of the loose tissue, so that the
lesion may be mistaken for erysipelas. Ulceration of the cornea and
iris sometimes occurs, and, when lower divisions of the trifacial are
affected, vesicles may appear in the mucous membrane of the mouth
and palate. The cervical nerves and those of the upper extremity are
also affected in their distribution. The eruption on the arm rarely
goes below the elbow. When the second and third intercostal nerves
are affected the intercostohumeral branch produces an eruption down
the inner side of the arm. The eruption occurs frequently on the
trunk. Following the course of the dorsal nerves it slants downward
as it approaches the pubes.
In the distribution of the disease in the lower limbs the eruption
rarely extends below the knee or buttocks. It follows the course of
the external cutaneous or anterior crural nerves, or that of the small
sciatic. Some of the branches of the sacral nerves are also affected.
138 GENERAL DIAGNOSIS.
The disease is unilateral, and its precise limitation to one-half of the
body is of the greatest diagnostic significance.
While fever or general symptoms do not usually attend its course
in any marked degree, insomnia and depression are likely to occur,
probably on account of the severe neuralgic pain. Pain is the most
important subjective symptom. It is localized in the nerves, hi the
distribution of which the eruption takes place. It is not so likely to
be present in the young. The pain may precede the eruption by
several days, and persist long after the eruption subsides. This is
particularly the case in old people.
Herpes eabialis, or facialis, consists of vesicles arranged in
groups or clusters upon an inflamed surface. They appear very sud-
denly upon the upper lid or the alae of the nose, sometimes on the
cheek or chin, and they may appear inside the mouth. They undergo
some changes, as in herpes zoster, but are not attended by severe
neuralgic pain. They are also symptomatic of an internal disorder,
an acute catarrh (cold), or follow a rigor, as in intermittent fever or
pneumonia. They may be present in epidemic cerebro-spinal menin-
gitis, but are neyer present in tuberculous meningitis. Diagnosis of
the former disease is confirmed by their presence (Klemperer). Herpes
iris and herpes preputialis have no diagnostic significance of internal
disease.
Erythema Nodosum. With the erythema there is great oedema.
The spots are somewhat painful and tender, but do not itch. The
redness of the erythema is modified by the hue of venous congestion.
Small hemorrhages may be seen. The patches develop on the legs,
their long diameter being parallel to the tibia. They rise slowly into
hard masses. They may be seen on the ankles or the calf, and some-
times on the ulna. They occur frequently in those who have suffered
from rheumatic fever.
Urticaria is a form of erythema in which wheals, sometimes sur-
rounded by an erythematous blush, are seen. It is an acute inflamma-
tory oedema of the cutis. The serous exudation fills the lymph-spaces
and expels blood from the venules. It takes place suddenly, and may
be excited by chemical irritation or a mechanical irritant, as the finger
drawn across the skin. Small patches, or large white areas, are seen,
due to the coalescence of smaller ones (giant urticaria). All parts of
the body may be affected, except the scalp, face, and soles of the feet.
The eruption is not symmetrical. Its course may be acute, or it may
be chronic and transitory, characterized by successive attacks. It is
the form of erythema in which intense itching is the most pronounced
symptom. There are no other subjective symptoms. The itching
causes restlessness and loss of sleep. Urticaria is symptomatic of gas-
tric or intestinal disturbance, or the ingestion of drugs or poisons.
Another form follows the tapping of a hydatid cyst. It occurs some-
times in women at each menstrual period, and may be traced to ovarian
disorder. It may occur after severe shock to the nervous system, with
high fever. It is not an infrequent complication of rheumatic fever.
It occurs in men and women equally, but is most frequent in children
and adolescents.
THE DATA OB TAIN ED B Y OBSER VA TION. 139
Medicinal Rashes. To the erythemata belong most of the so-called
medicinal rashes.
The following drugs are known to cause erythema : potassium bro-
mide and iodide, copaiba, cubebs, the essential oils, capsicum, santonin,
chloral, opium, morphine, antipyrin, salicylic acid and its compounds,
iodoform, belladonna and atropine, tar, carbolic acid, arsenic, cannabis
indica, digitalis, mercury, silver, copper, and antitoxin.
Belladonna produces in susceptible persons, or when administered
in poisonous doses, a diffuse, bright-red erythema, closely resembling
that of scarlet fever, but without the darker red points which interrupt
the latter. Atropine also produces in some persons, especially on the
shoulders, arms, chest, and face, an eruption of disseminated, small,
hard vesico-papules, showing no tendency to pustulation. They are
seated on an inflammatory base, but are more superficial than acne.
The bromides produce a characteristic pustular eruption which is
most intense upon the shoulders, face, chest, and arms. Large doses,
or long-continued administration, are generally required to bring it
out. It is conspicuous upon the face of some epileptics.
The iodides produce an eruption which is not often pustular, but
an erythematous or papular rash is not uncommon. It appears chiefly
about the forearms, face, and neck. Vesicles, bullae, and purpuric
spots are also occasionally seen.
The eruption produced by quinine is generally erythematous, and is
attended with itching and burning ; the face and neck are attacked
first.
Opium and its alkaloid also produce, in susceptible persons, an
erythematous scarlatinoid eruption which is accompanied by intense
itching. Itching, especially about the nose, is much more common
without eruption.
Copaiba produces a vesico-papular or papular eruption which resem-
bles urticaria and erythema multiforme. It is itchy. It is more apt
to be seen on the extremities. It may be purpuric.
The eruption of cubebs is a diffused erythema, with millet-sized
papules, coalescent here and there. Unlike the eruption of copaiba,
it is more copious over the face and trunk than over the extremities.
Antipyrin causes a measles-like or urticaria-like eruption.
Erythemata of Infectious Diseases.
The inflammations of the skin which are symptomatic of a specific
infection are also of an erythematous variety. The term exanthemata
has been applied to the latter, but the eruptions of typhus and typhoid
(enterica) belong to the same class. The characteristics and distinc-
tions of the various forms will be described in sections devoted to the
respective diseases. The student should remember the associate general
phenomena, particularly fever, the onset and the course of which should
be carefully observed.
Roseola. Roseola is of a deep rose-color, not arranged in crescentic
patches, as in measles, nor scarlet and capable of being resolved into
innumerable red points, as in scarlatina. It is not so diffuse as the
140 GENERAL DIAGNOSIS.
latter. It precedes smallpox, scarlatina, measles, cholera, typhoid fever,
syphilis, diphtheria, and malaria. In smallpox, in cases of cholera, and
after parturition and surgical operations, the rash is copious, but is
characterized by being seated over the lower half of the abdomen and
the anterior and inner aspects of the thighs. It may appear elsewhere,
but is usually confined to that portion of the body.
The erythema of roseola may be mistaken for rubella, measles, or
scarlatina. The following are points of distinction : First, it is neither
contagious nor epidemic ; second, there are no prodromal symptoms ;
third, the rash does not come out after a definite period of fever ; fourth,
it is not confined to any special locality ; fifth, the fever is of short
duration and moderate degree, rarely above 101°; sixth, there is no
catarrhal discharge from the eyes or nose or in the pharynx ; the fauces
and palate are reddened without swelling ; seventh, it is not seen in
the mouth, like the eruptions of measles or scarlatina ; eighth, if pres-
ent, the fever which precedes the eruption is of only a few hours' dura-
tion (in scarlatina it lasts twenty-four hours, in measles seventy-two
hours) ; ninth, the rash is not crescentic as in measles, nor punctiform
as in scarlatina, though it must be admitted that severe cases of the
affection cannot be easily diagnosticated, the development of the sequelae
alone concluding the diagnosis.
To add to the confusion, an erythema called roseola often precedes
the eruption of a particular fever. The association with this class of
fevers has been indicated before.
Sufficient reference has been made to the erythemata that attend rheu-
matism. A few other internal (infectious) disorders are associated with
the development of an eruption. In cholera, during the period of reac-
tion, a rose rash which may resemble erythema, urticaria, or scarlatina
appears comcidently with a rise of temperature. It is most frequently
seen on the forearms and backs of the hands, but may cover the back
and limbs. It may be slisrhtlv hemorrhagic and last two or three da vs.
A slight desquamation usually follows. In influenza a roseolous erup-
tion, covering the trunks and limbs and becoming papular, is seen in
rare cases.
In addition, erythematous eruptions are sometimes seen in the course
of B right's disease. Two forms, quite distinct from the previously
mentioned erythema lseve, are observed : the roseola on the feet, legs,
and hands — rarely on the chest and abdomen ; and the papular form
on the thighs, arms, and shoulders. Itching and other subjective
symptoms do not attend the eruption. A form with desquamation
may begin on the limbs. These erythemata are common in the later
stages of Bright's disease, but are not of ill omen. In acute Bright's
disease a transient roseola is observed very rarely ; so also is purpura.
If there is much anasarca in tubal nephritis, erythema is more common.
The eruptions usually appear independently of ursemic symptoms, and
disappear during their continuance. They are in all probability allied
with the inflammation which attacks the lungs and serous membranes
in Bright's disease.
Sudamina. Here may be mentioned another eruption, or condition
of skin, common in the course of internal diseases. Sudamina, or
THE DATA OBTAINED BY OBSERVATION. 141
miliaria, are small, clear vesicles seen in large numbers, usually on the
abdomen, but also on any other part which reflects the light strongly.
They are seen during and after the subsidence of profuse sweats.
While actual perspiration is seen on the forehead, the trunk may
appear free from moisture. When the hand is placed over it, as on
the abdomen, the dryness is noted, but at the same time a roughened,
nutmeg-grater-like sensation is felt. On close inspection this is ob-
served to be due to the eruption just mentioned. The vesicles are
usually of good prognostic omen in the course of febrile diseases, par-
ticularly typhoid fever. They are due to the accumulation of perspi-
ration under the epidermis.
General Diagnosis of Skin Affections.
{Condensed from Pye-Smith.)
I. Factitious Eruptions. We must never forget the possibility of
the affection before us being artificial. AH kinds of dermatites, eczema,
erysipelas, pemphigus, impetigo, may be simulated by the application
of various irritants. Pigmentation also has often been imitated with
success. Such artificial lesions will generally be found upon the arms,
rarely on the face, and scarcely ever beyond reach of the patient's
hands. Mustard, cantharides, and some other irritants can be distin-
guished with the aid of the microscope.
II. Traumatic Eruptions. In all cases of dermatitis we should
seek for the irritant, and sometimes it is so directly the cause of the
disease that the eczema or impetigo in question may be considered
purely traumatic, and efficient treatment immediately follows accurate
diagnosis : sublata causa tollitur effectus.
Pediculi in the hair should be carefully looked for in all cases of
impetigo in children ; pediculi vestimentorum in prurigo of old people.
The acarus of scabies, fleas, bugs, and gnats may be found. In adults,
pediculi pubis may sometimes be found in the axillae as well as in their
proper region, and when they have been destroyed by mercurial oint-
ment the patient is at once relieved from pruritus.
Frequently the irritant must be sought for in the objects which the
patient habitually handles. The coarser kinds of brown sugar are a
frequent cause of eczema of the hands (grocer's itch). So with many
of the " chemicals " used in a variety of modern handicrafts. Constant
washing of the hands in washerwomen, in scrubbers, in potmen, and
many others produces eczema rimosum. The heat of the sun is the
cause of eczema solare and ephelides ; the heat of the fire, of the pig-
ment spots on the shins of elderly people. Sweat, again, is a very
common irritant, producing the erythema which usually accompanies
sudamina and also intertrigo of opposed surfaces. Scratching, as a
cause of traumatic dermatitis, has been repeatedly referred to.
III. Febrile Rashes. We must never forget that a cutaneous
eruption may possibly be part of an acute exanthem. The use of a
clinical thermometer is a great help in this respect. Variola is fre-
quently mistaken for syphilis and other affections.
142 GENERAL DIAGNOSIS.
IV. Medicinal Rashes. Other cases are due to certain kinds of
food or to drugs. They have been described above.
V. Syphilodermata. When we have satisfied ourselves that the
eruption before us is not factitious, nor directly traumatic, nor a symp-
tomatic eruption, we may next consider whether or not it is due to
syphilis. In this inquiry it is undesirable to ask questions the answers
to which are as apt to mislead as to guide aright.
1. We should first consider the color of the affected skin, remember-
ing, however, that the pigmentation which gives the so-called coppery
or raw-ham tint to a syphilitic eruption is the same which is sooner or
later produced by all forms of dermatitis. Psoriasis, chronic eczema,
lichen planus, and prurigo may all produce shades which bear the
closest resemblance to syphiloderma.
2. The lesions of syphilis are multiform. It is rare in any but
syphilitic affections to find mere hyperemia in one part and associated
pustules, papules, scales, or ulcers in others; and it is not often that a
syphilitic eruption exhibits only a single elementary lesion.
A pustular eruption in an adult should always suggest the question
of syphilis when that of scabies has been answered in the negative.
3. Syphilitic eruptions, for some unknown reason, do not itch — the
exceptions to this rule are remarkably few; they usually occur during
the stage of scabbing of pustular rashes or during the healing of
tertiary ulcers. An ordinary secondary syphilide may, however, as a
rare exception, be so irritating that wheals and scratch-marks are
present. On the other hand, psoriasis is often free from irritation,
while the degree of itching of eczema, and even of scabies and prurigo,
varies greatly.
4. The local distribution of syphilitic disease is a great aid in diag-
nosis. Specific eruptions are certainly not, as a rule, symmetrical; the
early roseolous rash is only so because it is general, and therefore, upon
a surface like the human body, more or less symmetrical. Moreover, as
it chiefly affects the face, chest, and trunk generally, it is near the
middle line. But we do not see symmetrical patches of syphilide in
corresponding parts of both sides of the face, both sides of the trunk,
or the right and left limbs. In all but the earliest syphilides the
affected patches are very decidedly and constantly un symmetrical,
irregularly scattered over head, trunk, and limbs, and chiefly remark-
able for having no well-marked seats of predilection.
The forehead, especially about the roots of the hair, is, however,
very frequently the seat both of the early and middle erythematous,
scaly, and pustular syphilides, and the palms of the hands and soles of
the feet are frequently symmetrically affected with the later scaly eruption.
Practically, when we find a disease of the skin occupying some un-
usual position, we should at least consider the question of syphilitic
origin.
5. These signs, alone or in combination, serve to distinguish early
specific roseola from erythema, eczema, scarlatina, and measles, and the
later eruptions from eczema, lichen, impetigo, and psoriasis.
The eruptions of congenital syphilis which are most liable to be mis-
taken are : The so-called pemphigus of infants, which is known by its
THE DATA OBTAINED BY OBSERVATION. 143
affecting the palms and soles ; rupia, which, by the form of the crusts
and the ulcerated surface beneath, may always be distinguished from
impetigo ; an erythematous rash of the nates and genitals of infants,
which is distinguished from eczema of the same parts, also common at
that age, by its coppery color, its blotchy distribution, and more clearly
defined margin.
The tertiary ulcers of syphilis are distinguished by their presence in
unusual places, by their punched-out edges, circular or so-called horseshoe
shape, and by the fact that they usually give little pain or discomfort.
Tertiary ulcers have no predilection for the outer side of the leg, but,
inasmuch as the part above the inner malleolus is, from anatomical
causes, the chosen seat of varicose ulcers, most ulcers in the first posi-
tion will be syphilitic and in the latter not. Moreover, the age helps
in the diagnosis, as varicose ulcers rarely occur before the fortieth year.
Most ulcers on the arms are found to be tertiary syphilitic ulcers.
VI. Tineae. The next group of skin diseases includes those which
are due to vegetable parasites — tinea versicolor of the trunk, eczema
marginatum of the perineum and thighs, tinea circinata of the neck
and other parts, tinea sycosis of the chin, and tinea tonsurans of the
scalp. In all doubtful cases the microscope should be employed.
Tinea of the scalp is rare in adults, and tinea circinata still more so ;
tinea marginata occurs only in adult males.
VII. Primary Superficial Inflammations. To distinguish the
superficial from the deeper kinds of dermatitis, we should notice
whether the cutis alone is infiltrated and thickened, or whether it is
bound down by adhesions to the subcutaneous tissues. The presence
of scars, however slight, is a proof that the process has gone deeper
than the papillae, and has more or less extensively destroyed the papil-
lary layer. Superficial inflammations, excluding those due to acarus,
to pediculi, and to other direct irritants, and excluding also those which
are the result of vegetable parasites and of syphilis, fall, with respect
to their treatment, into three large groups :
The first group, represented by impetigo and most forms of eczema,
consists of inflammations which are subacute, and accompanied with
burning, itching, and pain, sometimes with a slight degree of fever.
The second group of superficial inflammations of the skin is typically
represented by psoriasis, but includes lichen planus, the more chronic,
dry, and obstinate forms of eczema, and true prurigo. These affec-
tions are chronic, with little irritation, exudation, pain, or active signs.
The third group is that of erythemata.
VIII. The Acne Group. Acne, both in its pathology and etiol-
ogy, differs from other forms of dermatitis. The age of the patient
and its distribution are sufficient for diagnosis. It is at once a super-
ficial and a deep dermatitis, and is often followed by scars. Its treat-
ment consists entirely, or almost entirely, in local applications directed
to the correction of the sebaceous affection. With acne may he classed
sycosis and furunculus.
IX. Deep Affections. When we have ascertained that the affect ion
of the skin is deep, that is to say, that it goes below the papillary layer,
the field of diagnosis is limited.
144 GENERAL DIAGNOSIS.
Excluding erysipelas, which is distinguished by its acute character
and febrile symptoms, excluding the pustular affections which affect
the skin deeply and produce scars only at isolated points, such as acne,
variola, and herpes zoster, and excluding, thirdly, leprosy and other
exotic diseases, we have to distinguish in the great majority of cases
which come before us in this country — first, traumatic and varicose
ulcers ; second, gummata and syphilitic ulcers ; third, lupus ; fourth,
rodent ulcer ; and fifth, carcinoma of the skin.
With regard to the first of these, we must not assume, because a sore
upon the skin is said to be the result of a blow or a kick, that it is
purely traumatic, for syphilitic ulcers often arise in this way. Malig-
nant ulcers are rare, and are usually obvious from the age of the
patient, the pain they occasion, their tumid margins, and their blood-
stained secretions. Moreover, they are, with few exceptions, confined
to the neighborhood of the orifices of the body, especially the lower
lip, the urethra, the vulva, and the anus. Rodent ulcer, however, is
very difficult to diagnose with certainty. Its locality, its slow and
painless progress, and its belonging to the latter half of life, usually
serve to distinguish it from lupus ; and its being single, excessively
chronic, and unaccompanied by nodes or other syphilitic lesions, are
the best characteristics for diagnosis from a tertiary ulcer.
The Nutrition of the Skin.
Palpation. The color, as determined by inspection, is a fair index
of the nutrition of the skin, but further information is obtained by pal-
pation. In health the skin is smooth, firm, and elastic. When pinched
between the thumb and fingers and then allowed to escape, it slips
quickly back into its former position. When pressed or squeezed, it
becomes pale from expression of blood, but resumes its natural hue
immediately.
The readiness with which the blood returns after pressure shows the
character of the capillary circulation of the skin. This is active in
health and sluggish in serious disease of the lungs, heart, and blood-
vessels. In the eruptive fevers, especially in measles, scarlet fever,
and smallpox, sluggish capillary circulation with dusky eruption is a
grave sign. In measles it is usually due to pulmonary complications,
and in other infectious diseases to the overwhelming effects of the poison.
As age advances the skin becomes less elastic, and in old persons
may lie in wrinkles. When pinched between the fingers the skin is
more inclined to remain wrinkled. Fat persons whose skin is firm
and hard are in much better condition than those whose skin is loose
and flabby. The latter condition is frequently met with in babies,
particularly those that are fed on artificial foods. When the skin is
thin and dry and loses its tone, so that, when pinched into folds, it
resumes its smoothness but slowly and sluggishly, it is usually evi-
dence, in a person under fifty, of some grave cachexia, as carcinoma.
Moisture and Dryness of the Skin. Moisture and dryness are in
one sense correlated with the nutrition of the skin. It is quite certain
that when the skin is abnormally dry its nutrition is impaired.
THE DATA OBTAINED BY OBSERVATION. 145
In health the skin is not perceptibly moist, except as the result of
physical exertion or under heat, or as the immediate result of imbibing
a hot fluid or a sudorific drug. There is considerable individual differ-
ence, however, within the limits of the normal. Rheumatic and stru-
mous persons may have a perceptibly moist and oily skin at all times,
while others have a skin which perspires very little, even under influ-
ences which usually bring about perspiration.
Pebspieation Ijsfceeased. Hyperidrosis. It may be general or
local.
A. General increased perspiration is seen — 1. With fever. It occurs
in the course of rheumatism, when the sweats are strong in odor and
acid in reaction. It is seen in tuberculosis, especially the miliary
variety. It is sometimes marked throughout cases of typhoid fever.
General perspiration also attends the violent muscular action of tetanus,
but is not seen in epilepsy. An example of general sweating is seen in
that curious affection to which the term " sweating sickness " has been
applied. It is a fever the nature of which is not well known, but in
which this symptom is most pronounced. Sweating is extreme in
trichinosis.
2. AVith normal or subnormal temperature, a. Sudden, temporary
perspiration. Sweats occur from excitement or slight exertion in
patients during convalescence. A general profuse perspiration may be
of short duration and occur suddenly after fright or shock in health.
It is the characteristic perspiration of collapse. The forehead is cov-
ered with sweat, large drops stand out on the face, the hands and feet
are moist or wet with perspiration, and the whole surface of the body
" leaks." It is attended by a cold and clammy skin. In the collapse
of all forms of shock, or after hemorrhage or profuse discharge, as in
cholera, this form of perspiration is seen.
More striking still are the perspirations that suddenly break out in
the course of acute disease coincidently with a fall of temperature. We
have (1) the critical sweats of pneumonia and relapsing fever ; (2) sweats
which terminate a paroxysm of intermitting fever, whether of malarial
or infectious origin (see Fever) ; (3) the profuse perspiration that
attends pyaemia, breaking out with each fall of temperature to disappear
as it rises ; (4) the night-sweats that attend tuberculosis and other ex-
hausting diseases. In tuberculosis and in pus-formation or accumula-
tion the oscillation of temperature, with or without chills, followed by
sweating, is known as hectic. Sudden breaking out of general per-
spiration, but more notably seen on the face, attends dyspnoea of pulmo-
nary origin and the attacks of dyspnoea in the course of organic heart
disease. These perspirations are at times the result of an effort at
elimination, on the part of the skin, to relieve the kidneys or bowels,
such as the perspiration of urcemia, which is attended by a urinous
odor. At times it may also occur in jaundice. In the conditions just
mentioned there are coolness of the skin and cold extremities.
b. Prolonged, Perspiration. In exhausting diseases, general and
persistent perspiration may occur, particularly in the later stages, as in
tuberculosis, and in any disease attended by persistent dyspnoea.
10
146 GENERAL DIAGNOSIS.
B. Local increased perspiration (hyperidrosis localis) occurs when
there is local vasomotor paresis. Thus, in organic diseases of the brain
and hi affections of the peripheral nerves, in some forms of neuralgia,
in migraine and in hysteria, it has been observed. Sometimes one
side of the body alone is affected, even in a malarial paroxysm (hemi-
drosis).
Local sweats are sometimes significant. This is the case particularly
with a sweat confined to the head, which occurs usually in children, and
is one of the striking characteristics of rickets. With the local sweat-
ing the patient rolls his head at night from discomfort. The hair on
the back of the head is rubbed off.
Unilateral sweating of the head may arise from destructive pressure
on the sympathetic nerves, causing paralysis of the dilator fibres of the
cilio-spinal branches, in thoracic aneurism, and in caries of the lower
cervical vertebrae. There are usually contraction of the pupil and con-
gestion of the face on the same side.
Diminished Peespieatiox. Anidrosis. The skin is abnormally
drv in the early stages of acute disease attended by fever, particularly
if the febrile rise takes place suddenly, as in acute digestive disorders
of children. In adults, when the disease is accompanied by high fever,
as in thermic fever, the skin is dry. In the first day of the eruption
of the exanthemata the dryness is marked. Dryness of the skin is of
frequent occurrence when there are copious discharges of water from
the bowels or the kidneys. In choleraic diarrhoea the dryness occurs
suddenly. In some affections, as diabetes and Bright's disease, the
dryness extends over a long period of time, and is frequently attended
by eruptions or desquamations and by the formation of boils. When
there are accumulations of serum in the lymph-spaces of the subcu-
taneous connective tissue, or changes in the connective tissue, as in
dystrophies or myxoedema, or scleroderma, the skin is dry because of
the stretching and pressure on the bloodvessels.
Scars. Scars are important proofs of the occurrence of previous
disease, especially smallpox, chickenpox, and syphilis. Scars of the
first two occur in the form of circular pits, and almost always on the
face. Scars of syphilis are larger, circular, or oval in shape, and seen
usually to the best advantage on the extremities, but the single scar on
the forehead is strikingly suggestive. Scars upon the legs in persons
under thirty years of age, when not traumatic, are almost always
syphilitic. Scars as the result of suppurating glands are seen most
frequently in the neck, but may be found wherever there are glands,
especially under the jaw and in the axilla and groin. They are most
liable to occur in tuberculous persons, either spontaneously or as the
result of the exanthemata, erysipelas, or other infectious disease. When
such scars are met with in a person with incipient tuberculosis the
prognosis becomes more anxious.
The appearance of the scar indicates its age in a general way, and
hence throws light upon the patient's previous history, and also serves
as a check upon the accuracy of his statements.
Scars the result of wounds, injuries, or operations may be seen any-
THE DATA OBTAINED BY OBSERVATION. 147
where ; they are of importance only so far as they may furnish a clue
to the cause of existing disease. Of such nature are the scars upon the
head in cases of brain disease, particularly epilepsy.
The scars of pregnancy, the strise seen upon the lower part of the
abdomen and the upper part of the thigh, must not be confounded
with similar scars that occur in great oedema, and which are some-
times found in fat persons. They are also seen after typhoid fever.
CHAPTER XI.
THE DATA OBTAINED BY OBSERVATION— {Continued).
The subcutaneous connective tissue. CEdema — causes — mode of recognition — situation
— feet, face, arms, and head — oedema of trichinosis — angioneurotic oedema.
Myxcedema. Connective tissue dystrophies. Scleroderma. Sarcomata — cysti-
cercus cellulosae — brawny induration. Subcutaneous nodules. The lymphatic
glands. Enlargements — local — general. Adenitis. Hodgkin's disease. Tuber-
culosis and leucaemia.
THE SUBCUTANEOUS CONNECTIVE TISSUE AND
LYMPHATIC GLANDS.
Enlargements or swellings of the subcutaneous connective tissue,
other than the skin tumors and papular eruptions, on any portion of
the surface of the body, are due to some change in the tissue or the
structure or organs directly underneath the swollen part. CEdema,
myxcedema, subcutaneous emphysema, dystrophies, scleroderma, brawny
induration, and local subcutaneous swellings are the principal ones to
be considered.
(Edema; Dropsy.
The lymph-spaces of the subcutaneous connective tissue become over-
distended with sermn, causing an accumulation to which the general
term dropsy is applied. If the accumulation is local and confined to
small areas it is known as oedema. If it is general, and if, in addi-
tion, the large lymph-cavities, the pleura, the peritoneum, and the
pericardium contain fluid, it is known as anasarca. Accumulation
occurs because more fluid is poured out by the vessels than can be
removed by the lymphatics and veins. This may depend either upon
obstruction of the veins and lymphatics, or excessive exudation from
the bloodvessels, or both. The former condition, however, is rare,
and usually local, because, unless the obstruction is very great, the
veins and lymphatics are able to carry away more fluid than is effused
from the capillaries.
1. Excess of fluid transudes when there is local capillary change
from inflammation or the effects of poisons. The change must be in
the capillaries. It was thought that this general process was of an
inflammatory nature, but at present it is believed to be due to the in-
fluence of poisons, probably absorbed from the intestinal canal, alter-
ing the nutrition of the capillary vessels. Thus, the oedema and
general dropsy of albuminuria, particularly in the early stage of that
affection, are thought to be due to a poison circulating in the blood
which also causes the nephritis. Mahomed found a pre-albuminuric
THE DATA OBTAINED BY OBSERVATION. 149
stage of scarlet fever, in which lie noted a peculiar reaction of the
urine, which gave a blue color with guaiac. A brisk purgative admin-
istered when this reaction was noticed would prevent the occurrence of
albuminuria, whereas if the drug was withheld albuminuria always
followed. The purgative removed the poison which caused the
nephritis and oedema.
It is well known that in urticaria there is marked local cedema.
Brunton thinks that some poisons circulating in the blood cause paral-
ysis of the secreting power of the sweat-glands, on account of which
there is not only effusion from the bloodvessels, but at the same time
such changes in the secreting-cells take place as to produce an acid,
the local irritative action of which, upon the capillaries, causes a
further transudation of fluid. That acids circulating in the blood have
the power of creating cedenia, the experiments of Cash and Brunton
fully demonstrate. AVhile, therefore, in the oedema of Bright's disease
in its earliest stage and in urticaria we have this explanation of the
phenomena, other factors are causal in other forms of cedema.
2. Increased transudation and obstruction to the flow of lymph are
the causes of some forms of oedema. It may be of local origin, as in
the oedema over the site of an inflammation or the oedema of an arm
or leg from venous occlusion, or it may be of general origin, as in car-
diac disease. The obstruction may be in the lymphatics or in the
veins. In the former it may occur («) from want of muscular action ;
(6) from want of inspiratory action of the thorax ; (c) diminution of
the diastolic suction of the heart ; (d) positive pressure on the veins.
In the latter, obstruction of the veins is caused by conditions similar to
those affecting the lymphatics, and arises from (a) want of muscular
action ; (6) want of movement of the thorax ; and (c) feeble action of
the heart ; and, in addition, it is likely to be caused by (d) complete
arrest of blood-flow from external pressure upon the vein or from
plugging of the vein. It can readily be seen, with a little knowledge
of physiology, how the above factors favor the development of cedenia
due to disease of the heart and to venous obstruction. The baneful
factors are those which retard the flow of blood, preventing its return
to the right heart. Hence it is called the oedema of passive congestion.
3. A third form of oedema, usually slight, is that which is seen in
anaemia. Several factors combine to produce it : (a) the watery con-
dition of the blood ; (6) the condition of the capillaries ; and (o) vaso-
motor paresis on account of imperfect nutrition of the vasomotor
centres. It may be diffused, as in the anasarca that attends the
anaemia of malaria.
4. (Edema may be of nervous origin. Such is the oedema that
occurs in diseases or injuries of nerves. To it possibly belongs the
cedema of beri-beri. It may be a trophoneurosis with secondary alter-
ations in the permeability of the vascular walls, or it may be clue to
vasomotor paralysis.
Mode of Recognition. Whether the accumulation is in local areas
or distends the entire subcutaneous tissue, the cedema is not difficult of
recognition. The part is swollen and puffy, the surface is pale, smooth,
and shiny, the temperature is usually low, and the affected area pits
150 GENERAL DIAGNOSIS.
on pressure. Pitting is more pronounced if the finger is pressed over
a part which is seated upon a firm background, as bone. CEdema of
the ankle or over the tibia is more readily recognized than oedema in
the calves.
The oedema obliterates normal depressions and increases the rotundity
of the affected part, It causes deformity, as of the face and neck
or of the penis, when the accumulation of serum is considerable. The
swelling appears in the most dependent parts if the oedema is diffuse
or the cause is general, as in cardiac disease ; or in parts made up of
loose connective tissue, as the eyelids or scrotum. The temporary dis-
appearance of the oedema, either entirely or from one part, to apj)ear
in another, is a prominent feature of it. It will disappear between
morning and evening, or its position will alter with change in the posi-
tion of the body. The presence of a previously existing oedema can
often be told by the scars or striae that resulted from overstretching of
the skin, as of the abdomen and thighs.
CEdema is to be distinguished from — (1) Inflammatory swellings,
by the absence of the classical signs of inflammation : pain, heat, and
redness. (2) The enlargement of myxoedema differs from oedema by
the absence of pitting on pressure, the occurrence of induration, which
resists the pressure of the finger, and by the occurrence of anaesthesia
or analgesia. (3) The swellings of connective-tissue dystrophies are
hard, localized areas that do not pit on pressure, and are not seated in
dependent parts of the body. They are found on the arm, for instance,
or on the thigh, or about the flanks and in the axillae. (4) The swell-
ing of subcutaneous emphysema differs from oedema in that it arises
hi the course of some disease of the air-passages, and, on palpation, the
crackling sensation of air under the finger is distinctly felt, while there
is no pitting on pressure. In the cases that the writer has seen the
parts were particularly tender, although pain in subcutaneous emphy-
sema is said usually to be absent,
Diagnostic Significance. The value of oedema as a diagnostic sign
depends upon its location, its mode of development, and its association
with disease of other organs or structures of the body.
Location. The oedema may be limited to small areas, as the eyelids,
the face, or the feet, or to an arm or leg ; it may involve an arm and
leg of the same side ; or it may involve the extremities and trunk and
even include the face. We therefore have local and general oedema.
Local (Edema. Local oedema occurs when there is pressure on a
vein or occlusion of it by a thrombus. CEdema of the arm from press-
ure on the veins by enlarged lymphatic glands in the axilla, and oedema
of the leg from thrombosis of the femoral vein, are examples of this
form of local oedema. Dropsy of an arm often occurs when the patient
has laid upon it. Local oedema also occurs over the seat of inflamma-
tion, and is a valuable diagnostic sign. It is an indication of suppura-
tion. It is known as " inflammatory " or " collateral oedema." It is
due to obstruction of the lymph circulation. It is seen over the mas-
toid when its cells are the seat of inflammation ; over the parotid
gland under the same circumstances ; over parts of the thorax in em-
pyema ; over the prsecordia in purulent pericarditis ; over the surface
THE DATA OBTA IN ED B Y OBSEB VA TION. 151
of the liver in some cases of hepatic abscess ; in the abdominal parietes
in purulent peritonitis, but more marked over the primary focus of in-
flammation, as the gall-bladder region or the region of the appendix.
The Arms and Thorax. Another form of local oedema occurs
when there is pressure upon the superior vena cava from aneurism or
disease of the mediastinal glands. The oedema is then limited to the
arms, head, neck, and thorax. Such oedema is usually associated with
cyanosis of the hands and arms. There is also marked distention of
the veins of the upper parts of the body. The oedema has been found,
in a few instances, to be more marked on one side than on the other.
This has occurred in cases of aneurism which communicated with the
vena cava. Either the collateral circulation on one side had been
established or pressure was greater on the left innominate vein. The
oedema is sometimes limited to the head and arms. If the obstruction
of the superior cava is situated below the entrance of the azygos vein
the chest shares in the venous congestion and resulting oedema. If,
on the other hand, the obstruction is above the azygos vein there is
no oedema of the chest-wall. This form of oedema, as a rule, is easily
recognized by the presence of the above-mentioned symptoms, with
other pressure-symptoms, due to disease of the mediastinum and by
the results of physical examination, which reveals the presence of a
tumor in the thorax. It usually develops slowly, hand-in-hand with
the other symptoms. At times, however, it occurs suddenly. Sudden
oedema in this situation is always due to an aneurism which has rup-
tured into the vena cava (see above). The sudden onset is attended
by physical signs of aneurism, or, if they are not present, by a murmur
characteristic of the communication between an artery and a vein. It
must be confessed that often the physical signs are not precise and the
murmur is absent. The suddenness of the peculiar localized oedema is
the chief point of oliagnosis in favor of this rare form of aneurism.
The GEdema of Trichinosis. (See Face.) (Edema of the skin over
the affected muscles, as well as of the face, occurs in trichinosis. It
begins early in the disease, disappears after a few days, to return again
later. It is localized over the muscles, and is associated with the
growth of trichinae in them. It is distinguished from cardiac and
renal dropsy by its course and situation as well as by the fact that the
scrotum and labia majora are never cedematous.
The cause of the above forms of oedema is local and in close prox-
imity to or in intimate anatomical relation with the dropsical swelling.
But the cause of local oedema may be central, or in a sense general.
It then develops gradually and begins in special localities, as in the
feet or face.
The Feet. (Edema of the feet or ankles is usually due to disturb-
ance of the circulation. It arises in heart disease, or hi the course of
any exhausting and debilitating disease in which the heart has become
weakened. The organic change which takes place in the heart-muscle
(dilatation) in the course of obstructive valvular disease and in. lung
disease is often attended by oedema of the feet. Later a general dropsy
may ensue. But oedema of the feet may occur from another cause —
i. e., ancemia. In all forms of this affection puffiness of the ankles may
152
GENERAL DIAGNOSIS.
be seen. An explanation of the cause has been given. Similar local-
ized oedema in individuals of relaxed fibre occurs in the evening after
a day of considerable physical exertion. GEdeina of the feet, subse-
quently becoming diffuse, occurs in beri-beri.
(Edema of the Face. (Edema may begm or remain localized in
the face, and is very striking. (See Face and Eyelids.) It may be
limited to the eyelids, as a simple puffiness, or may spread over the
entire face, causing complete * obscuration of the normal outlines. It
is the oedema of renal disease, and differs from oedema of the feet in
Fig. 19.
Face of a patient with general anasarca due to chronic parenchymatous nephritis. (Hare.)
that it is more marked in the morning on rising and disappears toward
nicht. Of all forms of local oedema it is the most grave, and should
at once call attention to the condition of the urine, particularly if the
patient has just had an attack of scarlatina, or if it occurs in a woman
who is pregnant.
The diagnostic significance of primary local oedema may be summar-
ized as follows : (1) Eyelids or eyes (" Bright " eye, " tear that does not
fall ") in nephritis ; (2) faee, nephritis ; (3) forehead, trichinosis; (4)
head, pressure upon superior vena cava above the azygos vein ; (5) one
side of head, pressure upon innominate vein ; (6) head and arms, or
head, arms, and thorax, pressure upon superior vena cava ; (7) one
arm, pressure upon axillary veins ; (8) one leg, pressure upon femoral
vein ; (9) both feet or legs, pressure upon inferior vena cava by abdomi-
nal tumor, loss of vasomotor tone, heart disease, anaemia, late nephritis ;
(10) the loins, " lumbar cushion," nephritis, cardiac disease if patient is
in recumbent posture ; (11) the scrotum, nephritis and cardiac disease ;
THE DA TA OB TAINED B Y OBSER VA TION. 1 53
(12) local oeclemas over inflammations of structures underneath, as
bones, the gall-bladder, the appendix, the pleura, peritoneum, or peri-
cardium.
General (Edema. Anasarca. General anasarca is due to heart or
to kidney disease in most of the cases. (Edema of the face and feet
may become general. In cases in which the face is first oedematous its
extension may be very rapid, so that twenty-four to forty-eight hours
after the swelling is noticed the whole body is in a state of anasarca.
Renal disease. The extension of oedema, primarily seated in the feet
and legs (cardiac dropsy), throughout the rest of the body is more
gradual, and develops with other signs and symptoms of weakness of
the heart. Hence cyanosis gradually appears. This may be seen first
in the extremities. Finally the face and lips take on the peculiar hue.
On the other hand, in the general anasarca that follows the local
oedema of the face in Bright's disease, pallor occurs, and as the oedema
increases it becomes more and more of a waxy hue, while the extremi-
ties beome glistening or shining in appearance. In the so-called " wet
form " of beri-beri general oedema comes on rapidly.
Angioneurotic (Edema. This curious affection is not of frequent
occurrence. It may be present in the individuals of several genera-
tions of a family. The attack comes on suddenly. The swelling is
circumscribed. It may appear on the face, on the brow, the lips, or
cheek. The eyelid is a common situation. It may also occur on the
backs of the hands, the legs, or in the throat. It remains but a short
time and disappears as quickly as it came on. The outbreaks have
exhibited distinct periodicity. Local symptoms of itching, heat, or
redness, or general urticaria, may precede the swelling. The sudden
swelling causes great deformity. If the upper lip is affected, the
mouth cannot be opened ; if the hands, the fingers cannot be bent. In
the hereditary cases the attack recurs every three or four weeks. The
danger to life is from oedema of the larynx, which caused death in two
of Osier's cases. The general symptoms that attend the attack are
gastro-intestinal. Nausea and vomiting occur, followed by severe colic.
It must not be confounded with simple urticaria, or the giant form of
that affection, with which it may, however, have close affinities. It is
regarded by Quincke as a vasomotor neurosis, which leads to impair-
ment of the permeability of the vessels.
Recapitulation. From what has been said the student will observe
that oedema may be local or general ; that local oedema may be uni-
lateral or bilateral ; that oedema may be further subdivided, in accord-
ance with the cause, into inflammatory dropsy, oedema or dropsy of
passive congestion, hydrsemic dropsy, and vasomotor dropsy. The
forms of passive dropsies just indicated may be subdivided into cardiac
dropsy, hepatic dropsy, and renal dropsy, according to anatomical
causes.
While the account of oedema just given refers more particularly to
the subcutaneous accumulation of serum, the same pathology and
etiology apply to accumulations in the large lymph-cavities, and hence,
in addition to general oedema, we may have ascites, hydroperica;rdi '/u tin ,
hydrothorax, hydrocele, and effusion in the joints. The methods of
154
GENERAL DIAGNOSIS.
recognition of dropsy of the larger cavities will be deferred until dis-
eases associated with these particular regions are discussed. It must
be remembered that oedema or accumulations of serum in cavities may
be of local or general origin.
It must not be forgotten that two or more causes may combine to
produce a dropsy, or that a dropsy of one cause may for a time be
dependent upon a second and even a more pronounced factor later on
in the development of the disease. Thus (a) the dropsy of hydremia
may be aggravated by that of (6) weak heart which arises from
ansemia, to which may be added later the dropsy of vasomotor paresis.
The dropsy in Bright's disease is clue to (a) capillary changes pro-
duced by a poison circulating in the blood, and (6), later, to the con-
dition of the heart if, as is frequently the case, it undergoes dilatation.
Myxoedema.
Enlargement of the surface of the body, local or general, is also seen
in myxoedema, a condition which simulates dropsy, as already stated.
In myxoedema the swelling is general. The face is involved. The
Flo. 20.
A typical case of myxcedema. (Starr.)
arms are more markedly swollen, however, than the fingers ; the legs
more than the feet. Usually the swelling of the legs and arms is
irregular. In some cases supraclavicular paddings are marked. These
THE DATA OBTAINED BY OBSERVATION. 155
paddings must not be confounded with the pseudo-lipomata, described by
Verneuil, occurring in these situations. The swelling is due to the
infiltration of mucin into the connective tissue, and arises from some
affection of the thyroid gland. The gland is absent, functionally or
actually. The hard, indurating, non-pitting swelling is associated
with striking change in the appearance of the face, particularly the
nose and forehead. The nose becomes thickened, the forehead more
prominent and overhanging. The outline of the face is rounded, so
that the term " full-moon " is applied to it. The skin is thickened,
dry, and rough, somewhat translucent in appearance, pale or yellow in
color, and of a doughy consistence, but with a moderate degree of elas-
ticity. The perspiration is diminished. The hands change in shape,
they become square or spade-shaped, and the fingers clubbed. The
appendages of the skin change. The nails become brittle and dis-
torted, the hair dry, harsh, and brittle, and it may fall out. With
these remarkable changes in the exterior marked nervous and mental
symptoms arise. Speech is thick and hesitating, the memory feeble.
The intellect is dull and irresponsive, the temper irritable. Sensibility
is impaired, particularly the loss of sensation to pain. Patients have
been burned without their knowledge. This happened in one of the
writer's cases. Abnormal sensations of heat and chilliness are com-
plained of, as well as other paresthesias. The patient is anaemic, the
temperature is subnormal, the heart's action weak, the respiration slug-
gish. Breathlessness on slight exertion is pronounced, and exertion
itself is very difficult, while there is a greater sense of fatigue than the
exertion and the condition of the organs would warrant. The mus-
cularity is enfeebled. There are impairment of appetite, indigestion,
and flatulency. The urine may become albuminous, but for a long
time is not characteristic save in amount and specific gravity. The
former is increased, the latter lowered.
As the case advances mental and physical failure become more pro-
nounced, the patient is subject to hallucination, and is extremely irrita-
ble. Stupor sets in ; death may take place in coma or from uraemia.
It is a disease of mature life, and occurs most frequently in women.
The following varieties are seen : (1) Spontaneous myxoedema of
the adult ; (2) infantile myxoedema ; (3) operative myxoedema ; and
(4) endemic myxoedema or cretinism. In infantile myxoedema the
functions of the thyroid body are suppressed during the period of the
development of the individual. Typical cases justify the name of
myxoedematous idiocy.
Subcutaneous Emphysema.
Enlargement or swelling of the surface, either local or general,
may occur on account of air underneath the skin. The skin is pale
and quite distended, and hence depressions are filled up, as the axil-
lary, clavicular, and intercostal spaces. The primary seat of the swell-
ing is in close proximity to the air-passages, and occurs because of
communication between them and the subcutaneous connective tissue.
It may occur in ulcerations of the upper passages, as the larynx or
156
GENERAL DIAGNOSIS.
Fig. 21.
trachea ; in ulcerations of the oesophagus into the mediastinum ; in the
ulceration and rupture of phthisical cavities into the chest-wall ; and
in rupture of the lungs from hard coughing, sharp crying, severe
exertions, such as blowing of wind instruments. The air may escape
under the pleura to the mediastinum and thence to the neck, or, when
the pleura is adherent, air will pass from the lung into the connective
tissue. The swelling gradually spreads over the entire body from the
seat of rupture or in close proximity to it. In a case of laryngeal
phthisis under the writer's care it encircled the neck and spread uni-
formly over the anterior and posterior portion of the thorax. Thence
it extended downward until it met a corresponding infiltration of the
lymph-spaces in the thighs, due to serum. The distinction between
cedematous swelling and subcutaneous
emphysema could thus be made : the
latter offered no resistance, did not
pit on pressure, crackled under the
finger, and was quite tender on press-
ure. Spontaneous pain was not pres-
ent ; but any position was painful in
which the weight of the body pressed
upon the part affected.
Connective-tissue Dystrophies.
Enlargements of the surface -are
seen in the so-called dystrophies.
The dystrophy is usually due to a
localized anomalous overgrowth of
connective tissue, probably of trophic
origin. It can easily be distinguished
from oedema by the absence of the
signs of cedema, or from local inflam-
matory swelling by the absence of
pain, heat, and redness. The swell-
ing occurs on the arms and legs,
usually on the outer aspects, and may
occur in various portions of the trunk.
In one of the writer's cases the swell-
ings were periodical ; or, rather, the
persistent swellings increased in size
at irregular intervals.
Dercum and Henry have described
cases of dystrophy in which the en-
largements had been attributed to
accumulations of fat. The patients
presented marked subjective nervous
phenomena, paresthesias of all kinds,
with flushings and sensations of sinking and depression. There were
areas of anaesthesia, pain, and tenderness in the nerve-trunks. Pain
preceded the advent of the swellings.
Note accumulations on back and on ex-
tremities. See knees and elbows ; wrists and
ankles unusually small. Patient aged 56.
Second attack of insanity. (Original.)
THE DA TA OB TAINED B Y OBSER VA TION. \ 57
Herpes zoster occurred in Dercum's case, and other symptoms of
neuritis were marked. The irregularity in the distribution of the
swellings, their character and mode of development, the occurrence of
neuritis, and the absence of perspiration, distinguished dystrophy from
lipomatosis or excess of fat. The patients were of a neurotic type, and
mental impairment usually resulted in the course of the disease. The
general nutrition failed, particularly as gastro-intestinal disorders
ensued.
Scleroderma.
Scleroderma is a hyperplasia of the subcutaneous connective tissue
with swelling and induration. It is brawny. As the tissues are almost
immovable, the term "hide-bound " is applied to this condition There
are marked stiffness and also pain.
In localized scleroderma, or morphcea, the skin has a waxy or dead-
white appearance, is brawny and inelastic. There may be preliminary
hyperemia of the skin. Subsequently pigmentation of the hypersemic
area takes place, causing changes in color, or the pigment may atrophy,
causing leucoderma. The secretion of sweat is diminished or entirely
abolished. In the diffused form the affection begins in the extremities
or face, and is accompanied by a sense of stiffness or tension ; the skin
is usually hard and firm, and gradually a diffuse, brawny induration
develops. The skin cannot be picked up in folds. It may appear
normal, but is generally very smooth, glossy, and dryer than usual,
rarely pigmented. Scleroderma may be confined to a limb or may
become universal. The appearance of the face is characteristic. It is
expressionless, and the lips cannot be moved, while mastication is im-
possible ; the eyes and the nose are deformed ; the hands become fixed
and the fingers immobile and contracted, on account of induration
about the joints, the deformity being called sclerodactyle. It is thought
to be due to a trophoneurosis, or to fibrosis of the arteries of the skin,
with connective-tissue overgrowth in the adjacent areas.
Brawny Induration.
(Edema must not be confounded with the brawny induration of the
calves of the legs in scurvy, probably from deep-seated hemorrhage.
It must be remembered, however, that oedema of the ankles is very
common in this affection. Brawny induration may also be found in
syphilis. In a patient recently under the writer's care, in the Presby-
terian Hospital, a brawny induration of the thigh, with painless swell-
ing and stiffness of the leg, appeared to be due to syphilis. It disap-
peared rapidly under treatment with potassium iodide.
Localized Subcutaneous Nodules.
Sarcomata. The subcutaneous nodules seen in these affections are
rarely, if ever, confounded with oedema or other swellings. In sar-
coma the subcutaneous tumor becomes attached to the skin and may
change its color. It is usually secondary to sarcoma in some other
158 GENERAL DIAGNOSIS.
organ of the body. When primary, or secondary to organs in which
there is normal pigmentation, as the eye, they become blue or bluish-
black. On palpation the surface is found to be rough and uneven if
the tumors are numerous.
Primary melanotic sarcomata of the skin can always be distinguished
by their color. In both forms of sarcomata the general symptoms of
this affection daily become more and more pronounced, and subcuta-
neous hemorrhages are commonly associated with the local phenomena.
The first external evidence of lymphosarcoma may be subcutaneous
nodules in unusual situations. Thus, in a case under my observation,
a lymphoid nodule was first observed in the third interspace on the
right side. Subsequently the glandular involvement followed.
Carcinomata. Subcutaneous lymphatic glands may be the seat of
secondary carcinoma, and from their location may indicate the primary
source of the disease. The glands above the left clavicle are some-
times secondarily affected in cancer of the stomach. In similar dis-
eases of abdominal organs glands in the abdominal wall are enlarged.
The subcutaneous nodules should be removed and examined microscop-
icall y. The structures of the umbilicus (skin and subcutaneous tissues)
enlarge, become nodulated, and sometimes the seat of fungoid ulcera-
tion in abdominal carcinoma, particularly of the stomach. It must
not be forgotten that primary sarcoma or carcinoma of the skin, lim-
ited to one area, and simulating an intra-abdominal growth, may occur,
as in a case under my care in the Philadelphia Hospital, operated on
by Horwitz.
Cysticercus Oellulosse. The nature of the subcutaneous nodules
of cysticercus are recognized by microscopic examination. They are
usually associated with the larvae in other tissues, hence the patient
complains of great soreness and stiffness, and may become helpless.
Rheumatic Nodules. Subcutaneous nodules are seen in rheumatic
patients in the course of the disease, or after the attacks. They are
common in the young. They are particularly frequent in cases of
rheumatic endocarditis. They may occur independently of the articu-
lar symptoms. They may occur in large numbers, and vary in size
from a small shot to a large pea. They are of fibrous structure.
They are attached to the tendons and fasciae, particularly on the fingers,
hands, and wrists, but may be found over the elbows, knees, the
scapulae, and the spines of the vertebrae.
Syphilitic Nodes. Gummata are observed in the tertiary periods
of syphilis. They must not be confounded with the enlarged glands.
They are attached to the skin, and may from time to time ulcerate.
They may be seen on the back or buttocks ; less frequently on other
parts.
The Lymphatic Glands.
Information of diagnostic value may be obtained from the condition
of the lymphatic glands. (See Chapter VII.) Enlargement may be
general or local.
Enlargement of the cervical glands, and of the axillary and inguinal
glands attended by fever, occurs in that obscure infection described by
THE DATA OBTA IN ED B Y OBSER VA TION. 159
Dawson Williams and others called glandular fever. Similar glandu-
lar enlargement is quite characteristic of German measles or rotheln.
(See the Infections.)
Enlargement of the post-cervical glands, the epitrochlear glands, and
lymphatic glands in other portions of the body points to syphilis. In
the two first-mentioned localities the enlargement is of great diagnostic
importance, as it is less likely to be due to any other causes. Suppu-
rating glands do not here concern us.
Inguinal and Axillary Enlargement. With or without suppuration,
enlargement always points to an irritation or lymphatic invasion in
the area drained by the affected lymphatic gland. When in the groins
the feet are affected, and when in the axilla? the hands. Great enlarge-
ment in either situation causes oedema of the corresponding extremity
if the veins are pressed upon. The axillary glands are early affected
and enlarged in mammary cancer. The breast should always be
examined in oedema of the arm.
The Supraclavicular Glands. These glands are often enlarged
and indurated, and may cause pressure-symptoms. The only local
enlargement that is of special diagnostic significance is that which is
seen above the clavicle on the left side. They often point to carci-
noma of the stomach, as Troisier announced. 1 Indeed, there are cases
of this disease in which only the general symptoms of carcinoma are
present. Local symptoms are wanting and the locality of the cancer
cannot be made out by the symptoms. The enlarged glands above the
clavicle are a fair indication that the stomach is the seat of the disease.
The enlargement is probably due to transmission of the infection
along the thoracic duct and its lodgement in the associated glands.
The Cervical and Submaxillary Glands. Enlargement of the
submaxillary and cervical glands points to affections of the mouth
and throat or of the jaw and teeth. It is caused particularly by infec-
tious disorders in these localities. They are often the seat of nodular
enlargement in actinomycosis. (See " collar " in adenitis of leukaemia.)
Scars at the site of former glands point to tuberculous destruction
or former bubo, and are suggestive.
The glands are enlarged in simple adenitis, tuberculosis, Hodgkin's
disease, leucocythcemia, sarcoma, and cancer. The moderate enlarge-
ment of syphilis and the local enlargement from irritation in the area
of lymph-drainage have been mentioned. Adenitis is usually local.
The gland is tender and the connective tissue around it is affected.
There are local heat and pain. At first the gland is hard, later it
softens in the centre, and finally it exhibits fluctuation. In tuberculosis
more than one gland is affected. Usually the glandular involvement
is bilateral (as in the neck). At first the glands are isolated. Later
they become matted. The local symptoms are not marked and the
process is very indolent. Thick, cheesy pus is discharged which may
contain tubercle bacilli. It causes tuberculosis when inoculated in
lower animals — a method of diagnosis necessary to be resorted to fre-
quently. The tuberculin test must be used. Fever and " decline "
1 Bulletin et Memoires de la Soci£te Medicale des Hopitaux, January 13, 1888.
160
GENERAL DIAGNOSIS.
occur later, but often not until other structures, as the lungs, are in-
fected. (See Leucocytheniia.)
Lympho Sarcoma is an infection of the glandular structures of ob-
scure origin. A local group of glands may be involved or the glands
throughout the body may be the seat of the overgrowth. When the
infection is general the deep-seated glands, as the mediastinal and
retroperitoneal, may be the first involved. Anaemia, fever, and signs
of intrathoracic and abdominal pressure may be present without decisive
indications of the nature of the disease. In a short time, however, a
superficial gland may enlarge, and from thence rapidly other glands be
involved. The occurrence of an enlarged gland in any part of the
body may be suggestive of the nature of a deep-seated process. Posi-
tive diagnosis can be established, and the method should be resorted
to by removal of the gland and its examination microscopically. A
case of this character seen with Hare showed the first evidence of
glandular infection in the enlargement of a small gland over the third
interspace on the right side of the chest in front.
Hodgkin's Disease.
Hodgkin's disease (pseudoleukemia, lymphadenoma, or lymphatic
anemia) is characterized by enlargement of the lymphatic glands and
other adenoid tissue ; bv pro-
gressive oligocythemia with-
out, in most cases, much in-
crease of leucocytes ; and by
the development of lymphatic
tumors in unusual situations.
The disease is most frequent
in the first half of life, three-
fourths of the cases being in
males.
The first symptom noted is
enlargement of the glands of
the neck ; but sometimes the
inguinal, less frequently the
axillary glands, are first en-
larged ; rarely the tonsils are
the first to be affected. The
enlargement is painless and
progressive, appearing first on
one side of the neck and ex-
tending under the jaw to the
opposite side. The tumors at
first are distinct and movable
under the skin. The swollen
glands may remain in this condition indefinitely for months or years ;
but eventually they begin to enlarge very rapidly, lose their separate
identity, and coalesce into large masses. Other glands in remote parts,
as the axilla and groin, retroperitoneum, and arm, are affected. They
Hodgkin's disease. Glands in right axilla and neck
much enlarged.
THE DATA OBTAINED BY OBSERVATION. 161
may be soft and fluctuating, or very dense and hard, but heat, tender-
ness, suppuration, and other evidences of inflammation are absent.
The spleen becomes very much enlarged, but rarely attains the
dimensions common in leucocythsemia.
Other adenoid tissue in the intestine, tonsil, and posterior nares,
and even the thymus, may enlarge and give rise to pressure symptoms.
Fever is a very constant symptom, but the type is not constant. The
onset of the disease may be marked by fever and constitutional symp-
toms, and the glandular enlargement appears later. On the other
hand, in three cases reported by J. Dreschfeld, 1 all the patients enjoyed
good health and were able to follow their work until a few weeks
before death. In all symptoms appeared suddenly, and consisted of
pain, weakness, pallor, loss of appetite, and pyrexia.
Coincident with the rapid and extensive enlargement of the glands,
anaemia becomes pronounced and is accompanied by the usual symp-
toms. Cough is often associated with anaemic dyspnoea, and in women
menstruation may cease.
Along with the general symptoms there are numerous local ones,
due to the pressure or impairment of function — cerebral anaemia from
pressure on the carotids ; cerebral congestion from pressure on the
veins of the neck ; disturbance of the heart from pressure on the
pneumogastric ; deafness ; difficulty in deglutition and mastication ;
and pleural, peritoneal, and pericardial effusions.
The most frequent complications are nephritis, fatty degeneration of
the heart, pleurisy, and, less frequently, pneumonia and pericarditis.
The duration of the disease is from six to eighteen months. Two-
thirds of fifty fatal cases referred to by Gowers 2 ended in less than two
years. It is difficult to determine accurately the beginning of the
disease ; sometimes a long period of latency follows the early glandular
swelling ; sometimes a general anaemia precedes any noticeable swelling
of the glands ; and sometimes the disease runs an acute course, ending
fatally in two or three months.
Death results most frequently from exhaustion ; but pressure upon
the trachea producing asphyxia is not uncommon, and death has
occurred from starvation, the result of occlusion by pressure of the
oesophagus. The complications already mentioned are the immediate
causes of death in other cases.
The diagnosis is not difficult with blood examination. By this means
leucocythaemia is excluded. It may be distinguished from tuberculosis
in the early stages when local by the site of the enlargement. In the
former the submaxillary glands are involved ; in the latter the glands
in the anterior and posterior cervical triangles. The tuberculin test is
required, as insisted upon by Otis, to establish tuberculous adenitis.
Lymphangitis or Angioleucitis. The streaked redness over the
surface of the skin, with tenderness along the course of the lymphatics
and oedema, is characteristic of inflammation of the lymphatic vessels,
and need not be further mentioned. The glandular and dermal changes
1 British Medical Journal, April 30, 1892.
2 Reynolds' System of Medicine, Philadelphia, 1880, vol. iii. 549.
11
162 GENERAL DIAGNOSIS.
of elephantiasis, with chyluria, with or without lymph scrotum, are
unmistakable ; the disease is due to the Jilaria sanguinis hominis.
Lymphatism. Poor physical development has recently been ob-
served with lymphatic overgrowth, or the constitutio lymphatieo. In
this state sudden death is liable to occur. It is believed that one of
the causes of death from anaesthesia and from antitoxin of diphtheria is
a condition known as status lym/phaticus. Hyperplasia of the lym-
phatic glands, the spleen, the thymus, and the bone marrow are rarely
found in patients with rhachitis, and in hypoplasia of the heart and
aorta. The internal lymphatic glands and the lymphatic structures of
the alimentary tract are more frequently involved than the more
external glands. With this overgrowth of lymph-tissue the spleen
and the thymus gland are enlarged, and red marroAV replaces the yellow
marrow in young adults. The hypoplasia of the vascular system is
not easily recognized. The left ventricle may be dilated and the
peripheral arteries diminished in size.
CHAPTER XII.
THE DATA OBTAINED BY OBSERVATION— {Continued).
The muscles — idiopathic muscular atrophy — pseudohypertrophy — Thomsen's disease —
paramyoclonus multiplex. Myositis — myalgia — muscular rheumatism.
THE MUSCLES.
The Nutrition. The nutrition of the muscles is observed by the
hand of the examiner while the muscles are made to relax and contract
alternately. We compare corresponding muscles of the two sides.
Measurement of the limbs at corresponding situations makes the obser-
vation more accurate. The muscles may atrophy or hypertrophy.
Either condition may be local, unilateral, bilateral, or general.
Myoidema is a local contraction of the muscle which occurs upon
striking it with a pleximeter or the finger, as in percussion. It is more
particularly seen in thin subjects, usually tuberculous, and elicited by
tapping the pectoral muscles. The fasciculi raise in little humps, which
persist for a short time and gradually subside. At one time they were
thought to be diagnostic of tuberculosis. They are of no special
significance.
Atrophy.
There are several varieties of atrophy: 1. The atrophy of disuse.
2. Myopathic atrophy. 3. Myelopathic atrophy, or the atrophy of
degeneration. It follows lesions of the motor path, of the cortex,
medulla, or spinal cord ; and neuritis. (See Nervous Diseases.)
The Atrophy of Disuse. It is also known as the atrophy of inac-
tivity. The muscles are slightly lessened in volume. The atrophy
takes place very sloAvly ; it supervenes in cases of paralysis and in
the joint-diseases which cause immobility. It occurs also in joint-
disease from reflex influences. The electrical reactions of the muscles
are qualitative and unchanged. By this reaction atrophy from disuse
and atrophy from disease of the muscles can be distinguished from myelo-
pathic atrophy, due to disease of the nerves (neuritis), or to degeneration
of motor nerves and ganglia.
Myopathic Atrophy. Muscular Dystrophy. In this form of
atrophy the muscle is diseased. It diminishes in volume and finally
becomes completely shrunken. Complete paralysis rarely ensues, but
the reaction of degeneration cannot be determined.
Idiopathic Muscular Atrophy. Dystrophia muscular is pro-
gressiva (Erb). In this affection muscular wasting takes place with or
without initial hypertrophy. Three forms are seen :
1. Atrophy with Pseudohypertrophy. It usually begins in
childhood, and is often of congenital origin, being transmitted through
164 GENERAL DIAGNOSIS.
the mother. It is first noticed just as the child is learning to walk.
The extensors of the leg, the glutei, the lumbar muscles, the deltoids,
and the triceps and infraspinati muscles are involved, but the first
change takes place in the muscles of the calves. The muscles of the
face, neck, and forearm are not usually affected in this form of the
disease ; the muscles of the hand are not involved. While hypertrophy
progresses hi certain muscles others waste. The calves may hypertro-
phy, for instance, while the extensors of the leg waste away and become
weak. Attitude and gait are characteristic. (See page 73.) The patient
stands erect, with the legs apart, the shoulders thrown back, the spine
curved, and the abdomen prominent. The waddling gait is character-
istic, and the method of getting up from the floor is pathognomonic.
The course of the disease is slow, wasting follows the hypertrophy, but
the weakness is greatest in the muscles first atrophied. Contractures
and distortions of the spine and of the bones of the leg take place.
2. Primary Atrophy. This is likewise congenital or manifests
itself in early life. It is divided into different types, according to the
groups of muscles that are affected. The same process occurs as in
the former, except that pseudohypertrophy is not primary. There
may be several forms in different members of the same family. Of
these we have the juvenile form of Erb. The upper arm and shoulder
and the thigh muscles are first involved. Later the muscles of the
gluteal region and calf may become enlarged and hard. The back
muscles are gradually affected, inducing the attitude previously men-
tioned. The reaction of degeneration is not present. There is also an
infantile type, first described by Duchenne, or the fascio-seapulo-humeral
type, Erb's form begins about puberty. The other forms usually
begin in childhood, but may be delayed. The face is involved ; it is
expressionless, and in laughing the muscles move slowly ; the child
cannot whistle, as the lips are thick and everted. The eyes remain
partlv open. The muscles of the group waste ; later the thighs become
involved. Erb has given a useful test to determine the strength of the
shoulder and girdle muscles. When the child is lifted by the armpits,
if the scapulohumeral groups are weak, the shoulders are forced up to
the child's ears without resistance.
3. Peeoxeal Ateophy. A peroneal type of muscular atrophy has
been described by Charcot. The extensors of the great toe and after-
ward the common extensors and peronei muscles are affected ; club-
foot results. The muscles of the thigh may become involved later.
When the disease occurs hi childhood it gradually spreads to the upper
extremities and affects the muscles of the hand, differing in this respect
from other forms of muscular atrophy. The thenar, hypothenar, and
interossei muscles are symmetrically involved, producing the claw-hand.
Unlike the other forms of atrophy embraced under this heading, the
peroneal type is attended by disturbances of sensation, and by pain, fibril-
lary contractions, and vasomotor changes. The reactions of degeneration
may be present. It is thought by competent observers to be simply a
form of neuritis ; and it is also called progressive neural muscular atrophy.
Diagnostic Featuees of Myopathic Ateophies. The disease
is characterized by gradual progression of the wasting and weakness in
THE DATA OBTAINED BY OBSERVATION.
165
various groups of muscles not specially related. We never see wasting
of the intrinsic muscles of the hands, as in the spinal forms of muscular
atrophy, or of the tongue, pharynx, larynx, and eye. Electrical irri-
tability is lessened and reaction of degeneration is not present. Fibril-
lary twitching is not seen. Sensation is not affected. The reflexes are
diminished and later may be lost. The sphincters are not involved ;
deformities about the joints or in the spinal column may occur.
The diagnosis of idiopathic muscular atrophy is not difficult if the
above-mentioned facts are borne in mind. The fact that it occurs in
family groups is an important point in the diagnosis. In cerebral
atrophy there is primary loss of power. In chronic anterior poliomy-
elitis (spinal atrophy) wasting begins in the muscles of the hands ; in
both the simple and spastic form there are reactions of degeneration,
fibrillary twitching, and increase in the reflexes, and, in the latter,
spastic contraction of the legs. The myopathies occur early in life, and
are hereditary.
In neuritis the paralysis is proportionately greater than the atrophy.
Sensory symptoms are often present. The cause is distinct. There is
no family history.
General Atrophy. In cachexias the muscles as well as the tissues
undergo atrophy. Even in nervous disease the atrophy of the muscles
markedly increases when general wasting takes place.
Circumscribed atrophies
Progressive atrophies .
Diffuse atrophies
Facial hemiatrophy .
Progressive myopathic .
Raymond's Table of Atrophies.
Atrophy from compression.
Atrophy in inflammatory conditions (pleurisy, joint-disease, etc.).
Atrophy from injury or inflammation of individual nerves.
Progressive spinal muscular atrophy ; type Aran-Duchenne.
Pseudohypertrophic muscular paralysis.
Type Leyden-Mobius.
Type Zimmerlin.
atrophy ."."*. . . ■ Type Erb.
I Type Landouzy-Dejerine.
I Type Charcot-Marie.
f Infantile form.
Acute of adults : spinal paralysis, with
rapid course and curable (Landouzy-
Dejerine) ; subacute and chronic form ;
chronic mixed form (Erb); diffuse
subacute, general spinal paralysis
(Duchenne).
Anterior poliomyelitis
I Syringomyelia.
r Lead paralysis.
J Multiple neuritis
■~\ . . .. . . -I Leprous neuritis.
I (amyotrophic form) 1 ., . ,.
v ' v. Alcoholic neuritis.
Muscular atrophies of cere- j with secondary degeneration involving the anterior cornua.
bral origin ( Without secondary degeneration involving the anterior cornua.
Muscular atrophy in hysteria 1 . , .
,, . . * , . L Amyotrophic sclerosis.
Muscular atrophy from sys- f -,, , T- , , , .
temic disease of the cord . Wosso-labio- laryngeal paralysis.
1 Atrophy in myelitis.
Atrophy in compression of the cord.
Atrophy in multiple sclerosis.
Atrophy in tabes dorsalis.
166 GENERAL DIAGNOSIS.
Hypertrophy.
Hypertrophy of individual muscles occurs from overuse, as when an
extremity or a portion of the trunk is used in excess. General hyper-
trophy of muscles occurs in Thomsen's disease. True hypertrophy is
recognized by increased volume, great hardness, and increased vigor of
the muscle.
Pseudo-hypertrophy (see under Muscular Atrophy) is associated
with increased volume of muscle but diminished power.
Thomsen's Disease (Myotonia congenita). This is an hereditary
disease and may occur in several generations of a family. Tonic
cramps take place in the muscles when voluntary movements are
attempted. The disease begins in childhood, rarely after puberty.
The muscles become rigid and fixed when put in action. The lack of
voluntary control of the muscles is shown by the slow contraction and
relaxation when voluntary efforts are made. The rigidity may wear
off and the limb can then be used. It is particularly noticeable when
walking is attempted. As the leg is advanced slowly it may remain
stiff for a second or two, but after it becomes limber the patient can
walk for hours. If he stops walking the same difficulty is experi-
enced when he starts again. Both arms and legs are affected. Patients
are usually well nourished, however. There are no atrophies. The
muscles are irritable, so that mechanical stimulus or pressure causes
tonic contraction. Movement and cold aggravate it. Sensation and
the reflexes are not affected, and there is no evidence of disease of the
cerebro-spinal system, save the occurrence of hypochondriasis in some
cases. The myotonic reaction described by Erb is induced. (See
electrical diagnosis — Diseases of the Nerves.)
Paramyoclonus Multiplex. In this affection there is clonic con-
traction of the muscles. It is usually confined to the extremities and
occurs in paroxysms. It may have been caused by sudden twitching
or violent motion. The clonic spasms at first do not interfere with
the patient's occupation, but gradually they increase. Both legs are
affected, and the number of contractions varies from 50 to 150 a minute.
The contractions may be rhythmical. In severe cases the muscles of
the back and abdomen contract violently. Tremor of the muscles
may be present in the intervals. (For paralysis, spasm, tremor, contrac-
tion, etc., see Nervous System.)
Myositis. Inflammation of the muscles. (See also Trichinosis.) In
inflammation of the muscles there is pain, swelling, and loss of power.
In universal myositis the inflammation begins in the lower extremities
and gradually involves other muscles of the body. They are swollen,
hard, and painful on pressure. Atrophy supervenes in groups of
muscles. The muscles may become more or less rigid. Local oedema
of the skin over the muscles occurs. The progress is gradual, and
death ensues when the respiratory muscles are involved.
The three cardinal symptoms that attend the disease as described by
THE DATA OBTAINED BY OBSERVATION. 167
Loenfeld are : (1) Swelling of the extremities due to subcutaneous
oedema and swelling of the muscle, causing functional disturbance ; (2)
extension to the muscles of respiration and deglutition ; (3) a more or
less extensive eruption. The latter is erythematous, its distribution is
usually general but irregular, and may be followed by pigmentation.
The disease must not be confounded 'with trichinosis. In the latter
examination of a small portion of muscle reveals the trichinae.
Progressive ossification of the muscles is rare. The muscle-tissues
undergo gradual ossification, either in localized spots or in wide-spread
areas. Inflammation of the muscle precedes the ossification. As the
inflammatory swelling subsides the muscles become hard and are grad-
ually converted into bony tissue. The disease lasts many years.
Myalgia is an inflammation of the muscles produced by cold or
trauma. There is pain on movement and spontaneous pain in the
muscle ; it is tender on pressure. It may be the seat of spasm.
Muscular Rheumatism. In this variety of rheumatism there is pain
in the affected muscles, which often comes on suddenly in the night,
or is first noticed when the patient attempts to rise in the morning.
The pain when the patient is at rest may be inconsiderable, rarely
amounting to more than a dull, aching, sore feeling ; on attempting to
move, to bend, or twist, or straighten himself, however, the patient
catches himself suddenly on account of the agonizing, tearing, or burning
pain. When the muscles are relaxed the patient is fairly comfortable.
Sudden movement is the most painful. The affected muscles are
tender to the touch and to sharp blows. Muscular rheumatism may be
acute or chronic. In the latter the symptoms are very much like those
of chronic articular rheumatism, except that the muscles and not the
joints are affected. There is the same proneness to recur in unfavor-
able weather and in cold, damp seasons.
The disease receives different names according to the muscle affected.
The most common subvarieties are : lumbago, in which the muscles
of the small of the back are affected ; 'pleurodynia, in which the inter-
costal muscles suffer ; and torticollis, in which the sternomastoid and
trapezius are painfully contracted.
In lumbago the patient holds himself rigid and is unwilling to rotate
the trunk upon the vertebra?. Often the most comfortable position is
that in which he sits and bends slightly forward over another chair.
Motion is painful, but pressure is not. Fever is absent. There is
a history of repeated attacks, or of exposure, such as lying upon
damp ground. Lumbago needs to be distinguished from disease of
the spinal membranes, from disease of the vertebras, aneurism, abdomi-
nal abscess, and diseases of the uterus and ovaries. The diagnosis of
rheumatism is arrived at by exclusion.
In pleurodynia there is usually tenderness upon pressure as well as
upon motion and deep inspiration. The pain is of the same sore, burn-
ing character, aggravated by coughing and sneezing. The patient
breathes as little as possible, and often bends over toward the affected
side to lessen the motion. Pleurodynia is distinguished from pleurisy
168 GENERAL DIAGNOSIS.
by the absence of fever, cough, and, above all, of friction-sounds. In
intercostal neuralgia there are painful points upon pressure, whereas in
pleurodynia firm pressure is grateful, though tapping is painful.
In torticollis the head is drawn to one side and fixed in that position.
The sternomastoid especially is rigid and tender on pinching. In
spinal affections the head is retracted, and there are antecedent symp-
toms, as headache and darting pains with fever.
Fibrous Tissues. Intimately associated with rheumatic affections
of the muscles is that of the fibrous tissues or fascia. Pain, fixation,
and tenderness are noted, and if with them other rheumatic manifesta-
tions are foimd the diagnosis is established ; especially is the above true
of trauma.
CHAPTER XIII.
THE DATA OBTAINED BY OBSERVATION— (Continued).
The bones — general examination. Enlargement — acromegaly — osteitis deformans — pul-
monary osteo-arthropathy — Diminution — rhachitis osteomalacia. Local examination
— position and shape — nodes — inflammation — osteomyelitis.
THE BONES AND JOINTS.
Method of Examination. When the bones and joints, especially
the spinal column, are to be examined, the patient should be stripped,
and after the movements and position in the upright or semi-upright
position have been noted, he should be made to lie down on a hard,
smooth surface, and the trunk and joints examined in that position.
Anterior, posterior, and lateral movements of the spinal column must
be made to determine its flexibility. In this manner deformities,
changes in the length of the bones, and abnormal posture can be care-
fully observed. In addition we must note muscular wasting, the pres-
ence of local tenderness and swelling, changes in the movements of the
joints, and loss of other functional activity causing lameness or joint-
disability.
To distinguish joint lesions from abnormal flexions or extensions,
the result of spasm of muscles, anaesthesia must be employed.
The Bones.
The bones are fixed landmarks by which the location of organs is
determined. The student should familiarize himself with the shape of
the bones and the location of normal tuberosities.
The bones may be the seat of nutritive changes which involve the
skeleton in whole or in part, causing enlargement or diminution of the
osseous system, and hence of the body. Local changes are traumatic
(periostitis) or infectious, giving rise to nodes or to swellings.
General Examination. Enlargements. Nutritive changes giving
rise to enlargement of the bones occur in acromegalia, osteitis defor-
mans, and pulmonary osteo-arthropathy.
Acromegalia.
Marie first described acromegaly, a skeletal change, characterized
by hypertrophy of the bones of the hands, feet, and face. The tibro-
cartilages of the ear and larynx are also enlarged. The enlargement
of the inferior maxillary and frontal bones causes the face to assume a
peculiar, elongated, elliptical outline. The nasal bones are enlarged,
170
GENERAL DIAGNOSIS.
and the nose thickened ; the temporal fossae are deepened, on account of
enlargement of the malar bones. The forehead retreats because of the
enlargement of the frontal sinuses and projection of the superciliary
ridges ; the chin is prominent and the lower teeth project beyond the
plane of the upper ; the lips and eyelids may be thickened ; the tongue
is enlarged and thickened. The hair is coarse and dry ; the face dry
and pigmented.
^ The hands are peculiar ; they are much broader, the fingers are
sausage shaped, and the hand spade-like in shape ; the nails are flat,
striated, and too small. There is usually
spinal curvature ; the abdomen is prom-
inent, and, as before intimated, the
height is increased. The muscles be-
come weak and may atrophy ; the skin
is often pigmented ; varicose veins have
been observed, and the patient complains
of hemorrhoids. The thyroid gland may
be atrophied or hypertrophied. It may
be well to state, in passing, that with
these appearances nervous phenomena
are observed and disorder of special
senses complained of. Hemianopsia,
limitation of the visual field, and blind-
ness or deafness arise.
Osteitis Deformans.
Another remarkable change is seen
in the skeleton, and has been described
by Sir James Paget ; in this there is
marked change in the contour of the
patient and a peculiarity in the mode
of locomotion. It is known as osteitis
deformans. The head is advanced and
lowered, so that the neck is very short,
and the chin, when the head is at
ease, is more than an inch below the
top of the sternum. The chest becomes
contracted, narrow, flattened laterally,
deep from before backward, and the
movements of the ribs and spine are
lessened ; the arms appear unnaturally long ; the shafts of each tibia
and femur are bent so that the patient becomes bow-legged. There is
some stiffness, but no loss of power and not a great deal of pain. The
skull is increased considerably in thickness.
These changes in the bones cause a dwarfed appearance of the trunk
in comparison with the legs and arms, and the posterior lateral curva-
ture necessitates a characteristic attitude. The skeletal changes are
noted particularly in the long bones. As a result of the enlargement
of the cranial bones, the face presents a triangular outline, with the base
Case of acromegaly. (Osborne.)
THE DATA OBTAINED BY OBSERVATION.
Ill
above and the apex below (see Fig. 24, outline 3), thus differing in
appearance from the outline in acromegaly (Fig. 24, outline 2).
Fig. 24.
Outline of face in
myxcedema.
Outline in acro-
megaly.
Outline in osteitis
deformans.
Pulmonary Osteo-arthropathy.
Marie distinguishes acromegaly from another skeletal change in
which there is hypertrophy of the bones of the extremities, including
enlargement of the shafts. In this form of arthropathy the bones of
the head and face are not affected. The hands and feet are enlarged,
and the patellae and other bones of the knee-joints increased in size.
Fig. 25.
Pulmonary osteo-arthropathy. Female, aged eleven. Tuberculous vertebral caries and pulmonary
tuberculosis. Enlarged clubbed fingers and thickened ulna and radius. Private patient, 1885.
Curvature of the spine is present. The appearance of the fingers is
different from that seen in acromegalia. The ends are enlarged and
bulbous, and the nails are too large and are curved in a transverse and
172
GENERAL DIAGNOSIS.
longitudinal direction, like the clubbed fingers of phthisis, although the
chief enlargement of the fingers is not terminal, and there is no cyanosis,
as in phthisical clubbing. The change seemed to be associated with pul-
monary affections, and Marie called it osteo-arthropathie pneumonique.
Diminution. Small development of the bones is seen in idiots and
cretins ; later in life diminution in size may occur from rhachitis and
osteomalacia.
Rhachitis.
In this affection the size of the body is lessened. For its recognition
it is important to know how rapidly the osseous deposits in childhood
have formed. The fontanelles and the epiphyses must be examined.
If the fontanelles are open beyond their period of closure in health, or
if the epiphyses are enlarged and lack firmness, the condition points
either to simple malnutrition or to rhachitis.
In rhachitis late development of the teeth is observed. If the ribs are
examined, nodules will be detected at the junction of the bone with
Fig. 26. Fig. 27.
■Br ^sH
ffik 9
■k M
Rhachitis; attitude in sitting; one hand raised
to exhibit swelling at the wrist. (Williams.)
Rhachitis in moderate degree in a hoy aged
fifteen months ; showing backward escurvation
of the spine. (Williams.)
the cartilage. These may be seen, as w r ell as felt, if the child is thin.
Thev form the so-called rhachitie rosary. The thorax also is changed
in shape. At the junction of the cartilages and ribs a depression takes
place which is continuous with a groove which passes out from the
ensiform cartilage toward the axilla. This transverse curve is known
as Harrison's groove. It may deepen with inspiration. The sternum
projects, forming the so-called " pigeon-breast." (See Thorax.) Such
THE DA TA OB TA INED B Y OB SEE VA TION. 173
deformity must not be confounded with a similar one seen in adenoid
disease. Changes at the lower end of the radius and ulna, and some-
times at the end of the humerus, are noticed. The parts are enlarged
at the junction of the shaft and epiphyses. There may be thickening
of the clavicles at the sternal ends. In the legs the lower end of the
tibia becomes enlarged, and at times the upper end, or even the shaft,
becomes thickened. The child becomes bow-legged, or the tibia? and
femora may arch forward. Knock-knee sometimes occurs. The
bones of the vertebral column and of the pelvis are also affected. The
spine is usually curved posteriorly, but the lateral curvature may also
be produced with it. The contraction of the pelvis is such as to
narrow its outlet — a matter of much importance for the future of
female children.
The head of the child with rickets is quite characteristic. It has
been mentioned that the fontanelles remain open for a long time, and
areas of ossification are imperfect, so that the bone yields to the press-
ure of the finger. This occurs particularly at the side, and the term
■craniotabes is applied to it. The large head is square in shape, not
globular, when seen from above downward. It gives the face a pecu-
liar appearance. It is proportionately very small, especially in the
lower two-thirds, while the forehead is broad and square.
Rhachitis is usually developed in childhood, and is most common in
children with bad hygienic surroundings, who have lived upon a
starchy diet and have taken cow's milk for too long a period of time.
A child that has been nursed during the mother's pregnancy is liable
to have the disease.
In addition to changes in the bones a child presents other evidences
of defective nutrition. There is marked pallor ; the muscles are flabby ;
the child is feeble ; and the weakness of the muscles results in an inac-
tion which resembles paralysis.
The disease usually progresses slowly, and is eminently chronic. A
form is seen, however, in which the progress of the symptoms is more
acute. With some gastro-intestinal disturbances there are mild fever,
considerable weakness, and great restlessness. Sleep is disturbed, and
pain is complained of if the child is of an age to make such com-
plaint. Soreness of the body is observed on handling the child ; and
of its own accord, on account of the pain and soreness, it avoids all
customary movements. The child lies on its back and shrinks from
any attempts to disturb it. The pain is not only caused by handling
of the muscles, but the bones also are sore and tender. Sometimes the
most marked manifestations of the more acute forms are the gastro-
intestinal symptoms. It may often happen that vomiting and diar-
rhoea have as an underlying basis this rhachitic condition.
With the above symptoms, and also in chronic cases, perspirations
about the head are common. There is usually more heat of the head
than is natural, hence in sleep the child rolls the head. This . rolling
causes the hair on the back of the head to be worn off. This sign is
most characteristic of rhachitis when observed along with changes in
the skeleton.
In the acute and chronic forms enlargement of the liver and spleen is
174 GENERAL DIAGNOSIS.
observed. The enlargement is not only actual, but also a false enlarge-
ment may be seen from distortion of the organs, on account of changes in
the vertebrae and ribs. The abdomen is prominent, usually on account
of flatulency, although the enlarged organs contribute to the swelling.
Nervous phenomena are common in the course of rhachitis. Tetany,
limited to the upper extremities, and laryngismus stridulus are the most
frequent. Either of these complications may occur before the disease
is otherwise suspected.
Diagnosis. The possible presence of rhachitis must not be over-
looked in cases of chronic vomiting in childhood. The acute form of
the disease must not be confounded with scurvy, as often happens in
the case of children. It must not be forgotten that scurvy may set in
in the course of rhachitis. In scurvy the pain, tenderness, and weak-
ness are limited to the lower extremities. The immobility of the
extremities may go on to pseudoparalysis. The tenderness, however,
is great ; oedema is more pronounced, and local areas of periostitis are
more common. In scurvy the gums are swollen and may be spongy,
or may be the seat of ecchymoses. The most decisive diagnostic crite-
rion is the therapeutic test, scurvy rapidly yielding to a proper regimen.
Osteomalacia.
Among the general affections of the skeleton which may cause lessened
size, osteomalacia must not be forgotten. As the lime salts are dis-
solved the bones become preternaturally soft, break on the slightest
provocation, or bend in various directions, depending upon the external
pressure and the direction of the muscular force. The ribs are drawn
in by inspiratory force until the cavity of the thorax is lessened to a
degree incompatible with life. The pelvis is deformed so that labor is
impossible. (It occurs frequently in pregnancy.) All sorts of fixed
contortions are assumed. If the patient is able to be up the body
shortens, the back becomes rounded, the neck flexed, so that the chin is
brought close to the sternum. On palpation the bones can be indented
with the finger, and crepitate like egg-shells.
Osteomalacia is easily distinguished from carcinoma or sarcoma of
the bones. In the latter spontaneous fracture occurs in various parts
of the skeleton, but is generally preceded by pain and swelling at the
seat of fracture. Then, in sarcoma, subcutaneous hemorrhages are
present. When a single joint is affected in osteosarcoma the same egg-
shell crackling is observed.
Local Examination. The Position and Shape of Bones.
The peculiar position (falling downward) of the scapula in paralysis of
the serratus magnus is diagnostic of that affection, and indicates disease
of the posterior thoracic nerve. In examination of the clavicles frac-
tures must not be mistaken for disease of the bones, such as rickets.
The examination of the spinal column is of the greatest importance.
(See Spinal Joints.) A study of the diseases of the spinal column due
to caries from tuberculosis is not within the province of this work ;
no physical examination, however, is complete without an investigation
THE DATA OBTAINED BY OBSERVATION. 175
of the movability of the spine and the presence or absence of curvature.
I refer to the curvature due to weakness of groups of spinal muscles.
Functional disorders of the gastro-intestinal tract and of the uterus
are undoubtedly intensified by the presence of curvature, which leads
to deformity of the body, and hence to the assuming of abnormal posi-
tions when sitting or walking. The recognition of lateral or anterior
curvature leads to the adoption of lines of treatment which otherwise
would not be followed, but without which weak muscles, improper
aeration of the blood, and sluggish circulation would persist. Pain in
the distribution of nerves, or at their termination, is often due to spinal
caries pressing on them as they pass through the foramina. The most
noticeable is the pain about the umbilicus in children due to Pott's
disease.
The bones and cartilages connected with the thorax will be consid-
ered under Diseases of the Lungs.
Inflammation. The discovery of a slight change may lead to the
recognition of a grave general process. Simple local inflammation or
periostitis may be due to syphilis, and is recognized by local pain, swell-
ing, and slight oedema. It may be diffuse. It is seen most frequently
on the tibia, sternum, and clavicle. It not infrequently follows typhoid
.fever.
Nodules or nodes are usually due to syphilis. They form on vari-
ous portions of the skeleton, but are most frequently seen on the skull,
especially on the forehead ; they are also found on the shafts of the
long bones, preferably the tibia, ulna, and clavicles. They are usually
multiple or bilateral. They are painful and tender on pressure, and
may be the seat of heat and redness. They are not so hard and dense
as exostoses. The latter are situated on the outer aspects of the bone
and in relation with the strongest tendons or muscles.
As an illustration of the importance of recognizing nodes the writer
recalls a case of persistent headache, the true nature of which was only
ascertained by finding a small node on the skull. The headache had
been of long (five years) duration, and treatment for it had been
sought in many countries.
Tenderness of the sternum upon pressure is often of diagnostic signifi-
cance and is usually indicative of syphilis. The pain and tenderness just
noted, however, must not be confounded with local tenderness due to
necrosis, which often arises in convalescence from fevers, notably those
of an infectious nature.
Osteomyelitis. The occurrence of high fever, with or without
chills, but usually with pysemic symptoms, without recognized cause,
should lead to an examination of the bones. A spot of tenderness
followed by local redness and swelling — on the tibia, for instance —
would indicate the seat of suppuration in osteomyelitis.
The Joints.
The Data Obtained by Inquiry. Careful observation of the bones
enables us largely to discern the nature of the diseased process, as has
just been indicated. It is true osteomyelitis is less likely of recognition
176 GENERAL DIAGNOSIS.
than any other process, but when the patient has been exposed to an
infection, and fever is present, this condition must always be sought,
for in the absence of any other infectious area.
Such is not true, however, of joint-disease. By observation we deter-
mine the joint affected and in part the nature of the morbid process.
Other data are needed. Hence we collect the usual data obtained by
inquiry. The social history is not productive of valuable data. Acute
rheumatism is more common in early life, rheumatoid arthritis in the
middle periods, and cnronic rheumatism in late life. Females are
more commonly attacked than males in rheumatoid arthritis, and this
affection is more common in the poorer classes. Males and the well-
to-do are the victims of gout.
In the family history one learns of the transmission of gout from
generation to generation and of the occurrence of rheumatism or of
its various allied processes in members of the same or previous genera-
tions. Previous diseases elicited are those of an infectious nature or an
intoxication, as of lead. Such diseases must be sought for if the true
nature of an arthritis is to be discovered. The history of the present
disease is often that of recent infection or intoxication.
The subjective symptoms of joint-affections are worthy of note. Pain
is the most prominent. This may be spontaneous, or may arise upon,
pressure, or follow attempts at movement. Spontaneous pain with ten-
derness is more pronounced in rheumatic and gouty inflammations of
the joints. The pain is usually worse at night. This is particularly
the case in tuberculous joints, and is due to removal of the apprehen-
sive spasm of the muscles whereby the joints had been protected.
Pain in the joints must not be confounded with that of local or mul-
tiple neuritis. I have seen the pains of neuritis attributed to rheuma-
tism of the phalanges, tarsus, and ankle until paralysis of the exten-
sors took place. I have seen the pain of neuritis of the circumflex
mistaken for shoulder-joint disease. Multiple neuritis is attended by
pains that may be located in the joints by the patient ; but neither in
local nor in general neuritis are the joints ever swollen, tender, or
painful on passive movement.
Inspection. The size, shape, and color, the degree of movability and
the position of the joints are observed.
The Size aistd Shape. The joints may be enlarged. The enlarge-
ment may be due to infiltration of the tissues about the joints, to effu-
sion within the joints, serous or purulent, or to inflammation of the
ends of the bones.
1. When the enlargement is due to infiltration about the joint the
tissues are previously thickened, as shown by palpation, and the out-
line of the joint is changed. The normal contour is lost entirely, and,
instead, there is a globular swelling beginning above and extending
below the joint. 2. When the enlargement is due to effusion it may
be detected by palpation, as this secures fluctuation. This is particu-
larly so in the large joints. If the joint involved is the knee the
patella will float. The effusion changes the normal contour, but,
in the earlier stages, may cause local swellings where the synovial
.sacs are near the surface ; hence, at the articulation of the tibia and
THE DATA OBTAINED BY OBSERVATION. 177
fibula with the tarsus, on the inner and outer side, a boggy swelling is
observed. At the knee the swelling is on each side above and below
the patella. When the effusion is great the joint becomes immobile,
and may be flexed from distention of the sac. 3. When enlargement
of the joints is due to hypertrophy of the bones the latter are thick-
ened and very hard. There may or may not be, and usually is not,
fixation, and movement is but moderately interfered with.
Changes in the outline of the joint are also seen in rheumatoid arth-
ritis. The loss of the cartilaginous substance of the joint, with the
secondary osteophytic changes, causes deformity, so that in the case of
the small joints of the finger subluxation is seen ; similar subluxations
are seen in larger joints. The ends of the phalangeal bones are thickened.
The Color Change in the color is usually noticed in inflamma-
tions. The surface is either bright red or dusky.
The Position. The position assumed is of diagnostic importance.
Flexion of the limb of the affected joint occurs in over-distention. It
must be remembered that the hip-joint is flexed in appendicitis and in
psoas abscess or other affections in proximity to the psoas muscles.
In rheumatoid arthritis there is subluxation. Immobility is observed.
(See Palpation.)
Palpation. By palpation we determine the degree of movability of
the joints, the presence of fluctuation and of crepitation.
1. The movability of the joint is learned. Movement is inhibited in
inflammation on account of the pain. A reflex muscular spasm takes
place if osteitis and cartilage-destruction are present. The spasm pre-
vents movement. In effusion there is less movability or even none at
all. In rheumatoid arthritis movement is prevented by the osteophytic
growths which surround the joint.
2. Fluctuation is revealed by palpation, pointing to liquid effusion
within the joint. (Edema of the surrounding tissues occurs in puru-
lent effusions.
3. A crepitus or grating sensation is observed in rheumatoid arth-
ritis and other destructive diseases.
The Morbid Process. The processes which give rise to change in
the joints are inflammatory and degenerative, and, curiously, neurotic
or neuropathic. When a single joint is the seat of disease the process
may be local, as in traumatic synovitis. But tuberculosis and other
infections, gout and rheumatism or rheumatoid arthritis, may be local-
ized to one joint — the latter rarely, however. Multiple joint-disease,
polyarticular, is infectious or systemic (intoxication) usually.
Much information, therefore, is learned by noting if the process is
limited to one joint, monarticular; or to many joints, polyarticular ; if
to large joints or to small joints ; if it is fixed, as in synovitis, or fugi-
tive, as in rheumatic fever. Monarticular inflammation of small joints
points to gout ; of large joints, to gonorrhoeal rheumatism or pyaemia.
Polyarticular inflammation of small joints, to rheumatoid arthritis ; of
large joints, to rheumatism. Lesions may be unilateral or bilateral,
symmetrical or asymmetrical. Bilateral joint lesions are characteristic
of rheumatoid arthritis. Asymmetrical and fugacious lesions are seen
in rheumatic fever.
12
178 GENERAL DIAGNOSIS.
It must always be remembered that joint-lesions or processes may be
expressions of general infections, as septicaemia, influenza, cerebro-spinal
meningitis, scarlet fever, and dysentery ; or blood diseases, like purpura
or hemophilia or scurvy ; or of nervous diseases, like tabes dorsalis.
W e have to consider synovitis or arthritis single and multiple, trau-
matic, toxic, or infectious, of which gonorrheal and tuberculous infec-
tions are the most common monarticular causes. We will then consider
rheumatism and gout, rheumatoid arthritis, and follow with the neuro-
pathic joints.
Synovitis. The inflammation is recognized by pain, heat, redness,
and swelling. Effusion is present, and its physical signs are readily
elicited. It is both periarticular and intra-articular. It may be due
to traumatism, but we are chiefly concerned with inflammations due to
internal morbid processes. When single joints are affected the most
common causes are tuberculosis, pyemia, and gonorrheal infection.
A mild degree of inflammation may be limited to one joint in subacute
rheumatism. When many joints are affected the cause is an infectious
one, as rheumatism, septicemia, pyemia, epidemic cerebro-spinal men-
ingitis, scarlet fever, and dysentery, rarely gonorrhea.
The Tuberculous Joint. In 'tuberculosis the joint is swollen and
the neighboring tissue edematous. Effusion may be detected. There
is fever. The hip, the knee, the elbow, the wrist, and the ankle are
most frequently affected. Cheesy material may be withdrawn by tap-
ping. Destruction ultimately takes place, with subluxations and sub-
sequent fixation of the joint. With fever, wasting, and local signs of
tuberculosis in other portions of the body the true nature of the affec-
tion is indicated. The tuberculous process may be limited to the
affected joint, extend to the tendinous sheaths, or secondary tuberculosis
of internal organs may supervene.
The Joint of Gonorrhceal Rheumatism. The knee-joint is usually
affected. Signs of acute or subacute inflammation are present, with
edema and effusion. The patient is a male in whom an acute or
chronic urethral discharge is found. The pam is worse at night. The
process is of long duration. Metastasis does not take place. Destruc-
tion rarely occurs, but anchylosis may. General pyemic svmptoms
may ensue, and gonorrheal endocarditis supervene. The micro-organ-
isms (gonococci) can be found in the blood and in the pus of the
affected joint. There is entire absence of heart-symptoms from simple
endocarditis. The general and local signs of rheumatism or of a rheu-
matic diathesis, and changes in the urine, skin eruptions, cardiac
lesions, etc., are wanting. In certain cases many joints are affected,
but the temperature is not so high or the sweats so profuse as in acute
rheumatism. Tendo-synovitis is not infrequent.
Rheumatic Fever.
An acute, general, febrile, non-contagious disease, characterized by
specific inflammation of thejomfc and their contiguous structures, hence
called acute articular rheumatism. It is further characterized by a ten-
dency of the inflammation to involve the larger joints successively, to
THE DA TA OB TAIN ED B Y OBSEB VA TION. \ 7 9
skip from one joint to another, and to be associated with endocarditis
or pericarditis.
The predisposing causes of rheumatic fever are heredity, which is
operative in 25 or 30 per cent, of the cases ; age — 81 per cent, of first
attacks occur between the eleventh and thirtieth years (Pye-Smith) ;
sex — in childhood girls are more frequently affected than boys, but after
that period sex appears to have no influence. Polyarticular inflamma-
tions, sometimes rheumatic hi nature, are met with during convales-
cence from scarlatina and dysentery. They also occur in association
with the puerperal state and gonorrhoea, in which they are probably
pyaemia The nature of the polyarthritis which occurs in connection
with dengue, and haemophilia is obscure.
Symptoms. The onset of the disease is not characterized by con-
stant symptoms. Sometimes the fever and joint-inflammations are
preceded a day or two by debility, wandering pains in the joints or
muscles, and loss of appetite. In other cases there is a chill or repeated
attacks of chilliness, followed in a day or two by fever and inflamma-
tion of the joints. In rare cases the onset may be followed not by in-
flammation of the joints but by inflammation of the serous membranes,
particularly those of the heart and its sac.
The temperature may rise a day or two before there are any joint-
symptoms, or fever and arthritis may begin almost simultaneously.
The temperature rises rapidly to 102°, 103°, or 104° F., and one or
more of the larger joints, generally the knee and ankle, become painful,
tender, swollen, and hot.
The Joixt. There may be great pain on motion before there is
evident swelling or much local tenderness. The pain varies from mere
discomfort to the most excruciating suffering. It is always aggravated
by motion or pressure, and is at times so exquisite that the slightest
touch, the weight of the bedclothing, or the jar of the bed from a heavy
step in the room makes the patient cry out. It may extend beyond
the joint to neighboring tendons and nerves. The swelling like-
wise varies greatly ; sometimes there is only slight puffiness with
increased distinctness of the cutaneous veins, increased heat in the part,
but no general redness ; in other cases there is considerable swelling
about the joint, so that the bony prominences are obliterated, the sur-
face being tense, red, and very hot to the touch. There is often effu-
sion into the joint. Swelling is most marked in the w T rist and ankle,
and less so in the shoulders, hips, elbows, and knees.
Multiplicity of Joints Affected. A characteristic peculiarity of rheu-
matism is its tendency to involve one joint after another. One or
several joints may be affected at first ; it is very common for the
right ankle to be affected, and then in a short time the opposite ankle,
followed by the left knee and right knee, and so on with the other
joints. The inflammation usually lasts in each joint from two to four
days. The process may subside in one articulation and begin . in
another with startling rapidity. At one visit of the physician the
patient's right ankle may be swollen, hot, and unbearably painful, and
on the next day the right ankle maybe quite well again and the patient
be found suffering acute pain in the right knee or left ankle.
180
GENERAL DIAGNOSIS.
The pulse in the early stages of rheumatism is moderately accelerated
(99 to 110) ; it is regular, of good volume, often bounding, and some-
times hard. The urine is scanty, high-colored, abnormally acid, and
deposits on cooling a copious precipitate of urates, resembling red sand
in appearance. The skin does not feel so hot as one would expect from
the temperature. It is continuously covered with a copious, acid, and
somewhat pungent perspiration. Nervous symptoms are not marked.
There may, however, be slight nocturnal delirium. Sleeplessness from
pain is very common.
The temperature in rheumatic fever is not usually very high ; it is
much oftener under than over 103°. In rare cases, however, espe-
cially when the fever is complicated with pericarditis, pneumonia, or
Fig. 28.
May
Rheumatic fever. Admitted fourth day of disease.
some disturbance of the heat-regulating apparatus, the temperature
may attain the extraordinary range of 106°-112° F. Such high tem-
peratures may occur suddenly or gradually, and are sometimes attended
with marked brain-symptoms (so-called cerebral rheumatism).
Endocarditis and pericarditis may occur at any period of rheumatic
fever ; they may even precede any joint-inflammations. They are most
common,'however, in the first two weeks of the disease. The younger
the patient and the more severe the attack the greater the liability to
heart-complications. They occur in about one-fourth of all cases.
Endocarditis is most common ; often it is the only lesion, but some-
times it is associated with pericarditis and more rarely with myocar-
ditis. These complications usually give rise to no symptoms at first.
Hence the heart should be examined daily. A sense of constriction
in the prsecordia or pit of the stomach, an anxious expression of the
face, with pallor, a change in the frequency, but especially in the
rhythm of the pulse, and the occurrence of cough or dyspnoea, should
attract attention to the heart. The physical signs of the respective
lesions have been described fully under Diseases of the Heart.
The setting in of convalescence from rheumatic fever is marked by
cleaning of the tongue, which also becomes less red, and increase in
the secretion of urine, which remains of high specific gravity. The
fever subsides gradually, the joints cease to be red, swollen, and tender,
THE DATA OBTAINED BY OBSERVATION. 181
the acid sweats lessen, and the appetite improves. In proportion to
the duration of the case and its severity the patient is left with debility
and marked anaemia, both red cells and haemoglobin being diminished.
In anaemic cases a haamic murmur may be heard over the base of the
heart. In some cases acute dilatation has been observed, with a tri-
cuspid murmur.
Complications and Sequelae. Apart from heart complications which
have been mentioned, pleuritis, pneumonia, and bronchitis occur in from
10 to 15 per cent, of the cases. They are frequently bilateral, and are
very much more common in rheumatic fever with pericarditis or endo-
carditis than in simple rheumatic fever. Moreover, the pulmonary
complications are frequently latent, and would be overlooked but for
the daily physical examination of the chest. On the other hand they may
develop with great suddenness, and what appeared to be a full-blown
pneumonia may subside suddenly as a fresh joint is affected. They
behave more like sudden active congestions than true pneumonias.
Rheumatic pleurisies are characterized by the rapidity with which effu-
sion takes place, the persistence of pain in the side during effusion, the
tendency to involve both sides in succession, the readiness with which
the effusion is absorbed, and their acute course.
Nervous System. The most common complication of the nervous
system is delirium, which is generally associated with insomnia and
hyperpyrexia, but the latter is not constant. These brain-symptoms
generally appear in the second week of illness, and about the time of
convalescence, or while the joints are still inflamed. The delirium
may be low and muttering, accompanied by ataxic symptoms or even
by tremors and spasms of muscles ; or it may be furious. In favorable
cases a deep sleep ushers in recovery ; or, in unfavorable cases, the
delirium persists with adynamia, the patient dying hi collapse or coma,
preceded or not by convulsions.
Chorea sometimes occurs as a complication, but it is more common
as a sequel of mild cases in children. Cerebral meningitis occurs occa-
sionally, especially when there is ulcerative endocarditis. Cerebral
embolism is another rare complication.
Various spinal symptoms occur in some cases, at times with, and at
times without, demonstrable lesion of the cord or its membranes.
Tetanus, myelitis, and spinal meningitis may all be simulated. Per-
haps these symptoms are due to high temperature ; but very high tem-
peratures are met with without the occurrence of any cerebral or spinal
symptoms.
Nephritis is rare, but sometimes hemorrhage into the kidney occurs
with its usual symptoms. Peritonitis is extremely rare.
Various erythematous skin-eruptions are seen from time to time,
and occasionally purpura. Subcutaneous nodosities have been described
by several writers. They are attached to the tendons, fascia, and peri-
osteum, and are most frequent on the back of the elbow, the ankles,
and patella. They are painless, and may occur in any form of rheu-
matism.
Diagnosis. Rheumatic fever is distinguished from gout by the
profuse acid and acrid sweating, the tendency to involve a number
182 GENERAL DIAGNOSIS.
of joints, and particularly the larger ones, by the greater intensity of
constitutional symptoms, by the great liability to heart-complications,
and by the absence of uric acid from the blood.
It is distinguished from pycemia by the wandering character of the
inflammation ; the acid sweats ; the absence of any antecedent condi-
tion which would develop purulent foci — such as injuries, abscesses, or
specific eruptive fever ; the absence of chills, and the fact that in rheu-
matic fever the sweats are constant, whereas in pyeemia they follow a
fall in the temperature. Cutaneous abscesses do not occur in rheuma-
tism, and after its subsidence the joint's usefulness is not impaired.
: v Acute synovitis resembles rheumatic fever, because in both occur
symptoms of pain, tenderness, and swelling in connection with a joint.
Usually, however, in synovitis but one joint is involved, and there is
a history of exposure to cold or injury. The effusion is limited to the
synovial sac of the joint, is frequently abundant, and fluctuation can
easily be detected. The constitutional symptoms are much less marked
than in rheumatism.
Milk-leg, or phlegmasia alba dolens, differs from rheumatism in that
it usually occurs in women after confinement, or as a complication or
sequel of fever, as typhoid fever. Usually one leg is affected, or part
of the leg, especially the calf. This becomes tense, tender, uniformly
swollen, and the seat of great pain. The leg is moved with much diffi-
culty. The femoral vein may be found to be knotted and tender.
There is almost always evidence of antecedent disease.
Acute periostitis when close to a joint simulates rheumatism. But
the tenderness and heat are not in the joint itself ; they are superficial,
and are associated with less swelling. Pitting on pressure is common ;
and circumscribed fluctuation usually discloses the presence of suppu-
ration. Pyaemic symptoms are added to the local symptoms, particu-
larly if osteitis or osteomyelitis is present.
The articular symptoms of glanders are to be distinguished by the
occupation of the patient, the mode of onset, the associated symptoms,
especially one or more pustules, and the fact that the painful joints are
not so apt to be swollen and red as in rheumatic fever.
In syphilis joint-pains frequently occur, but their character is made
out by the fact that the joints are not inflamed, and that the pain is
much worse, or occurs only at night, and by the history of the patient
and the therapeutic test.
In some diseases of the brain and spinal cord joint-inflammations of
trophic origin occur. They are distinguished by the coexistence of
some lesion of brain or cord, with hemiplegia or other palsy, and of
other trophic changes, such as bed-sores, atrophied muscles, loss of
hair, shiny skin, and defective growth of nails.
Subacute Articular Rheumatism.
In some instances the joint-inflammation is less severe, and is
accompanied by only slight fever. One or more joints may be affected.
It differs from the ordinary form in being milder in degree and more
persistent, lasting sometimes for months. It is generally subacute from
THE DATA OB TA IN ED BY BSER VA TION. 183
the beginning, but may be the type present in those who have had
several attacks of rheumatic fever and have been left in a very sensi-
tive condition. Rheumatic fever is usually subacute in children, and
often only one joint is involved. Cardiac complications are more fre-
quent than in adults, and chorea may occur as a sequel. Erythema
nodosum and subcutaneous nodosities are more common in children.
Chronic Articular Rheumatism.
In this form the patient has pain and stiffness in one or more joints,
or in the contiguous tissues. The joints most frequently affected are
the shoulder and knee. The pain is more or less constant, but worse
in damp weather or on the approach of a storm, and worse also at
night in many cases. Conversely, it is better in warm, dry weather.
There is not much if any tenderness, and rarely any swelling or ele-
vation of temperature. The joints very frequently crack and grate on
motion. In the interval between the attacks there is no impairment
of the usefulness of the joints. In very chronic cases there may be
some atrophy of muscles and permanent stiffness, even fibrous anchy-
losis.
In some cases there are repeated attacks of subacute articular rheu-
matism, accompanied by the usual symptoms and joint-effusions.
Chronic articular rheumatism is distinguished from chronic gout by
the fact that there is no special tendency to involve the great toe, by
the absence of the deformities resulting from gout, and the absence of
deposits of sodium urate in the ears, fingers, and around the joints.
Gout.
A disease characterized by specific arthritis, associated with uric
acid in the blood and the deposit of sodium urate in the joints, or
manifesting itself as a diathesis in which occur other inflammations of
non-articular tissues and various disturbances of functions of organs,
the blood also containing uric acid.
Gout is common in Europe, particularly in England, but in its ar-
ticular form is rare in this country. There is an hereditary predispo-
sition in from 50 to 60 per cent, of the cases. It results from over-
eating of rich foods and the drinking of malt liquors, associated with
insufficient exercise and excretion. Garrod has called attention to its
association with lead-poisoning. Paroxysms are induced by indiscre-
tions in eating or drinking, by nervous shock or great mental strain,
by exposure to cold or injury, or by overwork and sexual excesses.
The characteristic phenomena of gout are preceded for a variable
time by acid flatulent dyspepsia, colicky pains in the stomach and
bowel, constipation alternating with diarrhoea, and scanty, heavily
loaded urine. Accompanying these dyspeptic symptoms often are
impairment of physical and mental vigor, irritability of temper, and
hypochondriasis.
In other cases the premonitory symptoms are palpitation of the heart,
or dyspnoea resembling asthma, or various nervous symptoms, as drow-
siness, insomnia, or headache.
184 GENERAL DIAGNOSIS.
In acute articular gout the onset is often sudden, especially in the
first attack. The patient may go to bed in apparent health, but wake
up early in the morning with a feeling of discomfort or uneasiness,
usually in the great toe. In some cases the pain is agonizing from the
first. The patient finds he is unable to step upon the foot without
torturing pain. The ball of the great toe is hot, swollen, red, and
exquisitely resentful of the slightest touch or jar of the bed. The
veins are swollen and the joint stiff. There is slight fever, perhaps
chilliness, thirst, coated tongue, constipation ; scanty, high-colored urine,
depositing urates on cooling ; the skin is warmer than normal, and
there is slight perspiration. The pain usually abates during the day
and increases at night. It is aggravated by motion and attended by
painful muscular cramps. By the end of the first day or two the swell-
ing increases and the pain lessens, owing to diminished tension of the
part. Pain on motion is still great, however, and without treatment
may continue for a week or two ; under treatment the paroxysm sab-
sides in four or five days.
Both great toes may be attacked in the first seizure, more often
alternately than simultaneously, and sometimes other joints than those
of the toes are affected.
After the subsidence of an attack the urine contains a larger quan-
tity of uric acid, and the patient feels better in health and spirits than
for some time. A second attack may be postponed for several years,
but usually after that the intervals between them steadily dimmish,
until an attack recurs every few weeks or months, and the patient
may be scarcely ever free from it. Other joints than the toes, particu-
larly those of the fingers, become involved in subsequent attacks.
The Blood. Neusser has attributed to gout and the uric-acid diath-
esis the presence of granules, observed after staining, in the white
corpuscles, but they have been found in other affections, and are not
diagnostic. The nature of many otherwise obscure gouty manifesta-
tions or arthritic changes may be determined by an examination of the
serum of the blood. Collect the serum which accumulates in a blister
and examine for uric acid. (See Blood.)
Chronic gout results from repeated acute attacks. It is characterized
by deformity of the affected joints, around which are deposited chalk-
stones (tophi) of sodium urate. Similar deposits occur in the helix of
the ear. The first appearance is that of a clear vesicle under the skin,
which subsequently becomes chalky-white and solid. The deposits of
sodium urate occur not only in the cartilages of the joints but in the
ligaments and bursas also, resulting in great impairment of motion and
deformity. " In extreme cases an appearance is presented by the
hand very closely resembling a bundle of French carrots with their
heads forward, the nails appearing to take the place of the stalks"
(Garrod).
Gouty abscesses consist of collections of liquid and solid sodium urate,
which discharge, with or without pus, through the skin. A patient
may have a number of them with but very little impairment of the
general health. They may even act as a helpful vent to the system.
In so-called retrocedmt gout the external joint-manifestation is sup-
THE DATA OBTAINED BY OBSERVATION. 185
pressed or replaced by an internal inflammation, as one of the serous
membranes.
Gout attacks the nervous system, causing headache, delirium, and
sometimes apoplexy, apoplectiform seizures, epilepsy, mania, various
neuralgias, and spinal symptoms.
It also affects the heart and bloodvessels, causing valvulitis and chronic
arteritis.
The symptoms presented by the digestive organs have been men-
tioned. They are often premonitory of an attack.
The kidneys may be affected, causing typical contracted kidney, or
there may be chronic cystitis and urethritis.
Rheumatoid Arthritis.
Rheumatoid arthritis, or rheumatic gout, is an affection characterized
by acute or chronic inflammation of the joints, of progressive charac-
ter, and resulting in deformities. It is attended with very little fever,
and occurs apart from any known systemic disease.
It may be acute or chronic. The acute form differs but little in its
manifestations from acute rheumatic fever. Several joints are en-
larged, tender, and painful. Constitutional symptoms, such as fever,
loss of appetite, frequent pulse, thirst, and furred tongue, occur as in
rheumatism. Profuse acid sweats, however, are absent, and so is the
tendency to serous inflammations. Moreover, while the larger joints, as
in rheumatism, may be affected, the smaller ones also, especially of the
fingers and toes, are inflamed and often the seat of serous effusions.
Furthermore, the inflammation persists in the affected joints and does
not jump from one to another. Instead of disappearing in a few
weeks, it drags on for a much longer time. The pain subsides, but
the swelling persists, and permanent deformity results in at least some
of the joints. The muscles of the arms and legs waste and are affected
with painful spasms.
The disease is most common in young women exhausted by repeated
pregnancies or prolonged lactation, and is favored by poverty, priva-
tion, and cold.
The chronic form is much more common. It also attacks most fre-
quently young women who are exhausted or are subjected to great
fatigue. There is pain, numbness, or formication in a joint, as the
knee. The joint becomes tender, painful, and may be slightly swollen.
This subsides after a while, but sooner or later the same joint or
another one becomes affected, the process is persistent, one joint after
another is attacked, and gradually all the joints may become greatly
distorted, enlarged, and the seat of contractions. There may be no
impairment of general health, or, at most, only dyspeptic symptoms.
The progress is interrupted by remissions from time to time. Pain
may be severe and subject to nocturnal exacerbations. The shape of
the joints is altered by the effusion into the joints and adjacent bursa?,
by thickening of the tissues around the joints, growths of new bone on
the joint-extremity of the bones, absorption of the articular cartilages,
and growths of new cartilage in the synovial sheaths, relaxation of
186 GENERAL DIAGNOSIS.
ligaments, muscular contractures, and luxation of the joints. The
joints crack and creak like rusty hinges, are sore and stiff, and the
attached muscles are affected with painful cramps. (See Fig. 29.)
Fig. 29.
Rheumatoid arthritis.
Great enlargement of the joints at times occurs from the causes
already mentioned and from infiltration of the overlying tissues. The
enlargement is rendered more conspicuous by the atrophy of adjacent
muscles. (See Fig. 14.)
In addition to the articular symptoms other phenomena attend the
process. One of the more common is increased frequency of the pulse.
Although the patient is afebrile, the average pulse-rate is 100 to 120,
or even more. Moreover, the pulse is soft and compressible, in con-
tradistinction to the pulse of gout and rheumatism. It is worth noting
that a return to the normal frequency of pulse is a sign that the pro-
cess of the disease is arrested, although the joint-lesions remain.
The skin is characteristic. It is soft and often much freckled, while
the complexion is fair. C. T. Griffiths has observed the pigmentary
cutaneous changes, along with neural symptoms, prior to the joint-
manifestations, and describes two forms : a diffuse melasmic discolora-
tion, and dark-brown spots resembling moles, but not raised. Moist-
ure of the skin with clamminess is common. It is limited to the palms
of the hands, or may occur in the distribution of certain nerves. The
sweats are not acid ; they are usually local, but may be profuse. Pain
independent of the joint-lesion is due to neuritis, and may precede the
joint-trouble. It is not merely confined to the nerve-trunks, but affects
the smaller branches which are distributed to muscles, as the base of
the thumb. Numbness and tingling are often present.
The progress of the disease is pretty steadily worse. In extreme
cases not only are the limbs crippled, deformed, and helpless, but there
is fixation of the cervical spine and of the articulations of the jaw, so
that the patient cannot move the head or masticate food.
THE DATA OBTAINED BY OBSERVATION. 187
The following describes the characteristic deformity of the hand :
The first phalanx of the fingers is either flexed upon the metacarpus or
extended, and the terminal phalanx in like manner is either markedly
flexed or extended upon the second, or these two phalanges are kept
at a straight line, while the first phalanx is, as usual, decidedly flexed
upon the metacarpus. The hand is pronated and the fingers turn
toward the ulnar side (Palmer Howard and Charcot). (See Fig. 29.)
The foot is abducted and flattened, and the great toe abducted across
and above the other toes. Rarely it may be beneath the other toes.
The metatarso-phalangeal joint is enlarged.
. A variety of the disease is sometimes met with, chiefly in old persons
(senile arthritis), in which the tendency is to involve one or two joints,
particularly the hip, or hip and knee. It is of slow progress, and is
otherwise attended with the same deformities as the usual polyarticular
form.
Rheumatoid arthritis is distinguished from gout by the absence of
heredity and by its development under the exhausting influences of
repeated pregnancies, lactation, poverty, and malnutrition. Rheuma-
toid arthritis is progressive, with occasional remissions ; gout occurs
in successive attacks, with intermissions. Uric acid is absent from the
blood in the former and is present in gout. Rheumatoid arthritis in
the vast majority of cases is subacute or chronic. The acute form is
distinguished from acute gout by the duration of the paroxysm and the
absence of intermissions ; by there being less heat, swelling, and red-
ness of the joints, and less infiltration of the soft parts ; by the fact
that large and small joints are involved, and that there is no special
tendency to inflammation of the great toe.
From chronic gout rheumatoid arthritis is distinguished by the
absence of hereditary predisposition, of repeated acute attacks, and of
the causes of gouty paroxysms — indulgence in sugars, acids, malt
liquors, etc. Moreover, rheumatoid arthritis most frequently begins
in the hands, and is symmetrical and bilateral. Gout has a predilec-
tion for the great toe, and is unilateral, x^gain, gout attacks well-fed
males most frequently after the age of thirty years, while rheumatoid
arthritis tends to attack women under the depressing influences already
mentioned. It may, however, occur in both sexes, and even be asso-
ciated with gout.
Rheumatic fever is distinguished from acute rheumatoid arthritis by
its tendency to involve the larger joints, its erratic course, acid sweats,
and heavy deposits of urates from the urine, its shorter course, its ten-
dency to heart-complications, and its subsidence without impairment of
the usefulness of the joints.
Chronic articular rheumatism is distinguished by the preceding his-
tory, the tendency to seasonal exacerbations, by its involving fewer
joints, and not being so symmetrical in the joints affected. It does not
produce so great deformity as is common in rheumatoid arthritis, nor is
it so likely to affect the vertebra? and jaws. The existence of valvular
heart disease or a history of antecedent chorea is in favor of rheumatism.
The joint-affections of locomotor ataxia are distinguished by the asso-
ciated symptoms of incoordination and absent knee-jerk, by their
188 GENERAL DIAGNOSIS.
sudden onset without pain or fever, by the occurrence of large effusion
into the joint, with subsequent disorganization, fractures, and dislo-
cations.
■ Gonorrhoea!, arthritis is distinguished by the history of gonorrhoea
or the existence of a discharge from the urethra, by the tendency of
the disease to attack the larger joints, particularly the knee or shoul-
der, and to become fixed in one, not wandering from one to another.
The affected joint suffers effusion, and the synovial membranes and
bursse are inflamed. The process is very chronic but indolent, and
the heart rarely becomes affected.
Scurvy.
The joints are swollen, painful, and tender in about one-third of all
cases of scurvy. When to these joint-symptoms the spongy gums, the
hemorrhages, the anaemia, and cachexia are added, scurvy may be'
suspected.
Scorbutus, or scurvy, is a constitutional condition brought about
by a long-continued diet deficient in fresh vegetables. It is character-
ized by pallor, great physical weakness and mental sluggishness,
dyspnoea, subcutaneous and submucous hemorrhages, a swollen, spongy
condition of the gums, and a brawny induration, especially of the calves
and hams.
The onset of the disease is gradual, and is marked by a peculiar
dirty-yellow or greenish pallor of the face, associated soon with an
apathetic expression of the face, physical iveakness, and decided lack of
customary energy. The appearance is so characteristic that patients
are said to detect it readily in others, though unaware of it themselves.
Sleep and digestion are good, but rheumatoid pains may be complained
of. Other prominent subjective symptoms are fatigue on slight exer-
tion, dyspnoea, faintness, and despondency. In the course of a week
or two petechia) appear upon the lower extremities, especially around
a hair as the centre. (See page 128.) Depending upon the severity of
the case there are also bulla?, vibices, and ecchymoses. Brawny indu-
ration, due to deep effusion of blood, occurs, especially in the calves
and hams, producing considerable pain on flexure of the knees.
There is no fever apart from complications. The pulse is frequent,
weak, and small, and the first sound of the heart and the impulse may
be very faint.
The face is swollen and of a dirty, possibly greenish-yellow color,
according to Bird, Buzzard, and others ; in some cases the eye and its
surroundings are the only parts exhibiting signs of scurvy at this time.
" The integument around one or both orbits is puffed up into a bruise-
colored swelling. The conjunctivae covering the sclerotic is tumid and
of a brilliant red color throughout, and about an eighth of an inch in
thickness or elevation above the cornea, leaving the cornea at the
bottom of a circular trench or well." l The condition is not inflam-
matory. These cases often terminate fatally.
1 Buzzard: Reynolds' System of Medicine, 1880, vol. i. p. 451.
THE DATA OB TAINED B Y OB SEE VA TION. 189
The gums swell almost always, become spongy, and bleed upon the
slightest irritation. They are dark cherry-red in color and look not
unlike a split cherry. Sometimes they swell, so as almost to hide the
teeth completely and even to protrude the lips. The breath has a
heavy, sickening odor, and the teeth sometimes drop out of their sockets.
In addition to the cutaneous and gingival hemorrhages, hemorrhages
occur from the nose and other mucous surfaces, and effusions take place
into the lungs, intestines, pericardium, and pleura, associated with in-
flammatory products. There may be no physical signs on the part of
the lungs to account for the dyspnoea, or some dulness and bronchial
breathing, or a few rales, may be detected.
A very peculiar symptom, and sometimes the earliest, is hemeral-
opia, nyctalopia, or night-blindness, in which the patient can see during
the day but not by moonlight, and apart from artificial light is totally
blind at night.
So-called scurvy-rickets is more or less common in infants fed on arti-
ficial food exclusively or on sterilized milk. It is therefore limited
to the first four or five years. The symptoms of scurvy are added to
those of rhachitis. In the eight cases I have seen, the most pronounced
features were those of weakness, ansemia, polyuria, restlessness, the
scorbutic gums, local periostitis, particularly of the tibia, sometimes
periarticular inflammation, and always a general tenderness of the
body, as in rhachitis.
The Tabetic Joint. In forms of nervous diseases, particularly in
sclerosis of the posterior columns, secondary joint-involvement some-
times occurs. The change in the large joints is preceded by pain,
stiffness, and inability to use them. Gradually nutritive changes take
place. At first there is boggy swelling. The cartilages become eroded,
the heads of the bone waste, the ligaments ossify, and irregular bony
growths project. Wasting of the head of the femur is followed by
dislocation. Sometimes an effusion takes place in the joints, and there
may be periarticular oedema. The large joints are most commonly
affected — the knee, hip, ankle, and elbow. Injury excites the abnor-
mal atrophic process. When the tarsal bones and the articulations are
affected the foot becomes flat, and the tarsal and metatarsal articulation
and the tarsal bones project forward or backward. This is called the
tabetic foot.
The Joint of Hysteria. Symptoms of joint-disease are seen in
hysteria. Pain and fixation of the joint are sometimes complained of.
The joint rarely undergoes organic changes, but sometimes a plastic
infiltration of the connective tissue outside of the capsule does occur.
The hysterical nature of the pain and immobility are recognized by
the absence of a cause for joint-lesion, the absence of fluctuation, or of
signs due to erosion, by the association of the local symptoms with the
phenomena of hysteria, but, more particularly, by the fact that con-
traction and even wasting precede the joint-symptoms. In true affec-
tions of the joint both occur after the joint has become diseased ; in
hysteria muscular contraction will take place first.
The knee is the joint usually affected. Care must be taken not to be
deceived by local vasomotor changes of hysterical origin which may
190 GENERAL DIAGNOSIS.
be observed under the surface of the joint. This local increased tem-
perature is not associated with general fever, however, while the vaso-
motor changes indicated by the swelling of the skin, increased tension,
and the shining appearance, with increased sensibility, are not per-
sistent, but occur once or twice in the twenty-four hours. In a
remarkable case of Mitchell's the local vasomotor change took place
at night. The temperature of the knee which was affected increased
three or four degrees, while the pulse remained at 80. The local symp-
toms of heat, redness, swelling, tension, and increased pain passed
away by three o'clock in the morning. The fact that the same symp-
toms could be brought on by handling the knee, or by pressure upon
the patella, pointed to its vasomotor origin.
In joint-cases of hysterical origin the reflexes must be studied.
They do not change, and the electrical reactions are normal, although
there may be atrophy from disuse, but not to the degree that occurs
in organic disease. The muscles may be contracted, but, as previously
noted, the contracture is primarily a relaxation, which takes place if
the tension is removed. Concerning these vasomotor changes, Sir James
Paget's expression, " A joint which is cold by day and hot by night
is not an inflamed joint," is a safe guide to the recognition of an hys-
terical joint. When the joint becomes hysterical after injury it is most
difficult to ascertain its true nature.
Special Joints. The three joints that should concern the student
more particularly are the shoulder, hip, and knee. When symptoms
are referred to either of these joints they should not be passed over
lightly. Grave consequences have followed the attributing of hip-
joint inflammation to rheumatism when it was of tuberculous origin.
Not only has hip-joint disease been mistaken for rheumatism, but the
mistake has even been made of considering the process to be going on
in the knee instead of in the hip. This is because there is often flexion
of the leg, and because pain is so often referred to the knee-joint.
On the other hand, cases of hip-joint disease have been mistaken for
suppuration in the pelvis or in the iliac fossa. Typhlitis or appendi-
citis has frequently been mistaken for hip-joint disease.
In the case of the shoulder- joint there is danger of confounding
neuritis of the circumflex nerve, and consequent paralysis of the del-
toid, with affections of the joint. Although the patient is unable to
move the joint, it is still readily moved by the physician, and the
physical signs of joint-inflammation are wanting.
CHAPTER XIV.
THE DATA OBTAINED BY OBSERVATION— {Continued).
Chills ; fever ; subnormal temperature.
THE TEMPERATURE.
Before discussing the subject of fever, it is not illogical to consider
chills.
Chills.
" Chills " vary from a passing " creep " or cold sensation, extending
up and down the spine, to the " shake " or true rigor of one-half hour
or even longer. In infectious diseases the milder form is of as much
significance as the more severe. The rigor may be so violent and pro-
longed as to terminate fatally. It must be distinguished from the
algid stage of cholera and the coldness of collapse. The chill is
attended by general tremor or shaking, chattering teeth, cold extremi-
ties, pallid face, often parched blue lips and finger-tips. Notwithstand-
ing the peripheral coldness and the extreme sensation of cold, the in-
ternal temperature rises, and may be 104° to 107°.
Clinically, a chill or rigor marks the onset of severe infection, as
pneumonia. " Chills " are symptoms of some affections, as malaria.
They are seen in the course of many diseases, as typhoid fever, tuber-
culosis, and septicemia. In typhoid fever they disclose the occurrence
of a secondary infection or a mixed infection ; they may be due to
antipyretic treatment by coal-tar remedies (Osier) or result from con-
stipation. Endocarditis is attended by daily chills or they occur at
irregular intervals. Pysemia and septicaemia, purulent inflammations
( infections), inflammations of the biliary or renal passages, stone in the .
biliary canal, or the pelvis of the kidney (see Intermitting Fever) are
frequently attended by chills. The morphine habit gives rise to chills,
with some fever.
Fever.
In conditions of health the body-temperature is maintained con-
stantly at about 98.6° F. (37° C). ' This stability of temperature is
due to the central regulating apparatus called the thermotaxic mechan-
ism, which controls the production and the dissipation of heat. Fever
is a condition characterized by an increase of temperature, with usually
increased disintegration of nitrogenous tissue. The muscles and large
glands, as is well known, are the chief seat of heat-production. Both
heat-production and heat-dissipation are believed to be under the
control of the nervous system, either through the motor nerves or
1 92 GENERAL DIA GNOSIS.
special nerves which pass with them to and from definite centres in
the brain, called heat-centres. In conditions of disease this thermo-
taxic mechanism may be altered, so that the normal temperature is
increased or lessened. (1) There may be elevation of temperature
from diminished dissipation of heat, though not necessarily increased
nitrogenous disintegration and disordered function. Or (2) there may
be increased production of heat with diminished dissipation, hence the
temperature will naturally be higher than if increased heat-production
were accompanied by normal heat-dissipation. (3) There may be in-
creased heat-production and at the same time increased heat-dissipation,
in which case there would be the increased waste of fever with or
without any elevation of temperature. (4) It is possible that heat-dis-
sipation may be greater than heat-production, or that the thermotaxic
mechanism may be disturbed, so as to promote loss, in which case
there will be subnormal temperature.
Mode of Determination of Fever. The temperature of the body
can be roughly estimated by the hand of the physician, but this method
is open to many sources of error. The skin is at times hot, and gives
a deceptive sensation of considerable elevation of temperature, whereas
when tested by the thermometer the temperature is found to be but
slightly or not at all above normal. So, too, when the skin feels cold
and clammy in phthisis and during a chill from any cause, the actual
temperature of the body is decidedly above normal, and may be as
high as 103° or 104°. To insure accuracy, therefore, it is now almost
the universal custom to employ clinical thermometers. They are of a
convenient size and shape for insertion under the arm or into the
mouth, rectum, or vagina. The better ones are provided with an inde-
structible index, so that the mercury in the capillary tube remains
stationary at the highest level to which it rose when the thermometer
was in the mouth or axilla. When not provided with such an index
the reading must be made when the thermometer is still in position.
Thermometers vary in the accuracy with which they register tem-
perature. The best ones are compared with an acknowledged standard,
and sold with a slip of paper which gives their fractional variations
from the standard. When the exact temperature is a matter of great
importance, it should be taken in the rectum or vagina, as their tem-
perature is more nearly that of the body. It is of advantage to take
the temperature in the rectum of children or in patients who are coma-
tose. This situation is also a good one to select when a bath is being
administered. If possible, scybalous masses should be removed from
the rectum. At least an incorrect reading may be obtained if the ther-
mometer should happen to be plunged into the faeces ; this must be
guarded against. From motives of delicacy, however, the axilla is to
be preferred to the rectum and vagina on all ordinary occasions. The
temperature it records is somewhat less than a degree below that of the
rectum. The temperature of the mouth is above that of the axilla and
below that of the rectum. It has some advantages over that of the
axilla, being more accessible and recording the temperature more
quickly and more accurately. Nevertheless, as the physician's ther-
mometer is carried from patient to patient, some place should be
THE DATA OBTAINED BY OBSERVATION. 193
selected which is less capable of absorbing disease-gemis than the
mouth. The axilla is, therefore, by common consent the usual place
for taking the temperature. Observe two precautions : (1) Before
introducing the thermometer see that there is no undue moisture ; if
there is, the axilla should be wiped dry, otherwise a lower than a true
reading will be obtained. (2) See that the instrument is inserted into
the armpit and does not project beyond the posterior fold, and that it
is not caught in a fold of the undershirt or night-dress. After the
thermometer is in position the arm should be brought gently across the
chest and kept in that position until the instrument is withdrawn.
The arm should not be held rigidly, as such muscular action increases
the hollow of the armpit and may keep the sides apart, instead of in
contact, as they should be to make a correct reading. The length of
time required to take the axillary temperature will depend upon the
instrument used ; generally from five to eight minutes are required.
Some very delicate thermometers register in one minute, but they are
too fragile for ordinary use. If the index is in such a position that it
can be seen, it is proper to withdraw the thermometer when the mer-
cury has ceased to rise for two minutes.
The index, of course, must be shaken down to normal, or slightly
below normal, before the thermometer is again ready for use ; and the
instrument must be carefully cleansed after use.
In children who are restless the temperature may be taken in the
groin, as the folds of fat readily admit of completely enveloping the
bulb of the thermometer. The height to which the mercury rises
will correspond to the temperature of the axilla. The temperature of
the urine corresponds exactly with that of the body, if taken when
freshly passed and during the act, a method only applicable in the
case of males. Sometimes this method of securing the temperature is
resorted to, particularly in patients who may act as malingerers, when
it is desirable to have the temperature taken in the physician's
presence.
If the mouth is selected as the place in which the temperature is to
be taken, care should be exercised that the thermometer is placed
under the tongue, or along its side between it and the lower jaw, and
retained in position by the lips of the patient. If the teeth are set
firmly on the thermometer, it maybe broken, or, what is of still greater
importance, it will be tilted out of position and a correct reading will
not be obtained. The lips should be closed and breathing be carried
on through the nostrils. Four to seven minutes is sufficient time to
allow it to remain in position. The patient should not have taken ice
or anything cold prior to the observation.
Observations of the temperature should be made at least twice a
day, in the morning and evening, and, as far as possible, at the same
hour on successive days. It is frequently desirable to have the tem-
perature taken every two or three hours, and sometimes at more fre-
quent intervals. This is particularly the case if observations of the
indications for, and the effect of, antipyretic treatment are to be made.
In obscure cases the observations should be repeated at night as well
as during the day. In this manner the presence of unsuspected tuber-
13
194
GESEEAL DIAGXOSIS.
culosis may be revealed, or the occurrence of suppuration in some por-
tion of the body definitely determined. It should not be forgotten,
however, that the temperature may be taken too frequently for the
patient's good, the disturbance of his needed rest being distinctly
harmful.
As the general range of temperature and its diurnal variations are of
more importance than the absolute temperature at any one time, ther-
mometers not perfectly accurate in their reading are still good enough
for clinical and therapeutic purposes.
Physiological Variations of Temperature. The temperature is
subject to physiological variations. 1. It rises from seven or eight in
the morning until seven or eight in the evening, at which time it
reaches its maximum. It then begins slowly to fall, reaching its lowest
point in the early hour- of morning, between two and four. This
diurnal fluctuation does not usually amount to more than a degree. 2.
Exercise, etc. Violent exertion rai-es the temperature, and so does a
heated atmosphere, cold having a contrary effect. 3. Age. In infants
and voting children, up to puberty, the temperature has a somewhat
higher range, and is subject to greater variations than at a later period.
In verv old persons the temperature may be subnormal. The normal
axillary temperature of adults is 98.6 z F. The period in the twenty-
four hour's in which the temperature is at its lowest ebb is from 12
p.m. to 4 a.m. It may then be subnormal. The writer has known
an over-cautious parent to make this physiological fall the subject of
meddlesome observation and ill-judged treatment.
Pathological Variations of Temperature. An elevation of tem-
perature above the normal, not to be accounted for by external heat or
severe exhaustion, may be considered febrile, and is pathological.
The range of febrile temperature varies from above normal to 105° or
106 c in ordinary cases. A range above 106 c may occur, but is not
usuallv compatible with life. Certain terms have been applied to
various degrees of temperature, to indicate in a general way the degree
of fever :
Very low or collapse temperature.
Subnormal temperature.
Xormal temperature.
Slightly aboye normal or sub-febrile temperatures.
Below
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Highly febrile temperature.
Hyperpyretie temperature.
From Futlatsoh.
The Degree of Danger. In general the degree of danger to the
patient increases with the height of the fever, but the duration of the
high fever modifies this greatly. A temperature of 106 ~ on the second
or third day of an acute lobar pneumonia i- not rare, such cases fre-
THE DATA OBTAINED BY OBSERVATION.
195
quently ending in recovery, while a temperature of 105° in the second
or third week of typhoid fever is of much graver significance. Da
Costa has reported a case of cerebral rheumatism in which the axillary
temperature reached 110°, yet the patient recovered. In the case of
injury of the spine, reported by Teale, the extraordinary temperature
of 122° was recorded, and the temperature-range for days was between
112° and 114°. The patient recovered.
Fig. 30.
Malarial intermittent fever. Quotidian type.
The Types of Fever. Fevers are divided, in accordance with the
character of their range, into certain definite types. The types may
Fig. 31.
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196
GENERAL DIAGNOSIS.
tinues for_ more than two days, in which the difference between the
daily maximum and minimum of temperature is less than 2°, is known
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The diagnosis from malarial intermittent fever can be established at
once by an examination of the blood, which reveals in the latter the
plasmodia of Laveran.
Remittent Fever. Fever of a remittent type occurs in many of the
conditions in which intermittent fever is present. It is characteristic
of one of the forms of malaria. It is most frequently encountered in
tuberculosis of the lungs. The remissions usually occur in the morn-
ings, but the order may be reversed. The same type of fever is met
with in puerperal fever, pyaemia, and septicaemia, and in local suppu-
rations, such as abscess of the liver and empyema. A continued fever
may be made to resemble a remittent by antipyretic treatment, which
may cause abnormal remissions. Remissions characterize the decline
of the continued fevers, particularly typhoid, during the period of lysis.
Continued Fever. Continued fever is met with in lobar pneumonia,
typhoid fever, typhus fever, erysipelas, and tuberculosis. In acute
lobar pneumonia the temperature rises rapidly, and in a few hours
from the initial chill reaches 103° or 105°. The morning and even-
ing temperatures vary but little, usually not more than one or two
degrees, until a crisis occurs in from four to eight days. The temper-
ature then falls to or slightly below normal, and does not rise again.
(See Fig. 37.)
208 GENERAL DIAGNOSIS.
A marked remission in the fever sometimes occurs on the fourth
day, before the actual crisis ; the temperature falls to 100°, and rises
again to 103° or 104°, remaining at that level for twenty-four or forty-
eight hours, when the true crisis occurs. The first fall is known as the
pseudocrisis. The fall of temperature of defervescence (crisis) may be
completed within a few hours.
The Ixfluence of Age and Sex. The significance of a high
febrile change is not so great in children as in adults. That is, the
high temperature is not so important, inasmuch as children are liable
to have sudden, excessive increase of temperature ; and a higher tem-
perature may persist in children without deleterious effects upon the
tissues which are noticed in adults. In women of nervous tempera-
ment the temperature is also likely to rise to a great height without
adequate cause or serious result.
CHAPTER XV.
THE DATA OBTAINED BY OBSERVATION— {Continued).
FEVER. THE INTOXICATIONS.
Practically, it may be said that the symptom fever may be due to
an intoxication, an infection, or a central cerebral lesion. In this
chapter a word may be said of the fever of an intoxication. The sub-
stance which produces fever of this type may be a toxic material, the
product of local or general disturbance of tissue metabolism. Thus in
a local catarrhal inflammation, as of the bronchi, the result of the
direct action of an irritant vapor, toxic substances are generated which
Fig. 39.
Fig. 3S
OATE AND
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Aseptic or fermentation fever.
disturb the heat mechanism and
produce fever. Now, an intoxica-
tion or simple inflammation, there-
fore, is attended by fever, which
may be styled catarrhal fever.
(See Fig. 41.) In anaemia, on the
other hand, if all infections can be
excluded, it may be said the gen-
eral disturbance of tissue metab-
Temperature curve after amputation of the forearm, olisill possibly gives rise to the
formation of a toxin which causes
the fever well known to attend this process — anaemic fever.
A better example of fever due to a poison is that which Collins
Warren terms aseptic fever. It is also known as absorption or fermen-
14
210
GENERAL DIAGNOSIS.
Fig. 40.
tation fever. The fever follows a perfectly aseptic operation, and no
causal factor is present. It is due to the absorption of ferments, from
blood clot, or coagulated serum, or tissue debris. The temperature
rises to 102°, and may remain above normal from three days to two
weeks. (See Figs. 38 and 39.) There is a striking absence of consti-
tutional symptoms, however. Another peculiarity is that the fever
begins immediately after the operation. The urine is not lessened, the
body-weight remains normal, and the pulse-rate corresponds to the
temperature rise. In some instances an eruption like that of scarlet
fever — surgical scarlet fever — breaks out.
Should it happen that the retained fluids undergo decomposition and
are absorbed, a more intense type of fever is seen, attended by marked
constitutional symptoms. "We then have traumatic fever — a fever which
subsides as soon as the poison is liberated from the wound. In the
meantime the temperature has been as high as 102° to 103° — the pulse
very rapid, delirium has been marked, and there has been furred
tongue, thirst, anorexia, restlessness, and malaise.
It may happen that septic infection of a wound takes place. Thus,
one of my patients, while dressing a suppurating vaccine wound, inoc-
ulated or infected her finger. The ten-
der spot was followed by redness along
the lymphatics, and enlargement of the
glands — a lymphangitis. She had fever.
A deep cut in the infected spot released
a serous discharge, the fever disap-
peared, and the lymphatic inflammation
subsided at once. Such accidents hap-
pen frequently to surgeons. Another
patient was infected by a surgeon who
had just operated on an osteomyelitis.
The temperature rose to 106.5° in twen-
ty-four hours, and the constitutional
symptoms were extreme. The wound
in the abdominal walls was opened and
cleansed, and the peritoneum was not
reopened ; no peritonitis resulted. The
temperature fell four degrees at once.
The muscles and other tissues of the
woimd became grayish and almost pu-
trid. Recovery was slow. Such cases are known as septic cases, the
ailment septicaemia, and the intoxication saprazmia. (See Fig. 40.)
No bacterial invasion of the body takes place, and there is no local
suppuration. Xo doubt, in each instance micro-organisms infected the
wound, but the symptoms arose from the chemical product resulting
from their growth.
In obstetric practice the retained putrefying placental fragment will
cause such symptoms. In medicine we see such intoxication tat e place
in infections. Thus in diphtheria, systemic intoxication with fever
results from the absorption of a toxin from the local point of bacterial
growth. In tetanus the same toxic fever and symptoms occur. It is
M E
M E
M E
M E
M E
M E
M E
1
I
1
1
1
1
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i
1
Septic intoxication.
THE DA TA OB TAIN ED B Y OB SEE VA TIOX. 21 1
impossible to draw hard-and-fast lines between the toxic fever and the
infective, pyogenic or suppurative fever, and, indeed, such cases prop-
erly belong and will be considered under the next prominent causes
of fever to be considered — the infections.
But " fever " may be due to other intoxications. It is well known
that pepsin and other digestive ferments injected into the body cause
fever. It is supposed products of imperfect assimilation or digestion
absorbed into the system from the gastro-intestinal tract give rise to
fever. Ptomaines or leucomaines, albumoses or peptones, absorbed
from the intestinal tract may thus cause fever. The retention of ex-
cretory products, as those of the renal organs, cause a systemic intoxi-
cation, with the frequent occurrence of fever. Gout, too, may be con-
sidered as an intoxication giving rise to fever.
The fever of auto-intoxication (gastro-intestinal or glandular), so
called, therefore, is an entity. The clinician, at least, without proof
by the bacteriologist, sweeps the intestinal tract with his mercurials and
salines, and thereby administers the causal antipyretic.
Poisoning by food products, as of cheese, meats, sausages, milk, etc.,
appear to cause fever, although it is possible intestinal bacteria may
play some part in the process.
Varieties of Febrile Intoxications. It is assumed that the student is
investigating a case of fever. In keeping in mind an intoxication as
a cause of fever, he must first consider all causes of intoxication from
within ; second, all causes from without the organism.
To the first belong gout, uraemia, cholesteraemia, and the auto-in-
toxications from the intestinal tract, as well as those from modification
or suppression of internal secretions, as of the thyroid and other glands.
To the second belong the following : Sunstroke, morphinism, and
food-poisoning. The fever due to an intoxication, as in the so-called/e6W-
cula and in the simple continued or catarrhal fever, is of doubtful origin.
Diagnosis. The Action of the Heart. Increased frequency of car-
diac action is a symptom common to all forms of fever. It is more
common to see irregularity and intermittency in the fever of intoxica-
tion, and especially of auto-intoxication, than in that of infections.
Indeed, I should call a fever which is attended by a cardiac neurosis,
cardiac mural disease and cerebral disease excluded, one of intoxication.
Increased Respiration. The same may be said of the breathing.
When a respiratory neurosis prevails in the course of fever, it and the
fever attending are due to a common cause, an intoxication. Of
course, pulmonary and central brain and medulla disease are excluded.
It seems both the above observations aid in the diagnosis of an in-
toxication from an infection.
Febrile Intoxications.
Sunstroke (siriasis, thermic fever, insolation, heatstroke). Whether
the cause is the direct action of heat upon the brain centres, or whether
a toxic substance is generated and becomes operative, in this affection
we have the most pronounced expression of fever outside of the in-
fectious disorders. The Hushed face, the pungent skin, the dyspnoea,
212 GENERAL DIAGNOSIS.
and the rapid pulse forebode the high body temperature which in
the axilla may reach 108° to 112°. This is reached very rapidly,
and death takes place in coma hyperpyrexia. If recovery takes place,
the temperature may be moderately continuous a few days. The pic-
ture is added to by the nervous and cardio-respiratory phenomena.
In some instances dyspnoea, heart-failure, and coma may follow on
rapidly, and death ensue in one or two hours. In other cases pain
in the head, dizziness, and languor precede the stupor. Nausea and
vomiting, perhaps diarrhoea, chest oppression, frequent micturition,
and convulsions may precede the insensibility. Unconsciousness is
lost quickly or gradually, and it may be transient or pass into deep
coma. Relaxation of the muscles with twitching is seen, and the pupils,
at first dilated, become contracted. As the coma deepens, the heart's
action becomes more rapid and feeble, the respirations hurried, shallow,
and irregular, and death ensues, preceded or not by convulsions.
The diagnosis is based on the history, the mode of onset, and the
hyperpyrexia. It must be distinguished from uraemia and apoplexy.
Heat exhaustion is readily recognized. The moist, pale, and
cool skin, the soft, feeble pulse, the quiet but hurried breathing, are
unattended by fever. The collapse, for such it is, is not attended by
coma, and it usually responds to treatment.
Morphinism. Lewin showed that morphinism is attended by fever.
The fever may be continued or intermittent. When the latter, chills
are of frequent occurrence. The diagnosis is based on the history, on
the evidence of poor nutrition without cause, on the general depression
and lassitude, and upon the temperament of the patient, to which is
added poor sleep, restlessness, and itching of the skin. The peculiar
sallowness of the complexion and the prematurely aged appearance are
well known. Pseudo-neuralgic pains are common, tabetic symptoms
may be present, and notably gastro-intestinal symptoms, as gastralgia,
vomiting, diarrhoea, especially if the drug is withheld. Fever, it
must be remembered, may be absent.
Simple Continued Fever. A non-contagious fever, lasting from
one to twelve days, not dependent upon any known specific cause, and
not attended with any definite local lesions. Its chief characteristic is
the continued elevation of temperature.
It occurs especially in children and in those prone to ready disturb-
ance of the heat-regulating apparatus. Great mental and physical
exhaustion, prolonged bathing in the hot sun, and disturbances in
digestion may cause it. Perhaps, as suggested by Guiteras, some of
the cases occurring in the tropics and in very hot weather should be
regarded as very mild forms of thermic fever.
The onset of the disease is abrupt. There may be a chill, or in ner-
vous children a convulsion ; but these are rare. The temperature rises
rapidly from 102° to 104°, accompanied by headache, thirst, restlessness
or drowsiness, loss of appetite, a coated tongue, constipation, and occa-
sionally nausea. The urine is scanty, and sometimes there is a heavy
deposit of urates. There may also be more or less muscular soreness.
Sometimes within twenty-four or forty-eight hours free perspiration
takes place, with rapid subsidence of the fever. This is ephemeral fere r.
THE DATA OBTAINED BY OBSERVATION.
213
In other cases the fever continues for a week or ten days longer.
During this time the symptoms already noted continue. Sleep is dis-
turbed and mild delirium is at times present. Respiration and pulse
are not much accelerated. Sudamina upon the abdomen and herpes
on the lips are common. Pale-bluish macula? are sometimes seen.
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Simple continued fever.
The spleen is not enlarged except in very rare cases, and there are no
local evidences of disease. The fever subsides more gradually than in
ephemeral fever, the defervescence being marked at times by perspira-
tion, a few loose stools, a copious deposit of urates in the urine, or by
hemorrhages from the nose, rectum, uterus, or urethra.
The diagnosis from other fevers and febrile affections is made by the
absence of any characteristic eruption, of enlargement of the spleen and
liver, and of any lesion, such as endocarditis, bronchitis, or pneumonia.
Food Intoxications. Among the intoxications which give rise to
fever are those due to food-poisoning. Meat, milk products, and shell-
fish cause an intoxication of the system which in the instance of the
first three forms often threatens life, and, from the suddenness of the
attack and the severity of the symptoms, points to an infection rather
than an intoxication.
The history of the case is often the first clue to its nature. The
symptoms are those of acute gastro-intestinal irritation, to which are
added, with or without afebrile periods, the symptoms of collapse.
Meat-poisoning". In the intoxication arising from poisoning by
meat, the temperature rises from 101° to 104°, preceded usually by a
brief period of chilliness. The occurrence of fever may be preceded
by a period of incubation lasting from twelve to forty-eight hours.
During the period of incubation there is malaise, loss of appetite,
nausea, and colicky pains. As they increase chilliness ensues, and in
some instances there is a marked rio-or. Prostration occurs almost
214 GENERAL DIAGNOSIS.
immediately, with giddiness and faintness, and the occurrence of cold
perspiration. Headache and backache are liable to occnr. Following
the chilliness the symptoms of gastro- intestinal irritation arise, diar-
rhoea being more frequent than vomiting. The abdominal pain in-
creases and the perspiration and clammy sweats become more pro-
nounced. As further evidence of the intoxication, there is an extreme
degree of muscular weakness. The pulse becomes rapid, and later,
thready. In addition to muscular weakness, cramps in the legs and
arms, followed by convulsive movements, occur, and the patient com-
plains of paresthesia of various forms. In milder cases the symptoms
of gastro-intestinal irritation and of muscular weakness attend the
fever. In the more severe cases fever is replaced by collapse.
Poisoning by Milk Products. Symptoms of gastro-intestinal irri-
tation and choleraic symptoms ensue. The diarrhoea of infants and
cholera infantum are types of this intoxication. The high degree of
fever that occurs is well known. In cheese-poisoning the fever is not
continuous as in the other forms, the temperature becoming subnormal
with the onset of collapse.
Poisoning by Shell-fish. In mussel-poisoning the symptoms are
those of an acute mineral poisoning with profound nervous symptoms.
Fever does not attend this condition, but collapse follows quickly.
There are no gastro-intestinal symptoms.
Fish-poisoning is also unattended by fever, collapse occurring early.
Afebrile Intoxications.
For convenience, and by contrast, the afebrile intoxications will be
considered. Herein will not be considered those important afebrile
intoxications due to disease of the ductless glands. They include some
diseases of the suprarenal bodies (Addison's disease), the thyroid gland
(exophthalmic goitre and myxcedema), the lymphatic glands (status
lymphaticus), and the spleen.
Alcoholism. In acute alcoholism the reeling gait, the incoherent
speech, followed by narcosis, are well known. The temperature is
afebrile. Often, indeed, it is subnormal, and when equal on both sides
of the body is very suggestive. The flushed face, possibly slightly
dusky, and the injected eye, would lead us to suspect the presence of
fever. The odor of the breath furnishes a clue. The heavy breath-
ing, the full pulse, the dilated pupils, the stuporous rather than coma-
tose state, are accompaniments of this intoxication. The flaccid limb
of one side would point to hemiplegia from hemorrhage, especially if
the coma is deeper than usual and the stupor more marked. But
uraemia and apoplexy, and either of the two in a drunken subject, must
be borne in mind.
Chronic Alcoholism. When the poison is taken for a long time it
acts as a tissue poison and a check upon waste. Epithelial and nerve
degeneration and fibrous overgrowth follow the first or poisonous irri-
tative action ; and fatty change the second. In the alcoholic, tremor
of the hands and tongue is seen. The action of the muscles is un-
steady. The mind is dull, the temper irritable, forgetf illness is most
THE DATA OBTAINED BY OBSERVATION. 215
common, and later a dementia and epilepsy may ensue. Alcoholic
neuritis, to be described later, is of frequent occurrence.
Gastro-intestinal catarrh with poor appetite and constipation is most
liable to ensue, and later cirrhosis of the liver and kidneys. Endar-
teritis and cardiac dilatation develop in some independently ; in others
with the nervous affections, delirium tremens.
Grain-poisoning'. Three forms are seen. When the grain is con-
taminated by ergot, symptoms known as ergotism occur. Chronic
ergotism may cause gangrene or a train of nervous symptoms in which
convulsive movements are most prominent. In the gangrenous form
the toes and fingers are the seat of mortification. The process is pre-
ceded by anaesthesia, paresthesia, and pain. In the convulsive form
there is slight fever with some weakness and tingling sensations in the
body. Cramps and contractures occur in the extremities, continuing
for hours or days, and relapsing frequently. A mild delirium or the
development of melancholia or dementia attends the convulsive form.
In other intoxications fever is not so pronounced. In lathyrism the
symptoms are those of spastic paralysis, which may proceed to para-
plegia. In pellagra, a disturbance due to maize, there are disorders
of digestion, loss of sleep, general pain, and debility. The digestive
symptoms are those of salivation, dyspepsia, and diarrhoea. A pecu-
liar erythema arises. Subsequently, desiccation and desquamation of
the epidermis occur, and often small boils develop. Headache, back-
ache, spasms, and paralysis of the legs occur in the severe and chronic
forms. The nervous symptoms may give way to melancholia.
Lead-poisoning. Intoxication due to lead or plumbism may be
acute or chronic. In the acute form we have symptoms of gastro-in-
testinal irritation with constipation and extreme colicky pains. Anae-
mia may develop rapidly, and pronounced nervous symptoms arise.
Among the latter we have neuritis, convulsions, epilepsy, and delirium.
Hemorrhages from mucous membranes may be seen, and a form of
nephritis develops rapidly. The urine contains albumin and tube-casts.
Fever is not a pronounced symptom.
The characteristic symptoms of chronic poisoning are (a) saturnine
cachexia, in which anaemia is most pronounced ; (6) colic; (c) paralysis,
which may be acute, subacute, or chronic, and which usually develops
without fever. The paralysis may be anti-brachial, causing character-
istic wrist-drop ; brachial, in which the scapulo-humoral form of paraly-
sis is seen, and an Aran-Duchenne class, resembling chronic anterior
poliomyelitis. Another is the peroneal type, in which the lateral
peroneal muscles, the extensor communis of the toes and the extensor
proprius of the big toe are paralyzed, causing the steppage gait. Fi-
nally, paralysis of the adductor muscles of the larynx occurs in lead-
poisoning. The paralysis often extends from a local group of muscles
throughout the body, presenting symptoms like those of an ascending
paralysis with rapid wasting. In other instances the general paralysis
occurs primarily, the wasting and loss of power going hand in hand.
Fever sometimes attends a general paralysis in lead-poisoning. (d) The
cerebral symptoms of the acute form have been mentioned. In the
chronic cases they may also occur. Optic neuritis, or neuro-retinitis, is
216 GENERAL DIAGNOSIS.
common. Delirium, with hallucination, may occur. Tremor is a common
symptom. It must not be forgotten that headache, convulsions, epi-
lepsy, and delirium may be manifestations of lead encephalopathy,
even in cases in which the history of exposure to lead is not direct ; (e)
chronic lead-poison leads to arterial sclerosis and contracted kidneys with
hypertrophy of the heart ; (/) gout is very common, and may be seen in
both acute and chronic forms, particularly in the big toe ; (g) as described
in the section in which the mouth and gums are discussed, the blue line
is the specific symptom of lead-poisoning. The reader is referred to
that chapter for a description of the line. It must be remembered that
in all forms of obscure nervous disease, in gastro-intestinal irritation,
in arterio-sclerosis, and gouty arthritis, this line must be looked for.
Arsenic-poisoning. Acute arsenical poisoning is attended by
severe symptoms of gastro-intestinal irritation followed by the rapid
development of collapse. Fever is not a prominent symptom unless
recovery is about to take place. The temperature is subnormal, but
as the collapse symptoms disappear fever due to gastro-intestinal ulcer-
ation develops.
In chronic arsenical poisoning the fever occurs only if there is great
irritation of the mucous membranes, as of the conjunctiva, mouth, or
pharnyx. In this form, in addition to the irritation of these mucous
membranes, there may be subacute gastro-intestinal catarrh, with diar-
rhoea. In other instances there is profound anaemia and debility, with
parsesthesia and neuralgia. In others, again, paralysis like that of lead
palsy may occur. It must not be forgotten that puffiness under the
eyelids may be due to this cause.
CHAPTER XVI.
THE DATA OBTAINED BY OBSERVATION -(Continued).
Causal relation of bacteria to disease, Koch's laws, value in diagnosis. Bacteria :
Saprophytes, parasites, pathogenic, non-pathogenic, aerobic, anaerobic, facul-
tative anaerobic. Morphology : Micrococci, bacilli, spirilla — Micrococci. Mor-
phology : Form and size. Reproduction, fission ; grouping. Biological char-
acters : Non-motile. Pigment production. Liquefaction of gelatin. Production
of acids Toxic ptomaines and toxalbumins — Bacilli. Morphology : Form and
size. Reproduction, fission, spores ; grouping. Biological characters: Motility.
Pigment production. Liquefaction of gelatin. Production of acids. Putrefaction,
fermentation. Spirilla. Morphology : Form and size. Reproduction, fission ;
grouping. Biological characters. Motility. Pigment- production. Liquefaction
of gelatin. Production of acids and fermentation wanting.
FEVER. THE INFECTIONS.
A\ t e have already indicated the diagnostic significance of the type of
the fever (Chapter XIV.). Following the lead in part of the subjective
symptoms, we next examine every organ and structure of the body
when the symptom — -fever — is present. By this examination we will
find either (1 ) a functional disturbance of some organ of the body ; (2)
an inflammation ; (3) or we will find a general process, or infection, any
local inflammation being secondary, brain disease and intoxications
having been excluded.
1. Any functional disturbance of one or more organs — glandular —
attended by fever must be looked upon as an intoxication. Fevers due
to such causes have been discussed in the preceding chapter, so we
pass on to inflammations, toxic and infectious, which cause fever.
2. Suppose we find local inflammation of some part, as an inflamma-
tion of the nares, a bronchitis, or an apparent gastritis or enteritis.
The inflammation may be toxic or it may be infectious. As another
example, let us take the kidneys. Blood, albumin, and renal casts
would show that they are the seat of inflammation. This inflammation
may be toxic, as from cantnarid.es, or the toxin of an infection, or it
may be infectious. In either instance the fever is caused by the local
process. To determine whether the inflammation is toxic (generally
catarrhal) or infectious, we must rely upon the data obtained by in-
quiry, the clinical course, and the result of the examination described
in Chapter XVII. , which discloses the method of determining the
presence of an infection.
3. If the above are excluded we proceed with the bacteriological
diagnosis. By this means we find if a general infection prevails. Such
diagnosis may be necessary also to recognize pyaemia and septicaemia.
218 GENERAL DIAGNOSIS.
The Infections.
It had long been surmised that micro-organisms had much to do
with morbid processes, and that the relationship was that of cause and
effect. It was known, for instance, that suppuration, surgical fever,
erysipelas, hospital gangrene, and puerperal fever were associated with
conditions which favored the multiplication of the lower forms of life.
What relationship the micro-organisms bore to the various affections
was not known. Least of all were the specific micro-organisms which
were the causes of particular specific morbid processes known. I have
said that it was surmised ; but there was groping about, a difference of
opinion, and a maximum of theory, a minimum of fact. It is true
that in relapsing fever the spirillum had been found, and that none
had been found in any other disease. Moreover, it is true that mon-
keys had been inoculated and the disease reproduced in them. It is
true that the bacillus of anthrax had been seen in the blood in the
early sixties. It is true that the great genius Pasteur had prosecuted
studies of bacteria in animal and vegetable pathology to most brilliant
and practical conclusions. Nevertheless, there were confusion and
doubt ; scientists were not satisfied with the demonstrations which
undertook to prove the causal relationship of micro-organisms to
disease.
Laws to Establish Causal Relationship. By the genius of Robert
Koch theories and objections were set at naught. The scientific world
was fully prepared by the labors of early investigators to accept Koch's
conclusions. They were based upon an array of well-authenticated
facts, which anyone could prove for himself. The postulates formu-
lated by Koch, the fulfilment of which he considered as necessary in
order to identify an organism as the etiological factor in a given disease,
are as follows : The constant presence of the organism in the affected
tissue of the diseased animal ; its isolation from the pathological lesions,
and its continuous cultivation in pure cultures under artificial condi-
tions through many generations ; the power of such pure cultures to
reproduce the disease when inoculated into susceptible animals ; and
the detection of the organism in pure culture in the lesion found in the
animal thus inoculated. The experimental circle was then repeated.
In this manner the causal relationship of micro-organisms to special
diseases had been proved by the distinguished investigator in the case
of anthrax, tuberculosis, and other affections. In a certain number of
cases particular species of bacteria and other micro-organisms have
been isolated from definite diseases and reasonably believed to stand in
causal relation to them, but which have, nevertheless, not fulfilled all
the requirements of the above-cited postulates. The difficulties often
encountered are : The impossibility of reproduction in animals of the
clinical and pathological features that the diseases present in human
beings, as is the case with typhoid fever, influenza, gonorrhoea, and
fibrinous or lobar pneumonia ; and the impossibility of satisfactorily
cultivating certain other organisms that are the constant accompani-
ment of particular diseases of man, as, for instance, the plasmodium
malarias, the bacillus of syphilis, and the amoeba coli.
THE DATA OBTAINED BY OBSERVATION. 219
The infectious diseases, then, are those that are produced by a living
contagion or micro-organism. The organism is introduced into the
body through the skin, if the latter is the seat of some lesion, as in
syphilis, tuberculosis, and anthrax ; through the air-passages, as in
diphtheria, scarlet fever, and other specific fevers ; or through the
digestive tract, as in typhoid fever, dysentery, and cholera. The
virus, as the living cause is named, m many instances produces certain
changes at the point of entrance — the initial phenomena. It is then
conveyed by the lymphatics or bloodvessels to near-by organs in the
related lymph-stream or blood-stream, or transmitted to the whole
body. When the whole body is affected an eruption is sometimes pro-
duced (eruptive fever), or the blood is changed in quality (diphtheria),
or many tissues are affected simultaneously, or the nervous system is
notably disturbed. The above are the phenomena of general distribu-
tion of the virus, or of infectiveness. The virus or poison thus distributed
may be the living organism, as in tuberculosis or anthrax, or it may be
a poison generated by the organism, a toxin or ptomaine, as in diphtheria.
Phenomena of secondary local distribution are due to local changes
in organs affected secondarily. The poison has a special affinity for
certain organs, as in whooping-cough, parotitis, pneumonia, or leprosy.
In some instances the local phenomena are so marked as to give to
the disease a corresponding distinctive feature. They are the granulo-
mata. Bearing in mind the above distinctions, specific infectious dis-
eases are divided into six classes.
First Class. Acute Specific Fevers. The initial phenomena are
slight. The phenomena of infectiveness are marked ; an eruption is
one of the most characteristic. The secondary local phenomena are
variable. The following are included in this class : Typhoid fever,
typhus fever, variola, varicella, scarlet fever, measles, relapsing fever,
rubella, influenza, dengue, the plague, and cholera.
Second Class. Specific Inflammation. Initial phenomena indefi-
nite. General phenomena (infectiveness) variable, but no eruption.
Specific affinity of poison for one particular structure. Whooping-
cough, mumps, diphtheria, dysentery, erysipelas, tetanus, hydrophobia,
cerebro-spinal meningitis, rheumatic fever, and pneumonia belong to
this class.
Third Class. Contagious or Infectious Suppuration. Initial phe-
nomena marked (suppuration) ; generalization not marked unless the
virus enters the blood ; secondary local phenomena decisive. Gonor-
rhoea is one type, pyaemia, or any infection from pus-producing micro-
organisms, as abscess, carbuncle, etc., a second, in which the blood is
infected.
Fourth Class. Infective Granulomata. Distinct initial phenom-
ena. Phenomena of generalization not marked, or like specific fevers.
Secondary local phenomena prominent. Examples : Tuberculosis,
.syphilis, leprosy, and glanders.
Fifth Class. Miasmatic Diseases. No initial phenomena.
Sixth Class. Vegetable Parasitic Disease*.
It is readily seen that when the definite cause of an infectious disease
is isolated, and the morphological and biological properties of the
220 GENERAL DIAGNOSIS.
causal micro-organism determined, the clinician has acquired a valu-
able aid to diagnosis. Indeed, in such affections the bacteriological
diagnosis has become an absolute certainty.
Bacteria.
To determine the micro-organism which causes the mfection the
student must be familiar with the morphology and biological properties
of the various forms of bacteria. (By means of this knowledge a bac-
teriological diagnosis is made.) The morphology : The shape, the size,
the mode of reproduction and grouping are to be studied. Bacteria or
fungi are divided morphologically into micrococci or spherical bacteria,
bacilli or rod-shaped bacteria, and spirilla or twisted forms. Bacteria
procreate by simple fission, and are therefore known as fission-fungi or
schizomycetes. Some forms also produce spores. The biological proper-
ties include motility, color, the growth on various culture-media and
under various temperatures, and the product of vital activity.
Micrococci.
Morphology. To this group belong the spherical bacteria. Each
coccus is of nearly equal diameter in all directions. They vary in size
from 0.1 /j. to 1 or 2ju. A micromillimetre (//) is one twenty-five thou-
sandths of an inch. The various micrococci resemble each other so
much in form and size that they cannot be distinguished by their micro-
scopic appearances. To distinguish them we depend on the color and
character of their growth in various culture-media, on their pathogenic
power, and on other biological differences. The mode of grouping,
after fission or reproduction, is an important characteristic by which
varieties are differentiated. Just before dividing they are not perfectly
spherical, but short or long, oval. After division (for they divide in-
definitely when growing) the staphylococci are solitary or in pairs, or,
occasionally, in groups of four or in clusters, roughly likened to a
bunch of grapes, from which latter grouping they derive their name.
The organism is called a diplococcus when associated in pairs. Some-
times two or four are included in a capsule. Zqogloea are groups of
cocci held together by a transparent glutinous substance. Streptococci
are characterized by a grouping in chains, known as chaplets or torula
chains, because division takes place in one direction onlv. When
division takes place in two directions, groups of fours, or tetrads, are
formed ; and when in three directions, groups or packets of eight are
formed, of which the sardnce are the most familiar examples. These
names, significant of the grouping, refer to the predominating groups
as seen in microscopic preparations. In some of such groups, for in-
stance, are seen only diplococci or streptococci ; but in all, transitional,
irregular, and accidental groupings may be observed.
Biological Characteristics. Micrococci are not motile and do not
form spores. Products of vital activity : The various forms of bacteria
are also distinguished by noting the difference in the products of vital
activity. Of these, pigment-production is one of the most apparent.
The staphylococcus pyogenes aureus and citreus are chromogenic or pig-
TE 111
Fig 2.
A ^ V ^ i\
*$$M
A. Tubercle-bacilli. B. Pueumococcus.
Fig. S.
A. Anthrax. B. Streptococcus and Staphylococcus.
Fig . 4.
A. Comma-bacillus. B. (ionococcus.
Fi te
A . Recurrent Spirilla. B. Leprosy.
Fig S
.•T Normal Blood. B. Normal Blood.
A. Leukaemia. B. Ebertli's Bacillus.
THE DATA OBTAINED BY OBSERVATION. 221
merit-producing bacteria. The liquefaction of gelatin, when cultures
are made, is a biological characteristic which assists in the diagnosis of
the various species. Some pathogenic as well as non-pathogenic germs
have this effect on the nutrient medium ; others of both classes do not
affect it. A peptonizing ferment is formed during the growth of cells
which acts upon and dissolves the gelatin. The amount, degree, and
character of the liquefaction serve to distinguish various species. The
staphylococcus pyogenes aureus and albus (as well as some others) are
liquefying micrococci. Production of acids: Many bacteria produce
an acid — lactic acid, acetic acid, butyric acid — which gives an acid
reaction to the culture-media. This may be seen if a neutral litmus
solution has been added to the gelatin. The pink color produced indi-
cates the presence of an acid. Culture-media, it must be remembered,
are alkaline or neutral. The pathogenic micrococci which produce an
acid are the staphylococci of pus — lactic acid.
Putrefactive fermentation is set up by bacilli and not by micrococci.
Other products of vital activity need not concern us, as they are pro-
duced by non-pathogenic forms.
Toxic ptomaines and toxalbumins are products of many forms of patho-
genic bacteria, and cause the symptoms of infective diseases in many
instances ; thus in diphtheria the local infective inflammation represents
the seat of activity of the bacillus, the point at which its poisons are
being manufactured at the expense of the tissues in and on which it is
growing ; the general symptoms are due to the toxalbumin that has
been absorbed by the circulating fluids from this local seat of action.
The isolation and detection of the toxalbumins are not sufficiently easy
to warrant such a mode of investigation for diagnostic purposes. Often
the results of inoculation, by which the lethal effect is produced, aid in
the diagnosis of the suspected ailment. (See Plate III., Fig. 2, b.)
The Bacilli.
Morphology. The bacilli, or rod-shaped bacteria, differ widely in
form, in size, and in modes of grouping after fission. Form and size :
The longitudinal diameter is greater than the transverse, and the
forms vary from short oval or slender rods to long filaments ; some-
times short rods and long filaments are seen in pure cultures of the
same bacillus, as in the typhoid bacillus. The transverse diameter of
a given species does not vary, as a rule. The form of the extremities
of the rods must be observed. They may be square, slightly rounded,
round, oval, or lance-shaped or spindle-shaped. Reproduction and
grouping: Fission or reproduction takes place by binary division,
transverse to the longitudinal axis. They group in long chains, or are
solitary or united in pairs. They may be surrounded by a capsule or
collect in zooglcea masses.
Spores. When conditions unfavorable to continuous multiplication
by transverse division arise certain bacilli possess the property of
entering into a permanent or resting stage. In this case there de-
velops within the body of the bacillus an oval, egg-shaped structure —
an endogenous spore. The spore represents the inactive stage, and lies
222 GENERAL DIAGNOSIS.
dormant until circumstances favorable to growth reappear, when it
develops into a bacillus identical with that from which it was formed.
Spores do not develop into spores but into bacilli. The spores retain
their vitality for months or years, and resist desiccation. They are
spherical or oval, and highly reproductive. They are formed by con-
densation of protoplasm at the centre or at one end of the bacillus,
where they are retained in a linear position until set free. Some
bacilli grow into long filaments during spore-formation ; others change
their shape, swelling at the centre, becoming spindle-shaped or club-
shaped, according to the location of the spore within it. Many bacilli
do not change their shape at this stage. The spores are free or col-
lected in masses with the bacilli as well as located in the parent bacillus.
Motility. The bacilli are often actively motile, because of the
presence of flagella. The movement is one of progression in different
directions. It may be slow and deliberate, in a to-and-fro motion, or
serpentine, or a quick, darting forward motion.
Biological Characters. Products of vital activity. They may be
ascertained in the same manner as in the study of micrococci. Pig-
merit-production is seen in cultures of the bacillus pyocyaneus or bacil-
lus of green pus, of which there are several varieties producing various
shades of blue or fluorescent green. Liquefaction of gelatin : This is
produced by the bacillus anthracis and the bacillus pyocyaneus, the
" comma " bacillus of cholera and many other species. Production of
acids : The bacillus coli communis produces lactic acid. Fermentation :
The latter bacillus sets up fermentation of carbohydrates, as of glucose,
lactose, and saccharose. (See Plate III.)
The Spirilla.
Morphology. They are seen in the form of curved rods or spiral
filaments. The shorter ones are curved, the longer are spiral, like a
corkscrew. The curved filaments may be short and rigid, or long and
flexible.
Reproduction. They reproduce by binary division (fission).
Biological Characters. Motility. They are motile ; the move-
ment is rotary, as well as progressive in the direction of the long axis
of the filament. The presence of flagella is determined by Loffler's
method of staining. They are single at the ends of rods, or several
are seen at one extremity, or one or more may occur at both ends.
Pigment-production: Pathogenic spirilla do not produce pigment.
Liquefaction of gelatin: The spirillum of cholera Asiatica (comma
bacillus) and the spirillum of cholera nostras (Finkler and Prior) both
liquefy gelatin in a peculiar manner. (See Plate III., Fig. 4, a.)
CHAPTER XVII.
THE DATA OBTAINED BY OBSEEVATION— {Continued).
Data obtained by inquiry — By observation. Local infection— General infection.
Pyaemia ; septicaemia. Terminal infections. Fever in carcinoma. Afebrile
infections. Infections of certain bacteriology; of uncertain bacteriology. Bac-
teriological diagnosis. Method of research : Microscopical examination, culti-
vation, inoculation. Essentials in technique. — Method of research : Blood, dis-
charges, exudations; mode of collection. Apparatus. Preparation of apparatus.
Sterilization. Microscopical examination : Technique, cover-glass preparations.
Methods of staining; spores. "Hanging drop" — Cultivation of micro-organ-
isms. Culture-media. Tube- and plate cultures. Smear- and stab-cultures —
Inoculation of animals — Special bacteriological diagnosis.
FEVER. THE INFECTIONS.
Unfortunately, the cause of many of the infectious diseases has
not been definitely isolated. This group is largely the infectious
disorders which are epidemic and contagious. In order to diagnosti-
cate them it is necessary to associate with the mode of onset and clini-
cal course of the disease the facts and laws pertaining to epidemics and
to contagion. Data, therefore, obtained by inquiry are quite necessary
to establish the diagnosis. Such data are useful in confirming the
results of an objective or bacteriological examination of the patient,
even though the diagnosis be at once established by the latter method.
Data Obtained by Inquiry. In the first place, we note the social
history, learning this while preparing for the objective examination.
It should be personal and general. The age, the sex, the habits, the
occupation, are looked into. The nature of the prevailing diseases in
the community are known or sought for, and all possible unusual cir-
cumstances in food, drink, clothing, are inquired for. In short, a his-
tory of exposure to influences which attend an intoxication or those
which permit infection are to be zealously sought for.
An inquiry for previous diseases does not imply a history alone of a
previous infectious disease, but a history of such diseases as are often
followed by infection. Thus, a history of a previous attack of gall-
stones or of renal calculus may be a clue to the localization of an infec-
tious process. Too much stress cannot be laid upon the diagnostic
value of the data obtained in this manner.
The next data obtained by inquiry is the history of the present, dis-
ease. The mode of onset is of itself suggestive. Sudden onset points
more closely to an intoxication, though not necessarily, although more
likely in children. Otherwise sudden onset usually indicates one of
the short infections, of which scarlatina and pneumonia are representa-
224 GENERAL DIAGNOSIS.
tive types ; while gradual onset, a long infection, of which typhoid
fever is a type.
The subjective symptoms are then inquired for and their site affords
a clue as to the steps to be taken in the objective examination. Thus,
pain in the throat with difficulty in swallowing calls for an examination
of the fauces ; pain in the chest, of the lungs ; in the prsecordia, of the
heart, etc. Any functional disturbance of an organ should also lead us
to a study of it.
Data Obtained by Observation. The appearance of the inflam-
matory process may be sufficient to decide its nature, however — a boil,
an abscess, a carbuncle, which gives rise to more or less fever, because
they are local infections, are readily recognized.
Local Infection. When not preceded or accompanied by any pro-
cess elsewhere the infection is said to be local. An appendicitis, a
cholangitis, an inflammation of a serous membrane, as well as a boil or
carbuncle, may be a local infection. In like manner the accidental
wound of a surgeon by which he is inoculated or infected by the micro-
organism of the pus may be an infection. The natural or acquired
wounds of the puerperium may also be infections. A local infection
here arises. It must be borne in mind that any local inflammation may
be infectious. It is not our purpose to consider here local infections.
Some, indeed nearly all, of the streptococcus and staphylococcus infec-
tions are local. The general symptoms are produced by a toxaemia,
the toxin alone passing into the blood.
General or Systemic Infections. General infections alone, and
those winch may have more pronounced local expression, as pneu-
monia or the pneumococcus infection, are discussed. It is of importance,
however, to remember that in determining whether a local inflamma-
tion is infectious or not, we use the same methods that are employed to
determine the nature of a general infection.
It is also important to remember that a local infection may be circum-
scribed and cause a toxic fever. On the other hand, a small portion of
the purulent exudate from the infection may get into the circulation
and be carried to distant parts, as the brain, the lungs, the kidney, the
joints, the spleen. Distant foci of inflammation are set up, giving rise
to multiple small abscesses in the organs affected. Pycemia is the name
of this form of systemic infection. Finally, such local infection may
become general and the case terminate in septicmnia.
Pyaemia is characterized by rigors, fever, usually intermittent, and
sweats. There is exhaustion ; the skin, is slightly icterode. The odor
of the breath is sweet. There is anorexia, nausea, perhaps vomiting,
frequently diarrhoea. Erythematous eruptions are seen. With these
general symptoms there are present the physical signs of abscess in the
lungs or the spleen or other organs of the body, or we may have an
endocarditis. When the affection is limited to the portal area, and
multiple abscesses of the liver succeed a purulent process in the area
of the portal vein, the general symptoms are combined with enlarge-
ment of the liver, which is tender and painful, and perhaps with deeper
jaundice. The micro-organisms which invade the system and cause
areas of suppuration are the streptococcus and staphylococcus pyo-
THE DATA OBTAINED BY OBSERVATION. 225
genes, the micrococcus lanceolatus, the gonococcus, the bacillus coli
communis, the bacillus typhi abdominalis, the bacillus proteus, the
bacillus pyocyaneus, the bacillus influenzae, and the bacillus aerogenes
capsulatus.
Diagnosis. Pyaemia resembles in many respects tuberculosis of the
kidneys and calculous pyelitis, in both of which recurring rigors and
sweats are common. In gross aspects it resembles malaria. (See Inter-
mittent Fever.) In prolonged cases of pyaemia the symptoms may
resemble typhoid fever, but leucocytosis is present in the former con-
dition. Ulcerative endocarditis and acute miliary tuberculosis usually
resemble septicaemia, but may be confounded with pysemia. Any febrile
process associated with chills may be taken for pyaemia. These phe-
nomena are seen in grave anaemias, in Hodgkin's disease, in hepatic
intermittent fever, and in the intermittent fever of carcinomatosis.
(See Chills, Chapter XIV. ) Post-febrile arthritis, after scarlet fever
and gonorrhoea, is in all probability pyaemic. Of course, we rely in the
diagnosis of pysemia upon the data obtained by bacteriological methods
when their employment is practical.
Septicaemia. Again, we may find with the above-described wound, or
without any apparent local inflammation, fever, which is more or less
continuous. In addition there may be an occasional rigor. The pulse
is rapid, exhaustion, anaemia, and some emaciation are present. Sec-
ondary infection of other structures may or may not be present.
Microbic infection of the blood usually takes place. The process is a
septiecemia. If it originates from a local infection it is known as pro-
gressive septicemia. If independently of any apparent local infection
it is a cryptogenetic septicaemia. The former is easily recognized, par-
ticularly if there is a history of a primary local infectious process.
The micro-organisms which may give rise to the latter are the staphy-
lococcus pyogenes, the streptococcus pyogenes, the bacillus proteus, the
bacillus pyocyaneus, and the micrococcus lanceolatus. It is recognized
by a bacteriological diagnosis.
The accompanying chart (Fig. 42) represents the course of an infec
tion and various areas of secondary infection in a general septicaemia.
The illness extended over a period of thirty-five days. The first five
days, as indicated by the chart, there was pneumonia at the base of the
left lung. The crisis only is represented. From the tenth to the
twenty-first day, to save space, the chart does not give the tempera-
ture range. During this time the fever was continuous. On the
twelfth the right pleura was infected ; on the nineteenth the fem-
oral vein of the right leg, the temperature not rising above 101°. On
the twenty-first, as the chart indicates, a patch of pneumonia was found
in the right lung posteriorly. On the twenty-fourth pseudocrisis, and
on the twenty-fifth and twenty-sixth the true crisis took place. On
the twenty-ninth and thirtieth there was reinfection of the pleura of
the left side. On April 3d phlebitis of the femoral vein of the left leg
developed. During the course of the disease there was a low-pitched
endocardia] murmur, which in all probability was anaemic. Sweats,
attacks of collapse, and irregular rigors took place. Life was imperiled
at the time of the collapse. The spleen was enlarged ; the sputa con-
15
226
GENERAL DIAGNOSIS.
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248 GENERAL DIAGNOSIS.
fused, heavy, drunken expression of countenance, by the absence of
local disease, and by a crisis which occurs on or about the fourteenth
day.
Typhus fever is variously known as ship fever, jail fever, camp fever.
The period of incubation is usually about twelve days ; it may be
five or eight days, or even a shorter time, depending upon the viru-
lence of the poison and the susceptibility of the patient. Malaise may
precede by a day or two the onset of the disease.
Invasion is characterized by headache, faintness, vertigo, chilliness,
or a distinct rigor, pains in the back and thighs, loss of appetite,
nausea, constipation, and extreme weakness. The prostration is some-
times so great as to compel the patient to go to bed at once. The
pulse is frequent, 100 or 140, and in grave cases shows a marked ten-
dency to become small, soft, and feeble. The patient is restless and
sleepless, and is annoyed by tinnitus. The expression of the flushed
face is listless and dull.
About the fourth or fifth day the typhus eruption begins to appear.
It consists at first of dull red spots of irregular size and shape. They
are most numerous on the covered parts. Moore l says they are
detected first near the axilla? and on the wrists, then on the sides of
the abdomen, afterward on the chest, back, shoulders, thighs, and
arms. The skin is also mottled by another crop of maculae under the
skin (" mulberry rash ").
When the disease is fully developed the face is flushed, the conjunc-
tivae red, the pupils contracted, so as to resemble pin-holes (" ferrety
eye "), the tongue dry and brown, the teeth covered with sordes, the
skin dry, hot, and stinging to the touch. The patient lies upon his
back oblivious to all his surroundings. Headache has given place to
delirium, which may be wild and fierce, but is more commonly low
and muttering. There are marked ataxic symptoms — subsultus ten-
dinum, tremors, picking at the bedclothes. Incontinence of urine and
faeces sometimes occurs. The breathing is frequent, shallow, and noisy,
and the pulse frequent, soft, and feeble. The macular rash now
becomes petechial. The patient is in a typical " typhoid state." The
stupor may gradually clear up, or, on the other hand, deepen into
coma ; or the patient may die from progressive weakening of the
heart, with or without pulmonary complications.
In the majority of favorable cases, on or about the fourteenth day,
the first sign of recovery is a sound sleep, from which the patient
awakes refreshed and rational. The temperature falls with ^ great
rapidity, the pulse and temperature improve ; a typical crisis has
occurred.
Certain objective phenomena of the disease require special mention.
The eruption is more copious in severe than in mild cases. A dull and
livid color is a grave sign. Purpura and hemorrhages are sometimes
met with in bad cases. The eruption does not occur in successive crops.
The patient seems to be surrounded by a vapor of a pungent, musty
odor which is peculiar.
1 Eruptive and Continued Fevers, by J. W. Moore, Dublin, 1892.
THE DATA OBTAINED BY OBSERVATION. 249
The heart early shows the effect of the poison. The impulse is
diminished, and the first sound is less distinct. In grave cases, with
threatening heart-failure, the sounds are feeble and distant, the impulse
imperceptible.
The pulse is usually very much more frequent than normal, but may
be abnormally slow (50 and even 30 per minute) ; this is sometimes a
bad sign.
The weak heart and prostrate position of the patient favor conges-
tion, with oedema of the lungs. This condition is common.
Digestive symptoms have already been referred to. Vomiting, tym-
panites, and diarrhoea are rare, and still more so is intestinal hemor-
rhage.
The urine is scanty and high-colored. Slight albuminuria is common,
and a few casts are found, but distinct nephritis is unusual. Convul-
sions, when they occur after the first week, are almost always urremic
and almost invariably fatal. They may be due to retention of the
urine, as recorded by Stokes and Corrigan.
The duration of the disease is from six to fifteen days ; the average
period is twelve to fourteen days. An abortive form is met with in
some epidemics, the disease being of a mild type and subsiding at the
end of a week. In some cases so large a dose of the poison is absorbed
by the patient that he is stricken down in a few hours or a few days.
To this form the name " blasting typhus " has been appropriately
given. The most important complications are hyperpyrexia, laryngitis,
bronchitis, and congestion of the lungs, extreme ataxia or profound
adynamia, nephritis, heart-failure, and parotitis, or other inflammatory
glandular swellings.
Laryngitis with oedema is a very rare but very dangerous complica-
tion.
Diagnosis. Cerebrospinal fever is distinguished from typhus fever
by greater intensity of the headache, by retraction of the head and
hyperesthesia, by greater liability to vomiting, and . by the absence of
the macular petechial eruption and the drunken, besotted aspect of
typhus fever. In cerebro-spinal fever the patient suffers with photo-
phobia, and is liable to local palsies of the eye-muscles (strabismus) and
to general convulsions. Convulsions do not occur in typhus except
from a complicating nephritis or retention of urine.
Uremia is distinguished from typhus by the preceding history, by
the absence of high temperature, and by the presence of oedema of the
face or extremities, a history of vomiting or diarrhoea preceding the
stupor. The condition of the urine and the absence of eruption are
the final tests.
Pneumonia is distinguished by the frequent respiration and rela-
tively slower pulse, and by the local physical signs and absence of
eruption.
TYPHOID fever is distinguished by its slow onset and marked
abdominal symptoms. The eruption of typhus is petechial and comes
out on the fourth or fifth day ; that of typhoid fever consists of rose-
spots and appears on the seventh or eighth day. In typhus fever
the severe initial chill, the sudden onset, the greater prostration, and
250
GENERAL DIAGNOSIS.
the earlier appearance of cerebral symptoms are helpful in distinguish-
ing it from typhoid fever.
Variola.
The temperature in variola, or smallpox, pursues a definite course,
which renders it of value in the diagnosis. Its sudden rise to an
unusual height without local inflammation but with severe backache is
significant. Its fall with the appearance of the eruption, followed in
two or three days by a secondary rise, is very characteristic.
Fig. 49.
Bale •"•i '■> 1<» 11 12 13 14 13 1G 17 IS 19 20 21 22 2:i 24 25 2C 27 _2^ 29 30 SI ^ 2 3
Temperature in smallpox. Adult ; mild case.
Variola, or smallpox, is a specific infectious and contagious fever,
beginning abruptly with chill, high temperature, headache, vomiting,
sweating, and intense pain in the back. On the second or third day
of the disease a characteristic shot-like, papular eruption appears, the
papules rapidly developing first into vesicles and then into pustules ;
with the appearance of the rash the temperature falls, but rises again
toward the end of the week in the pustular stage (fever of maturation
or suppuration). The contents of the pustules are discharged, crusts
form and are cast off about the eighteenth day. The disease may be
accompanied by a number of complications, particularly hemorrhages
into the skin (purpuric smallpox) and from the mucous membranes
(hemorrhagic smallpox), both forms being popularly called black
smallpox. For convenience of description the disease may be divided
into four stages : (1) Incubation, (2) invasion, (3) eruption, (4) des-
quamation.
Incubation. This stage lasts from ten to fourteen days, and is
usually unaccompanied by any symptoms except, toward its close, by
malaise.
Invasion. The invasion is abrupt, and is marked by chilliness or
a distinct rigor, headache, severe pain in the lumbar region, and some-
times delirium or convulsions, especially in children. The most promi-
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THE DATA OBTAINED BY OBSERVATION.
251
nent symptoms are the excruciating headache and backache. The tem-
perature usually rises rapidly to 104° F. or higher in the first twenty-
four or forty-eight hours. (See Fig. 49.) Headache and backache
continue ; there are pain in the epigastrium, a coated tongue, loss of
appetite, nausea or vomiting, constipation, and copious perspiration.
Prostration is extreme. Erythematous eruptions are not uncommon,
especially on the inner surfaces of the legs and thighs. Petechia? are
found in Simon's triangle, the base of which is at the umbilicus and
apex at the knees.
The stage of invasion lasts generally three days ; but it may be
shortened to two in very severe cases or lengthened to four in very
mild ones, and in complicated and hemorrhagic cases it merges into
the stage of eruption. (See Plate IV.)
Eruption. The characteristic eruption of smallpox appears first as
minute specks resembling flea bites. These in two or three days
develop into small papules which feel like shot under the skin. In a
day or two more the papules become vesicles, at first containing a
clear fluid, which, however, rapidly becomes turbid ; they are umbili-
FlG. 50.
Discrete variola on the sixth day of eruption. (Welch.)
cated. In the course of another day or two the vesicles have become
pustules and are globular in shape. The period of ripening or matu-
ration, when pustulation is at its height, lasts about three days ; it is
characterized by a marked secondary fever, the temperature rising as
high as, or higher than, in the onset of the disease. The pustules now
begin to dry up (desiccation) and form dry scales or scabs, which are
cast off toward the end of the third week of the disease (eighteenth
252 GENERAL DIAGNOSIS.
day) ; when the pustules have been deep enough to involve the true
skin, characteristic scars, called pits, are left.
The eruption appears on the forehead, along the margin of the hair,
and in the scalp, then over the rest of the face, especially about the
nose and lips, subsequently progressing over the rest of the body from
above downward. The eruption is most abundant upon the face and
hands, often being confluent here when discrete elsewhere. The face
may appear horribly swollen, bloated, and disfigured, and both face
and hands are extremely painful from the great distention and the
pustules, which are really small dermal abscesses.
Varieties. Three varieties of variola, depending upon the number
and disposition of the pocks and upon the presence of complications,
are recognized : (1) Discrete ; (2) confluent ; (3) malignant.
In discrete variola the pocks are not numerous, and are separated
from each other by intervening healthy skin.
In confluent smallpox the pustules are close-set, occupy almost
the whole body, and coalesce, so that the face looks as though covered
with a black, rough mask ; the mucous membranes are also covered.
The symptoms of the invasion are intensified, and the eruption may
appear before the third day. Patients are liable to suffer with profuse
salivation, uncontrollable vomiting or diarrhoea (especially in children),
and with delirium, which is often violent and destructive. The face is
dreadfully swollen and the eyelids may slough ; the feet and lirnbs
also may be swollen and painful. There may also be severe bronchitis
and pneumonia, abscesses, extensive sloughing, and a pyaemic condition.
Malignant, or black, smallpox is a form in which the blood is
so altered that hemorrhages into the skin or from the mucous mem-
branes occur. In the former case there are petechia? and ecchymoses
upon the skin ; in the latter more or less profuse hemorrhages occur
from the womb, kidney, bowels, lungs, and stomach. The mind of the
patient remains clear and he is conscious of his peril. The eruption is
delayed or does not occur at all.
Varioloid is a mild form of smallpox occurring in a person protected,
but not completely, by previous vaccination, or in a person who, from
other causes, does not possess the average susceptibility. It is charac-
terized, apart from its mildness, bv great irregularity in the develop-
ment of the symptoms. The initial symptoms, as a rule, are as severe
as in ordinary smallpox. Prodromal eruptions, especially the erythe-
matous, are very common. The eruption may appear first on the face,
or on the chest and trunk first, and later upon the face. The fever
subsides with its appearance. The eruption passes from the papular to
the vesicular stage, as in ordinary smallpox ; but here the process, as a
rule, ceases, the vesicle drying up on the fifth or sixth day of the erup-
tion. If pustules form they do not reach their full development. The
eruption is always discrete. There is usually no secondary fever.
Diagnosis. When fully developed, smallpox will not be mistaken
for any other disorder. In the initial stage, however, there may be
doubt whether the disease will prove to be pneumonia, cerebro-spinal
meningitis, or typhus. If the patient has been exposed to smallpox
and is unprotected by vaccination, and he is suddenly seized with a
THE DATA OBTAINED BY OBSERVATION. 253
chill, high temperature, and excruciating pain in the lumbar region,
there is great probability in favor of smallpox. If the patient has
complained of headache, pains in the ankles and other joints, and is
seized with a severe rigor, explosive vomiting, and great weakness of
the limbs, the chances favor meningitis in the absence of known expo-
sure to smallpox. In pneumonia, vomiting, chill, and high tempera-
ture succeed each other, but excruciating backache is wanting, and, on
the other hand, the respiration is increased out of proportion to the
pulse, and even in this early stage there may be cough and roughening
of the respiratory murmur on one side.
Typhus fever begins abruptly with chill and high temperature ; but
the eruption which comes out on the fourth or fifth day is first macular
and later petechial, the temperature does not fall with the appearance
of the eruption, the aspect of the patient is drunken and stuporous, the
conjunctivae are injected, the eye ferrety, the skin dry, hot, and biting
to the touch (calor mordex).
In the papular stage of the eruption it may be mistaken for measles ;
but the red, swollen, blear-eyed, photophobic little patient with measles,
with the characteristic coryza and obstinate cough, presents a very
different appearance from that seen in variola. Moreover, the eruption
of measles is relatively flat, smooth, and velvety ; that of smallpox is
acuminate, hard, and shot-like. The temperature in smallpox falls as
the eruption appears ; that of measles remains high and even increases.
The papules of measles do not develop into vesicles.
In the vesicular stage varioloid may be mistaken for chickenpox. In
the latter the eruption is practically vesicular from the start, occurs
without prodromata, appears first upon the chest and neck, later upon
the face and scalp, is usually very scanty, and rarely becomes umbili-
cated or pustular. There are, however, severe forms of varicella, in
which fever, restlessness, and cough precede the appearance of the rash,
which is copious, some of the vesicles being inflamed at the base, some
umbilicated, and some with purulent contents. These cases are most
common in scrofulous children whose hygienic surroundings are bad.
In such cases the diagnosis cannot be made from the eruption. A con-
sideration of the following points must decide : 1. History of exposure
to varicella on the one hand or smallpox on the other. 2. The pres-
ence or absence of effective vaccination or of scars of antecedent vari-
cella. 3. The age of the patient ; smallpox occurs at all ages, varicella
only in childhood. 4. The discovery among neighboring children of
varicella or varioloid. 5. The rapid evolution of a varicella pock.
Varicella.
Varicella is one of the infections of childhood in which the febrile
course is very mild. It is an acute specific infectious fever, occurring
almost exclusively in children, and characterized by the appearance, in
successive crops, of colorless or pearly vesicles, which dry up and are
shed in from two to five days. It is attended with very little constitu-
tional disturbance. A second attack is extremely rare.
The incubation is generally about two weeks, but may be one or
254 GENERAL DIAGNOSIS.
three weeks. In ordinary cases the first evidence of the invasion of
the disease is the appearance of the eruption. In other cases, the
severer ones, the child may be noticed for some hours or several days
to be indisposed, complaining of loss of appetite, nausea, headache, and
vague muscular pains. The fever is almost always moderate — 100°
to 101°.
The eruption consists first of hypera?mic macules, compared by Trous-
seau to the rose-rash of typhoid fever. These macules rapidly become
first papules and then vesicles. The papules are not hard as in variola.
They appear at first upon the chest, neck, face, and scalp, then upon the
trunk and limbs. The development of the vesicles is so rapid that the
eruption appears vesicular from the start. The vesicles vary in size
from a pinhead to a small pea. They are very superficial, and usually
Fig. 51.
Varicella on the fifth day of eruption.
rest upon a base that is slightly or not at all hypersemic. The contents
are at first watery, but subsequently become pearly. The reaction of
the fluid is alkaline. Distinct umbilication is rare, and pustulation
still more rare, but both occur. The vesicles almost always dry up and
form scabs, yellowish or brownish, which drop off, leaving a slightly
reddened, sometimes depressed spot. Sometimes the vesicles are to be
seen upon the buccal mucous membrane and upon the throat. While
most of the eruption appears on the first or second day, fresh vesicles
continue to appear for several days.
Desiccation usually occurs by the fourth or fifth day, and may be
present in the first day or two. As the eruption appears in successive
crops, often all stages, from the initial macule to the dried scales, can
be seen in one case.
Usually the vesicles are widely scattered, a dozen or two over the
entire body. They are most numerous upon the back, and may be as
close together as in discrete variola.
In scrofulous and badly nourished children the lesions are more in-
flammatory and pustules are more common. If they are scratched,
ulceration ensues. A gangrenous form has been described by Eustace
Smith and others ; the cases are apt to be fatal.
THE DATA OBTAINED BY OBSERVATION. 255
In ordinary cases during the eruption the child is rarely more than
indisposed ; complications are rare, and the prognosis most excellent.
The physician is not often consulted except to have his opinion as to
the diagnosis. (For the differential diagnosis from smallpox, see
Variola.)
It is distinguished from vesicular and pustular eczema by the fever,
the symmetrical grouping and discrete character of the lesions, the
comparative absence of itching and burning, and its shorter course.
Impetigo is distinguished by the absence of fever, the more local
character of the eruption, and the fact that it is generally pustular. It
is more common upon the face and hands than is varicella.
Scarlatina.
In this eruptive fever the course of the temperature varies some-
what with the severity of the infection. In many instances fever
would not be detected without the use of the thermometer. In others
it may rise to a great height, and even be hyperpyretic. Its onset is
sudden ; it reaches its greatest height when the eruption is complete.
The temperature in scarlet fever usually conforms to a clearly defined
type. The temperature increases gradually to the third or fourth day,
when the acme is reached. It declines by lysis in a period of four
days. A seven days' chart would be pyramidal in shape. In septic
forms (scarlatina anginosa), with ulceration of the fauces, the fever
continues and becomes remittent. In scarlatina maligna, hyperpyrexia
is likely to ensue rapidly.
Scarlet fever is an acute, specific, contagious, and infectious fever,
characterized by a sudden onset, with vomiting, sore-throat, and high
fever, followed in twelve or twenty-four hours by a bright-red, puncti-
form eruption, by a very frequent pulse, by a desquamation which is
often in large flakes, by a very variable degree of severity, and by a
large number of complications and sequela?, especially nephritis and
inflammation of serous membranes.
Scarlet fever preferably affects children from one to five years of
age. The liability to it diminishes after the tenth year ; but it is very
rare under the age of six months. Puerperal women are very suscep-
tible to the poison, and the existence of open wounds favors infection.
The disease occurs in epidemics at longer intervals than is true of
measles. Cases are most numerous in the autumn and winter months.
The peculiar poison is doubtless a living organism, but it has not been
isolated as yet. It is very tenacious of life, being capable of infecting,
through clothing in which it has been retained, months after the cloth-
ing absorbed the poison.
Few diseases vary so greatly in severity in different cases and in dif-
ferent epidemics. It may be the mildest or most malignant of diseases.
The period of hicubation is remarkably short, generally from three
to five days ; but it may be a few hours, and, in exceptional cases, six
days.
The invasion is abrupt. It is very common to be told that a child
was apparently well on going to bed, but awoke in the middle of the
256
G ENEBA L DIA GNOSIS.
night, vomiting profusely and complaining of sore-throat. The child
is found in the morning with a temperature of 103° or 104°, a pulse
of 120 to 140, and a scarlatinal eruption beginning to show upon the
neck and upper part of the chest. Close observation in such cases
might have discovered that the child was feverish on going to bed, and
that he had been somewhat chilly before that. Onset with decided
chill, vomiting, and nervous symptoms indicate a severe case.
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Scarlet fever. Mild attack ; intense eruption.
The subjective symptoms of scarlatina are few ; they consist usually
of pain in swallowing, with stiffness of the neck-muscles, some head-
ache, thirst, malaise, and a moderate amount of weakness. In the
eruptive stage the skin itches, burns, and is frequently hypera?sthetic.
The objective symptoms and their order of succession are very charac-
teristic. Vomiting is the rule, except in mild cases, and hence is of
importance in diagnosis, especially in otherwise doubtful cases. The
temperature is high at the onset, 'frequently 103° or 104°. It falls a
degree or so in the morning ; but the following evening, when the
eruption is' usually at its height, it rises to 104° or 105°, and then
gradually falls to normal in the course of a week in ordinary cases.
(Figs. 34 and 52.)
The pjulse-rate is characteristically frequent, being 120 to 160 oftener
than slower. This frequency is not an indication of danger.
The blood shows a leucocytosis, beginning on the first day and con-
tinuing through convalescence. A close relationship exists between
the degree of leucocvtosis and the rash. Suppurative complications
tend to increase the number of white cells. The finely granular eosino-
philes are greatlv increased during the first few days. The mononuclear
cells and lymphocytes are diminished at first, but after a short time
their percentage increases.
The throat exhibits a uniform flush extending over pharynx, tonsils,
soft palate, and sometimes forward on the hard palate, nearly to the
THE DATA OBTAINED BY OBSERVATION. 257
teeth. Sometimes dark-red points can be distinguished on the soft
palate. The tonsils are inflamed and projected toward the median line
from each side. Frequently the mouths of the follicles are blocked by
a creamy-white exudate. It is not uncommon to find a severe follicu-
lar tonsillitis at the first visit.
The tongue is at first covered with a thick, creamy fur, through which
enlarged red papilla? show. The enlarged papillae look like small
grains of red pepper sprinkled on the tongue. Sometimes the papilla?
are elevated and have a button-like appearance. The symptoms
appear very early in the disease, and may continue for three or four
weeks. The coating soon disappears from the tip, leaving it bright
red — the " strawberry tongue."
The skin is hot and dry. The characteristic eruption usually appears
within twenty-four hours, often within six to eighteen hours, of the
chilliness or vomiting which marks the onset. Sometimes it comes
out very slowly, seeming to be just ready to appear, but not appearing
in its full development for four or five days.
The intensity of the eruption varies from a scarcely perceptible ery-
thema to the color of a boiled lobster. Usually its intensity varies
with the severity of the disease. In ordinary cases the patient appears
to be covered with a uniform red efflorescence ; but a closer inspection
shows that there are darker red spots between which the skin is more
or less erythematous. It is first seen about the ears and neck, and
spreads with great rapidity, covering the entire body in a day. It is
most intense upon the trunk and flexor surfaces. Upon the extensor
surfaces the punctate character is better seen. Pressure causes the
redness to disappear, but it immediately reappears. Papular and vesic-
ular forms of eruption are also seen. The physiognomy of the disease
is peculiar. The circle about the eyes, nose, and lips remains pale,
and in marked contrast with the rest of the fiery red face. Itching
and burning are annoying symptoms at times. The eruption fades
gradually, in ordinary cases disappearing, except when there is press-
ure or irritation toward the end of the week.
The eruption is succeeded by desquamation, which is extensive in
proportion to the intensity of the eruption. The flakes are larger than
in measles, and in severe cases the epidermis may come off in long
strips. About the hands and feet this shedding is sometimes so great
as to be compared to a glove. This stage may be protracted for sev-
eral weeks, danger of infection lasting as long as desquamation con-
tinue-.
The urine is at first scanty, high-colored, and febrile. Later, when
desquamation is in progress, there is great liability to albuminuria as a
complication.
Varieties. In addition to the ordinary form already described scar-
latina exhibits many irregular tonus. There maybe only a sore-throat
or follicular tonsillitis. If a rash is present, it is very faint, and hence
easily overlooked. The diagnosis in such cases must be made from
the fact of exposure to infection and from the appearance of the throat.
The occurrence of vomiting is very important in the diagnosis, as it is
rare in-ordinary pharyngitis and tonsillitis. Often such cases escape
17
258 GENERAL DIAGNOSIS.
detection altogether, until possibly a dropsy from scarlatinal nephritis
indicates their nature.
Severe diarrhoea may prevent the eruption from developing upon the
skin. It appears upon the fauces, and the diagnosis is based upon this,
the pulse and temperature, and the fact of exposure.
In scarlatina anginosa the strength of the poison is spent upon the
throat. Pain is great and deglutition difficult. The tonsils are greatly
swollen, so as almost to occlude the fauces, and their surfaces are cov-
ered with creamy exudate. The cervical glands are swollen, and there
is a tense and brawny cellulitis. Sometimes the tonsils become gan-
grenous, and the cervical or submaxillary glands suppurate or become
gangrenous, with resulting pyaemia and death. Suppuration may
extend to the ears and maxillary sinuses. In this form, also, a false
membrane is sometimes found upon the fauces — post-scarlatinal diph-
theria. It is probably not due to the Klebs-Loffler bacillus, but to a
streptococcus.
In malignant forms the attack is ushered in with chill, followed by
hyperpyrexia, convulsions, marked ataxic symptoms, or stupor. The
profound blood-disturbance is shown by the dusky hue of the eruption.
Some patients lie in coma-vigil, others are very restless and delirious.
Vomiting and diarrhoea are sometimes superadded. Patients may
emerge from this condition and succumb later to a nephritis or to grave
anginose symptoms ; but death in a few days is the rule. In rare cases
the dose of poison is so enormous that death takes place in a few hours,
without the appearance of any eruption.
Complications and Sequelae. The severe local symptoms men-
tioned under the anginose variety, together with convulsions, hyper-
pyrexia, and ataxic symptoms, may properly be regarded as complica-
tions. Apart from these the most frequent are nephritis and endocar-
ditis or pericarditis. Nephritis generally appears with the beginning of
desquamation. It is nearly as frequent in mild as in severe cases,
probably because the danger of exposure to cold is greater in the
former, although the scarlatinal poison unquestionably has a selective
affinity for the epithelium of the kidney. The symptoms do not differ
from those of acute parenchymatous nephritis occurring under other
circumstances. In some cases we have weakness, languor, slight fever,
and prolonged convalescence ; in others, oedema, anuria, convulsions or
coma from urseniia. Endocarditis is often preceded by tenderness and
soreness of the muscles and joints — scarlatinal rheumatism.
Endocarditis and pericarditis develop in the course of the fever,
giving rise to an increase or continuance of the fever, to local pain or
dyspnoea, and to the usual physical signs.
Pleuritis and meningitis also may occur. Much more common com-
plications are otitis, peripheral neuritis, and affections of the joints,
grouped as scarlatinal rheumatism. Paralyses, peripheral and central
in origin, are occasional sequels of the disease. Scarlatina is found
also in association with other diseases.
Diagnosis. Sudden onset, rapid rise of temperature, persistent and
causeless vomiting, and sore-throat lead one to suspect this affection.
The characteristic eruption and its mode of evolution, the rapid pulse,
THE DATA OBTAINED BY OBSERVATION. 259
the peculiar tongue, the circle of pallor on the face, are characteristic
of the eruptive stage. " The appearance of a punctate eruption in the
axilla and in the groins, together with the congestion of the tonsils and
a punctate eruption in the roof of the mouth, no matter whether there
is any eruption anywhere else or not, are positive proofs of scarlet
fever" (McCollom).
Unfortunately, all cases do not develop to the same degree, so that
frequently we must wait for the period of desquamation ; more unfor-
tunately, for the occurrence of sequelae, as acute nephritis, otitis, or
adenitis.
Scarlet fever is distinguished from measles by the mode of onset, which
is sudden, with chilliness, high temperature, vomiting, and sore-throat,
and great rapidity of the pulse ; whereas the onset in measles is gradual,
with coryza, cough, moderate fever, perhaps looseness of the bowels,
but no sore-throat. The eruption of scarlatina occurs on the first day,
that of measles on the fourth ; the former consists of dark-red spots
with intervening erythematous skin, the whole looking at a distance
like a uniform bright-red flush ; the latter consists of raised, rounded,
or flattened spots or blotches, velvety to the touch, and, upon the body
and extremities, grouped in patches with crescentic outlines. The tem-
perature in scarlatina subsides gradually after the rash has reached its
height ; that of measles increases until the eruption is complete, then
subsides by crisis. The rash of scarlet fever persists for six or eight
days ; that of measles fades as soon as it is complete, on the fourth
day. In the former, desquamation is in flakes or large strips ; in the
latter it is branny and nearly invisible. Scarlatina involves by prefer-
ence the serous membranes and kidneys ; measles the mucous mem-
branes and lungs.
Scarlatina has to be differentiated from pharyngitis, tonsillitis, and
digestive disturbances, attended Math vomiting, high temperature, and
occasionally erythematous eruptions.
In ordinary pharyngitis and tonsillitis the redness is more apt to be
confined to the pharynx, tonsils, and arches of the soft palate ; in scar-
latina it extends as a flush over the soft and hard palate and buccal
surfaces. In the former, high temperature, a very frequent pulse, and
vomiting are unusual ; in the latter they are the rule.
The glands of the neck also are more apt to be involved in the latter.
In acute gastritis there is usually a history pointing to indiscretion
in eating, with constipation. The pulse is not so frequent as to suggest
scarlatina, sore-throat is absent, and any erythema present lacks the
characteristic dark-red points, and is not followed by desquamation.
The diagnosis from rubella is difficult at times. It differs from scar-
latina in presenting mild catarrhal symptoms, sneezing, suffusion of
the eyes, and cough, with a relatively fleeting eruption. The latter
perhaps appears most frequently upon the back and chest. Often the
eruption is the first thing noticed amiss with the child. It more com-
monly resembles the rash of measles than that of scarlatina, but when
it resembles the latter most it is apt to be discrete and of a darker red.
There may be a very intense rash without much constitutional disturb-
ance, the temperature being lower and the pulse much slower than
260 GENERAL DIAGNOSIS.
would be expected in a scarlatina presenting the same appearance.
Nausea may be present, but vomiting is very rare. The post-cervical
aud post-auricular glands are more commonly enlarged in rubella than
in mild scarlatina, though this symptom is not invariable.
Diphtheria is distinguished by its gradual onset, patches of false
membrane developing upon the fauces early. In anginose scarlet fever,
with severe follicular tonsillitis, the differential diagnosis is essentially
the same as between simple follicular tonsillitis and diphtheria (q. v.).
In addition, the pulse and temperature have a much higher range in
scarlatina. The erythema of diphtheria is distinguished from the erup-
tion of scarlatina by its fleeting character and the absence of desqua-
mation.
Grave cases Avhich begin with repeated vomiting, convulsions, del-
irium, and insomnia simulate meningitis ; but a satisfactory cause for
the latter is lacking, while the excessive heat of the skin, sore-throat,
very frequent pulse, and early eruption clear up the diagnosis.
So, also, the onset with vomiting, convulsion, and high temperature
resembles pneumonia; but in the latter the respiration is proportion-
ately more frequent than the pulse, with altered breath-sounds and
percussion-sounds, while sore-throat and eruption are wanting.
Measles.
The course of the fever in this affection resembles that of smallpox
in that after the initial rise of the first twenty-four hours the tempera-
ture remains normal until the appearance of the eruption on the third
day. It is an acute, specific, infectious, and highly contagious fever,
characterized by coryza and bronchitis, a red papular eruption, coming
out on the fourth day and followed by a branny desquamation about
the ninth or tenth day. The mucous membranes are especially liable
to complications.
Measles occurs in epidemics, especially in cold weather, but indi-
vidual cases are met with in large cities at all seasons of the year. It is
so contagious that when one case develops in a household or institution
almost every person exposed to it and not protected by a previous
attack acquires it. Children from one to five years of age are most
susceptible to the poison, but it may occur in utero and in old age ;
moreover, the same person may have several attacks, showing that one
attack does not afford the same protection as an attack of scarlatina or
variola.
Measles is sometimes found in association with scarlatina and vari-
cella, but it is especially liable to occur after pertussis.
The specific cause of the disease has not yet been isolated.
The period of incubation lasts from eleven to fourteen days. During
this time the patient may exhibit no symptoms, or may be irritable and
restless, with disturbed sleep and occasional cough, and looseness of
the bowels.
The invasion is marked by cough and fever, and by redness of the
eyes and lacrymation, sometimes with photophobia, sneezing, and an
irritating, watery discharge from the nose, which subsequently becomes
PLATE V.
Fig. I.
Fig. II.
Fig. III.
Fig. IV.
The Pathognomonic Sign of Measles (Koplik's Spots).
Fig. i. — The discrete measles spots on the buccal or labial mucous membrane, showing the isolated rose-
red spot, with the minute bluish-white centre, on the normally colored mucous membrane.
Fig. 2.— Shows the partially diffuse eruption on the mucous membrane of the cheeks and lips; patches of
pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots.
Fig. 3. — The appearance of the buccal or labial mucous membrane when the measles spots completely
coalesce and give a diffuse redness, with the myriads of bluish-white specks. The exanthema on the skin is at
this time generally fully developed.
Fig. 4. Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal in line.
Minute yello-w points are surrounded by a red area. Always discrete.
THE DATA OBTAINED BY OBSERVATION.
261
mucopurulent, and by cough and fever. In short, the early symp-
toms are those of a severe coryza. These symptoms last from three to
five days (generally four) before the eruption appears.
But an eruption is commonly visible upon the base of the uvula and
soft palate, as raised, discrete dark-red papules, several days before it
appears upon the body. The peculiar appearance of this eruption has
been accurately described by Koplik (1897). His observations have been
corroborated, so that " Koplik' s sign " is a well-established fact. Its
importance can be understood when the necessity for early diagnosis for
quarantine purposes is realized. This sign appears twenty-four hours,
forty-eight hours, and even three to five days before the skin erup-
tion. It precedes the conjunctivitis and begins at the first rise of
temperature. The eruption appears on the mucous membrane of the
cheeks and lips. It is not seen on the palate or the fauces. It is at
first discrete and then becomes confluent. It is at its height when
the skin eruption appears and is spreading. In strong daylight this
pathognomonic eruption is seen to consist of small irregular spots of a
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Measles. Characteristic chart. Female, aged twenty-seven.
Objective Symptoms. The eruption on the body appears first
about the neck, face, and wrists, and spreads in two or three days over
the entire body. It is usually most copious upon the face, which is
swollen, dark-red in color, and closely set with papules, which are
elevated, rounded at the summits, and feel like soft velvet to the touch.
When to this picture is added that of a severe coryza with mucoserous
exudate, which often glues the eyelids together and oozes out upon the
face, and a corresponding condition of the nasal orifices, the physiog-
nomv is at once 'seen to be very unusual. At this staa^e, moreover,
THE DATA OBTAINED BY OBSERVATION. 263
photophobia is often considerable, the child burrowing its head in the
pillows to escape light.
The eruption is not apt to be confluent upon the body ; here the
dark-red, elevated, smooth papules are very distinct. Sometimes they
are grouped so as to form crescentic outlines. The eruption fades in
the order in which it appeared, and is followed by a fine branny
desquamation. With the completion of the eruption the fever
falls rapidly to or below normal, the coryza and bronchitis im-
prove correspondingly, and in forty-eight hours convalescence is fully
established.
Complications. The complications of measles affect for the most
part the mucous membranes of the respiratory and digestive tracts.
The bronchitis, which is always present, may become capillary, or be
associated with oedema or with areas of catarrhal pneumonia. These
are the most frequent and the most dangerous complications. Pneu-
monia may develop while the eruption is coining out, in which case
the eruption is delayed or the spots have a dusky or bluish hue (black
measles). More commonly, perhaps, pneumonia is discovered when,
the eruption being complete, a crisis should occur.
Epistaxis is not usually dangerous. Profuse diarrhoea is very ex-
hausting and delays the evolution of the eruption. Severe conjuncti-
vitis, sometimes with ulceration of the cornea, is not uncommon.
Otitis media occurs oftener as a sequel than as a complication. Noma,
or cancrum oris, is a rare complication of measles occurring in ill-fed,
badly nourished children. It is frequently fatal.
Convulsions may occur as a complication, especially when pneu-
monia is developing.
Sequelae. In cases in which there has been diarrhoea, measles is
sometimes followed by considerable weakening of the digestive power.
The catarrh of the respiratory tract, which almost invariably accom-
panies it, predisposes to the development of whooping-cough and tuber-
culosis.
Paralysis may follow measles. It may be central or peripheral in
origin, but generally is of the hemiplegic type ; cases of acute polio-
myelitis, acute ascending paralysis, and disseminated myelitis have also
been reported.
Varieties. Measles without catarrh is rare. It cannot be recog-
nized from a measles-like rash, seen in rotheln, except by the occur-
rence in the neighborhood of other cases of undoubted measles.
Measles without eruption is to be recognized by the coryza, possibly
with eruption on the soft palate, the course of the temperature, and the
exposure to specific infection.
Black measles is the name given to malignant forms in which, owing
to complications, particularly pneumonia, the skin is dusky and the
eruption comes out poorly and lias a bluish color. In rare instances
the eruption shows a hemorrhagic tendency, the spots being livid or
ecchymotic. Actual hemorrhages from mucous surfaces may occur,
the patient dying in coma or convulsions.
264 GENERAL DIAGNOSIS.
Rubella.
In a few instances this infection may run its course without fever.
In the large majority of cases, however, a moderate degree of fever
prevails and in some it may reach a considerable height.
Rubella is an acute, specific, contagious, and infectious fever, char-
acterized by a gradual onset, with moderate fever, sore-throat, and
slight coryza. The eruption, which appears without prodromata,
usually resembles measles more than scarlatina. The duration, how-
ever, is shorter than measles, the disease milder, and complications are
rare.
The disease is amply proved not to be a hybrid of measles and
scarlet fever. The incubation-period varies from one to three weeks,
but is generally about two. As a rule, this period is past without
symptoms.
The invasion is without prodromata, or none more definite than
languor and indisposition, the first thing noticed being the eruption.
This in some cases consists of pale-red, smooth, slightly raised blotches,
closely resembling measles, but more pronounced on the trunk, and
discrete. This is probably a very rare form. More commonly it
consists of rose-red macula? or papules, occasionally confluent, but
usually discrete, and most marked upon the trunk. In still other
cases the eruption closely resembles that of scarlatina, differing chiefly
in being a paler red and accompanied by less heat of skin. Sometimes
the eruption is circumscribed, as upon the face or limbs. It is usually
the seat of considerable itching, and this may be the first symptom
that attracts the patient's attention. It will be seen that the eruption
is multiform in character. Concurrently with the eruption, there is
usually slight rise in temperature (100°— 101°), suffusion of the eyes,
with slight lacrymation and photophobia, and slight pharyngitis ;
nausea is not uncommon, but vomiting is very rare. Higher tempera-
tures have been recorded in a few cases, and so have nervous symp-
toms, such as delirium and convulsions, but they are chiefly interesting
as very exceptional possibilities. On the other hand, the disease may
run its course without any fever.
The eruption extends over the body in twenty-four to thirty-six
hours, less rapidly than in scarlatina, and pales much more quickly,
fading on the portions of the body first attacked before reaching its
height on the last, and being completed in three or four days. Some-
times a branny desquamation succeeds.
In addition to the mild coryza and eruption, the most important
objective symptom is swelling of the cervical glands, all of them being
sometimes swollen, especially those behind the sterno-mastoid, the
auricle, and along the margin of the hair. This adenopathy, however,
cannot be relied upon exclusively in the differentiation from scarlatina
and measles.
Rubella has few complications : bronchitis, pneumonia, and otitis
occur rarely, and still more rarely false membrane on the throat, and
albuminuria. The prognosis is excellent. It ends almost invariably
in recovery, except in very feeble children.
THE DATA OBTAINED BY OBSERVATION. 265
Infectious Diseases with Local Symptoms.
The following infections are characterized by local manifestations
which are of greater diagnostic significance than the fever. These
local manifestations must, therefore, be carefully considered in the
diagnosis, and, as intimated, must be relied upon for recognition of the
particular infection. The infections belong to Class I. and Class II.
of the classification in Chapter XVII.
Mumps.
This infection presents marked local changes about the jaws coinci-
dent with the rise of temperature. The infection is recognized by the
swelling of the parotid and submaxillary glands or by the occurrence
of orchitis. It has been described in the chapter devoted to objective
changes of the face.
Glandular Fever.
Glandular fever is an infectious disorder, the cause of which has not
been accurately determined. It is characterized by fever, usually
occurring abruptly, with headache, pains in the limbs and in the lymph
glands of the neck. On examination of the fauces a slight pharyngitis
is observed and the tonsils are enlarged. With the rise of temperature
there is frequent nausea and vomiting. The temperature rises abruptly
to about 102°. In the second twenty-four hours the glands of the
neck, particularly those behind the sternocleidomastoid muscles, en-
large. They are tender. Although there may be some slight
oedema there is no redness or swelling of the skin. The fever contin-
ues for three or four days ; the enlarged glands, however, may remain
for several weeks, and may end in suppuration.
The infection usually occurs in children between the age of five and
eight years. It may be epidemic and occur often earlier in life than
just mentioned. The other lymphatic glands about the neck and in
the axilla and groin may be enlarged. In not a few instances there is
enlargement of the spleen, and cases of enlarged liver and mesenteric
glands are reported. The absence of an eruption serves to determine
the infection from the eruptive fevers associated with adenitis, particu-
larly measles and rotheln.
Pertussis.
The attention of the physician is called to this infection by the pecu-
liar character of the respiratory symptoms. Fever is more notable as
an expression of one of the complications — broncho-pneumonia — than
of the general infection. It may, however, be a serious symptom of
the infection.
Whooping-cough is a specific catarrhal inflammation of the respira-
tory passages, involving especially the trachea and bronchi, and char-
acterized by paroxysms of cough, which are succeeded by spasmodic
(•Insure of the glottis and a peculiar inspiratory whoop. The disease
occurs especially in childhood, is contagious and infectious, and is some-
266 GENERAL DIAGNOSIS.
times epidemic. Whooping-cough may be conveniently divided into
three periods :
1. The catarrhal stage.
2. The spasmodic stage.
3. The stage of gradual subsidence of the disease.
First Stage. The patient appears to have an ordinary cold. The
amount of redness of the mucous membrane of the eyes, nose, and
throat varies considerably, but there is not much discharge from the
mucous surfaces. The cough is dry, and sometimes a ringing quality
can be detected. The patient is irritable, has slight fever, diminished
or capricious appetite, and restless sleep. A mild bronchitis of the
larger tubes can be detected by physical exploration.
The cough gradually becomes more frequent and paroxysmal, the
eyes are red and suffused, and there is a mucopurulent discharge from
the nose. The face often looks slightly swollen, especially about the
upper part and under the eyes. Lymphocytic leucocytosis is common.
The Second Stage. Transition from the first to the second stage is
marked by the appearance of the characteristic whoop. The parox-
ysmal cough is made up of a series of rapid expiratory efforts, diminish-
ing in force and duration ; when these cease there succeeds a prolonged
crowing inspiration — the whoop. There may be only one paroxysm
of coughing at a time, but more commonly, and always in severe cases,
one paroxysm is succeeded by another. During the coughing the
child's eyes become suffused, the tears overflow, and there is a discharge
.of serum or mucopus from the nose, and of saliva and bronchial secre-
tion from the mouth. The face becomes swollen and dusky. If the
child is walking about, it catches some object for support during the
paroxysm ; or, if old enough, rushes for the water-closet or a basin,
because the seizure usually terminates in vomiting. The matters
vomited consist of tenacious mucus and the contents of the stomach.
"With the mucus there may be streaks of blood, and occasionally there
is pure blood. During severe paroxysms, hemorrhages are apt to
occur ; these are generally small and most frequently submucous. In
well-marked cases, when the disease has lasted some time, the face has
a characteristic appearance — it is swollen, sodden, and dusky, with
dull, heavy, red, and watery eyes. There is often ulceration of the
lingual fraenum.
The number of paroxysms varies from two or three to twenty or
thirty or more in twenty-four hours, and they are worse at night.
The whoop, while characteristic, is not present in every case, being
absent especially in babies and very young children. Sometimes chil-
dren have " choking spells " without much coughing and without the
whoop. Again, when pneumonia or measles occurs as a complication,
the whoop usually ceases for the time, but may reappear later.
Third Stage. The third stage is less well defined than the first two.
It may be said to begin when the nocturnal exacerbations become less
frequent and severe. The number of paroxysms during the day dimin-
ishes, and vomiting is a less frequent accompaniment. Appetite begins
to improve, and the child begins to gain in flesh and to pass more
restful nights.
THE DATA OBTAINED BY OBSERVATION. 267
The duration of the disease is variable. Ordinarily it lasts from six
to eight weeks, but it may be prolonged for several months. The
patient is liable, whenever he catches a fresh cold, to a temporary
return of the spasmodic cough, sometimes with the whoop.
The great majority of the cases occur before the sixth year, and most
of these between the second and fourth years.
Rheumatic Fever.
Rheumatic fever is an infection associated with local symptoms of
joint-, endo-, and pericardial inflammation. The local symptoms are so
extreme as to call attention at once to the nature of the infection apart
from the course of the fever, as it is largely upon these symptoms that
the diagnosis is made. The reader is referred to Chapter XIII. , in
which the diagnosis of rheumatic fever is discussed.
Dengue.
The peculiarity of the fever in this infection is that it is attended by
severe paius in the muscles and joints. It is an acute contagious dis-
ease, occurring in epidemics and characterized by severe pains in the
head, back, and joints, various skin eruptions, a prolonged convales-
cence, and a very low rate of mortality.
The disease occurs in epidemics in tropical and subtropical countries,
and rarely in cooler climates. It derives its name, dengue (dandy),
from the stiff and unnatural gait assumed by convalescent patients.
In the southern parts of the United States an expressive name given
to the disease is " breakbone fever."
The specific cause of the disease is believed by Dr. McLoughlin to
be a micrococcus which is isolated. The period of incubation is short,
varying, however, from a few minutes to several days, or even a week.
Invasion is very sudden and is rarely preceded by any prodromata.
It is marked by chilliness or a chill, and very severe pains in the head,
back, and limbs. In children the onset may be by convulsions, which
are sometimes followed by stupor and vomiting. The pains are some-
times excruciating, and are accompanied by tenderness of the muscles ;
there is extreme debility. The temperature rises to 102° or 103°, but
rarely is much higher.
The pulse is frequent — 110, 120, or more. In from one to three
or five days the temperature falls to or below normal (the remission),
accompanied by sweating or diarrhoea, and fluctuates about this level
for several days, when a second and moderate rise in temperature,
which is of short duration, occurs. During the first rise in tempera-
ture there is a transient, generally scarlatiniform rash, which is not
followed by desquamation. The urine is febrile but not albuminous.
During the remission eruptions — scarlatiniform, herpetic, urticarial, or
like miliaria — begin to appear, accompanied by the secondary rise in
temperature. The eruptions may be in successive crops, and are fol-
lowed by desquamation. Convalescence is now established, but may be
interrupted by relapses. Strength is regained very slowly. The most
frequent complications arc disorders of the nervous system, but bron-
chitis and diarrhoea occasionally occur.
268 GENERAL DIAGNOSIS.
Beri-beri.
Beri-beri is a febrile infectious disorder which prevails in epidemic
form, limited to tropical and subtropical countries. It is characterized
by multiple neuritis associated with anasarca. By most observers it is
believed to be an acute infection, although not a few think it is an
intoxication due to certain kinds of food. This is the view which pre-
vails in Japan. The circumstances predisposing to infections generally
prevail, however, such as overcrowding, the prevalence in hot and
moist seasons, and the exposure of the patient to climatic influence.
It is far more common in men, and usually attacks subjects whose ages
range from sixteen to twenty-five.
Several clinical forms are seen. In the most complete form there is
rapid loss of power in the legs and arms, with atrophy of the muscles.
The patients complain of pain, and later oedematous symptoms may
appear. With the loss of power in the legs there is paresthesia, with
frequent palpitation of the heart and dyspnoea. The pain in the mus-
cles is associated with weakness and tenderness. In milder degrees of
this form, pain, weakness in the legs, diminishing of the sensibility,
and paresthesia are the most common symptoms. Their onset will
be gradual and be accompanied by catarrhal symptoms. The symp-
toms may recur from time to time, and are much more aggravated
during the warm season. Its recurrence and incomplete form may
continue ten or fifteen years.
Following the pain and weakness of the muscles, in some cases
oedema becomes very pronounced, associated with effusions into the
serous cavities. General anasarca is attended by palpitation and rapid
action of the heart and dyspnoea. In this so-called wet or dropsical
form atrophy of the muscles is not observed until the oedema disap-
pears. In some instances the infection is very intense, and is charac-
terized by more marked cardiac symptoms. In these instances acute
dilatation may be followed by cardiac paralysis and death in twenty-
four or forty-eight hours.
The diagnosis is based upon the occurrence epidemically or endemi-
cally in tropical regions of peripheral neuritis with oedema. Thus far
no bacteriological diagnosis obtains.
Constitutional Syphilis.
Intermittent, remittent, or continuous fever is attendant upon this
infection sometime during its course. (See Afebrile Infections, Chap-
ter XVI.) Want of recognition of the cause of this febrile phenomena
leads to many mistakes in diagnosis. (See Fig. 63.)
Constitutional syphilis may be acquired or congenital.
Acquired syphilis is characterized, first, by the initial lesion, or
chancre, which appears usually in a week after contagion ; second, by
a 'period of incubation generally lasting six weeks, but varying from
one to three months ; third, by so-called secondary symptoms, com-
prising febrile symptoms, polymorphous skin-eruptions, ulcers upon
the tonsils, adenitis, less frequently mucous patches in the mouth, or
condylomata about the anus, iritis and retinitis, and loss of hair. The
lesions of this period are symmetrical. Fourth, after an interval vary-
THE DA TA OB TA IN ED B Y OBSER VA TION. 269
ing from several months to twenty years, by so-called tertiary phenom-
ena, which manifest themselves in some cases. These are clue to chronic
inflammatory indurations of the skin and subcutaneous tissue, resulting
in suppuration and ulceration ; or of the bones, producing periostitis
and necrosis ; or of organs, producing gummata and cirrhosis ; or of
the nervous system, resulting in gummata or chronic degenerative
changes. The lesions of this period are unsymmetrical. 1
The course of syphilis in different persons varies as widely as any
of the eruptive fevers. In some the chancre is a mere papule which
heals almost unnoticed ; no secondary symptoms appear, and tertiary
symptoms also are altogether wanting, or a chronic degeneration of
the nervous system develops after the lapse of many years, the patient
in the meantime remaining in apparent health. All this may occur,
too, without the aid of specific treatment. In other cases the disease
is malignant ; tertiary symptoms appear very early or appear to take
the place of secondary symptoms ; ulceration may rapidly melt down
and destroy the alee of the nose or the soft palate ; or rebellious perios-
titis with necrosis may attack the tibiae, the nasal bones, or the cranium.
In an ordinary case of acquired syphilis, in about six weeks after
the appearance of the chancre, the patient complains of languor, weari-
ness, slight fever, pains in the bones, impaired digestion, and a ten-
dency to anaemia. An eruption now appears. It is most marked on
the trunk and upper extremities, especially the chest and forehead
(corona Veneris). The eruption may be roseolous, squamous, vesico-
papular, papular, pustular, bullous, or tubercular. The color has been
aptly compared to that of a slice of raw ham. The enlargement of the
inguinal, epitrochlear, and postcervical glands, which precedes the
eruption, persists. Shallow ulcers with a sharply defined grayish out-
line appear on both tonsils. They are painless and do not spread.
Ulcers are also liable to appear upon the pharynx, buccal surfaces,
tongue, angles of the mouth, penis, vulva, vagina, and around the
anus. In the mouth these are apt to be very painful, and may persist
in spite of treatment for weeks or months. Relapses are not uncom-
mon. Sometimes there are raised white patches upon the pharynx.
Sometimes the hair becomes very thin and falls out, leaving the patient
without eyebrows and more or less bald. Iritis and retinitis are usually
later symptoms. Other symptoms occasionally occurring at this stage
are periostitis, usually slight, and onychia.
The most common of the symptoms enumerated are the eruption and
the tonsillar ulceration.
The eruption comes out gradually during two or three weeks, and
persists for about two months. Rarely, hoAvever, it is fleeting, or, on
the other hand, is unduly prolonged.
The secondary symptoms last from six to eighteen months. After
their disappearance the patient may remain entirely well for life. In
other cases after apparent health, lasting for months or years, the
I ciliary phenomena already mentioned appear. In the interval the
patient may have suffered with various local skin eruptions or with
ulcers upon the buccal mucous membrane.
1 Fever is a constant accompaniment of all forms of syphilis. (See Fever.)
270 GENERAL DIAGNOSIS.
The tertiary lesions of syphilis are the late sypkilides (see Skin) and
gummata of the skin, subcutaneous connective tissue, muscles or inter-
nal organs. Visceral syphilis is seen at this stage. In the brain and
spinal cord gummatous tumors, gummatous meningitis, gummatous
arteritis, and localized scleroses are found. The symptoms are those
of brain tumor when the cerebrum is affected, and of tumor, menin-
gitis, or sclerosis when the cord is affected. In syphilis of the lung
we may find gummata scattered through the lung or a fibrous inter-
stitial pneumonia beginning at the root of the lung. Diffuse syphilitic
hepatitis or gummata may be found when the liver is affected. The
rectum is the most common seat of syphilis of the digestive tract.
Myocarditis and localized gummata and endarteritis occur in cardiac
syphilis, while in vascular syphilis obliterating endarteritis and gum-
matous periarteritis are found. Syphilitic orchitis often occurs. Its
presence may aid in the diagnosis of obscure visceral syphilis.
Hereditary syphilis differs in some respects from the acquired form.
At birth the syphilitic infant usually exhibits no evidence of its inher-
ited taint. In the course of from one to twelve weeks it develops a
catarrhal inflammation of the nasal mucous membrane, which causes
snuffling in breathing, and hence is called " snuffles." An eruption
soon appears, symmetrical in distribution. It is most frequently ery-
thematous or papular, but it may be squamous, vesicular, pustular, or
bullous. In hereditary syphilis it is more apt to be moist and to favor
the genitalia and flexures of the thigh than in acquired syphilis. It is
of the same ham-color as in acquired syphilis. Coincident with the
" snuffles " and eruption appear stomatitis and ulcers at the angles of
the mouth, and sometimes condylomata around the anus. Meantime
the child has begun to waste, to be peevish, to be anaemic, and gradu-
ally to assume the appearance of a wizened, dried-up old man. As in
acquired syphilis, there may be iritis, though it is uncommon, and
inflammation of the other structures of the eye, but nodes and disease
of the liver are rare. The infant very frequently dies during this
period from exhaustion and inanition.
If the child survives for a year the secondary symptoms usually
disappear and the disease becomes latent. Relapses may occur, and
in them, according to Mr. Hutchinson, condylomata are likely to
appear. The same observer states that the tertiary period may begin
at any time after the fifth year, but it is commonly delayed till about
the period of puberty. In the meantime the patient may appear fairly
well, but usually his development is retarded, there is a tendency to
ansemia, and he has often nasopharyngeal catarrh, flattening of the
bridge of the nose, premature decay of the upper incisor teeth, and
protuberant forehead.
The teeth may be perfectly normal, in other cases characteristically
syphilitic. The malformation affects especially the upper central in-
cisors of the permanent set. It was first described by Mr. Hutchin-
son. It " consists in a dwarfing of the tooth, which is usually both
narrow and short, and in the atrophy of its middle lobe. This atro-
phy leaves a single broad notch (vertical) in the edge of the tooth, and
sometimes from this notch a shallow furrow passes upward in both
anterior and posterior surfaces nearly to the gum. This notching is
THE DATA OBTAINED BY OBSERVATION.
271
It mav vary much in degree in different cases
the teeth diverge, and at others they slant toward each
usually symmetrical
sometimes
other." (See Part II., Chapter IV.)
Further, the patient may have had or may now be attacked with
keratitis, affecting both eyes, producing cloudy opacities and accom-
panied by great photophobia. Again, there may be nodes upon the
long bones, with nocturnal exacerbations of pain. Cerebral deafness,
according to Hutchinson, is not rare, but cerebral blindness is. There
may be ulceration upon the legs, and periostitis and necrosis. The
patient usually recovers completely, but he is more liable to be carried
off by intercurrent disease than a healthy person, and in general has
less resisting power, especially to tuberculosis.
Diagnosis. The diagnosis of hereditary syphilis is based upon the
occurrence of snuffles and skin eruptions, and the existence of keratitis
or of cicatrices, especially about the angles of the mouth. A history
of repeated miscarriages is suggestive of maternal syphilis. The diag-
nosis of acquired syphilis is based upon the history of chancre, when that
history is obtainable ; upon the existence of polymorphous eruptions,
or of non-traumatic ulcers upon the legs of young adults, or of scars
in the groins or over the tibia, or of nodes, or of alopecia associated
with sore-throat or mucous patches. The presence of obscure disease
of the bones, glands, or spinal cord should lead to the search for a
possible syphilitic infection. (See Malaria, Chapter XIX.)
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X = MERCURIAL INUNCTION
Reduction of haemoglobin after mercurial inunction in syphilis.
Examination of the blood during mercurial treatment may, in accord-
ance with Justus' observations, show the presence of syphilis. If this
disease is present the percentage of haemoglobin falls suddenly and
rapidly during the hours immediately following the first administration
of the drug. Cabot has confirmed his observations. The accompany-
ing chart shows the effect of mercury upon the blood. (See Fig. 56.)
Weil's Disease.
The occurrence of jaundice without local hepatic symptoms during
the course of fever suggests an infectious process. It is a well known
symptom of pyaemia and septicaemia. In the following infection
fever and jaundice are coordinate symptoms. Acute febrile jaun-
dice, which rapidly becomes malignant, occurring in butchers, laborers,
272 GENERAL DIAGNOSIS.
and brewers, has been described by Weil. After exposure to cold
generally, as in a beer-vault, the patient is seized with a chill, fol-
lowed by fever, with headache, vomiting, and epigastric pain. Jaun-
dice sets in rapidly. The temperature remains high, or may be inter-
mitting. Stupor, delirium, and coma, albuminuria, with suppression of
urine, subcutaneous hemorrhages, and hemorrhages from mucous mem-
branes, rapidly ensue. Black vomit occurs early. In one of my cases
there was enlargement of the liver, with subcutaneous oedema over the
hepatic area. The microscopical appearances were those of acute dif-
fused parenchymatous inflammation. In another, a brewery man, the
liver was enlarged, but without unusual change, save congestion.
The delirium is sometimes violent. The appearance and symptoms
suggest acute yellow atrophy of the liver. The etiological distinctions
are noteworthy : the liver is not small ; leucin and tyrosin are not
found in the urine ; the jaundice is more intense. The diagnostic cir-
cumstances of epidemic and contagious diseases serve to exclude yellow
fever. (See Yellow Fever.)
Miliary Fever.
The occurrence of fever in association with profuse sweating is rarely
seen without attendant signs of pyogenic infection. When several cases
with these symptoms occur at the same time, suggesting an epidemic,
the infection we are about to consider must be thought of.
Miliary fever, or sweating-sickness, is an infectious disease, occur-
ring in epidemics, and characterized by moderate fever, profuse sweat-
ing, tenderness and a sense of oppression at the epigastrium, and a
vesicular eruption. The disease has occurred epidemically in Eng-
land, but is not met with now outside of France and Italy.
After mild prodromal symptoms the disease sets in suddenly with
moderate fever, profuse sweating, and epigastric distress, sometimes
amounting to anguish. The characteristic eruption appears on the third
or fourth day. It consists first of small reddish macula?, in the centre
of which a vesicle develops. The latter varies in size from a pinhead
to a pea. The contents are at first clear, but subsequently become
purulent. Desiccation and desquamation follow. The eruption is
most profuse generally upon the neck and trunk. Sometimes there
are marked nervous symptoms, and even convulsions and fatal collapse.
It is distinguished from rheumatism by the moderate fever and
absence of joint-swellings, and from malarial fever by the absence of
chills, of periodicity in the febrile movement, and absence of malarial
organisms from the blood.
The duration of the disease is from one to four weeks. The mor-
tality in some epidemics has been very high, in others very low.
Infections Transmitted from Animals to Man.
When fever occurs in persons in contact with animals or their prod-
ucts the possible occurrence of the infections — milk-sickness, foot-and-
mouth-disease, and rabies, as well as glanders and anthrax — must be
thought of. The infections which follow are of uncertain bacteriology,
and are recognized not alone by the fever but also by the local symp-
toms and a history of infection.
THE DATA OBTAINED BY OBSERVATION. 273
Milk-sickness.
It is an acute disease affecting cattle, and transmitted from them to
human beings in the milk or meat. The disease is limited to a few
sparsely settled localities west of the Allegheny Mountains. It is char-
acterized by great debility, with muscular tremor upon motion (hence
the name " trembles "), vomiting (hence called " puking fever "), a
peculiar foetor of the breath, obstinate constipation, and moderate fever
or subnormal temperature. The vomited matters are said to be of a
peculiar soapy material of yellowish or greenish color. The duration
is usually less than a week. The patient may sink into a typhoid con-
dition and die in coma, or he may die in a few hours. Convalescence
is protracted.
Foot-and-mouth Disease.
A specific, infectious disease, communicated to man through cattle,
sheep, or pigs, and characterized by a stomatitis. It is communicable
by milk ; the period of incubation is from three to five days. Inva-
sion is characterized by slight fever, heat, and soreness of the mouth,
and the development of vesicles, which burst and leave shallow ulcers.
Saliva is freely poured out. The tongue swells greatly, and eating is
painful. Vesicles sometimes appear about the fingers, but not upon
the feet. The disease lasts from one to two weeks, and ends almost
invariably in recovery.
Hydrophobia.
An acute, specific disease communicated to human beings by the
bites of animals similarly affected. The animals most frequently
affected are the dog, fox, wolf, cat, and skunk ; 90 per cent, of the
cases in human beings are due to dog-bites.
The period of incubation is uncommonly long and very variable — from
two weeks to two months usually. It is said in some cases to be a
year or more. The disease has been divided into three stages — the
melancholic, the spasmodic, and the paralytic.
In the melancholic stage there is pain, hyperesthesia, or even reopen-
ing of the healed wound. The patient is extremely depressed in spirits,
and may be irritable. He seems to be laboring under a constant ten-
sion of fear, and is keenly sensitive to light, sounds, or draughts. He
is affected with thirst, but attempts to swallow water cause intensely
painful spasm of the larynx.
The second stage is reached usually on the second day. The laryn-
geal spasms are increased and lead to intense dyspnoea and to pitiable
struggling and gasping on the part of the patient. In addition to the
convulsive seizures, the patient foams and froths at the mouth, and his
face expresses the extreme terror and mental anguish he feels. The
second stage lasts from one to three days, and is followed by the third
stage, exhaustion intermitting with paroxysms of less severity. The
patient may now be able to swallow easily, but there is great weakness
of the heart, and death may occur from failure of the heart, from
asphyxia, or in a convulsion. The duration, as indicated, is only a few
days. The result is practically always fatal, but recovery may be
possible. Bites of the face are the most likely to be fatal.
18
CHAPTER XIX.
THE DATA OBTAINED BY OBSEEVATION— {Continued).
FEVER. THE INFECTIOUS DISEASES.
Infections Recognized by Examination of the Blood.
Microscopical Examination. The following infections are recog-
nized by the examination of fresh blood : Relapsing fever, malaria,
yellow fever, anthrax. Typhoid fever is also recognized, but is more
frequently diagnosticated by means of serum diagnosis and by culture
methods. By staining cover-slip preparations of the blood the diagnosis
by the direct method is confirmed.
Serum diagnosis enables us to determine the presence of typhoid
fever, yellow fever, and Malta fever.
Bacteriological examination of the blood corroborates the diag-
nosis of typhoid fever made by the above methods. By it we are also
enabled to determine the presence of gonorrheal infection, of cerebro-
spinal meningitis, of the pneumococcus infection, and, in many in-
stances, of infection due to the staphylococcus, streptococcus, and bacil-
lus coli communis. The gonococcus infection alone will be considered.
It must be remembered that the micro-organisms cannot be found in
the blood until late in the course of the disease, and even then the
infection must have a certain degree of intensity. Unfortunately, they
cannot be demonstrated in the majority of cases. Positive cultures
for the above reasons are very valuable. Negative cultures do not
exclude septic infections.
Relapsing Fever.
Relapsing fever is the first infection which we will consider, because
historically it is the most important. It is the first infection in which
a micro-organism was found to be causal, and is one to which Koch's
laws can be applied. It is an acute, infectious, and contagious fever,
occurring in epidemics, and characterized by the sudden onset of a
febrile period lasting five or seven days, which is followed by an inter-
mission lasting usually a week, and this in turn by a relapse lasting
three days. Its development is favored by filth and famine, but the
specific cause is believed to be the spirillum of Obermeier, which is
constantly present in the blood during the febrile stage.
The stage of incubation lasts from five to eight days (Pepper), during
which the patient may complain of malaise, lassitude, and flying pains.
The invasion is sudden. It manifests itself by a chill or chills, frontal
headache, pains in the back and limbs, vertigo, and great physical
weakness. The temperature rises very rapidly, reaching 105°, 106°,
THE DATA OBTAINED BY OBSERVATION. 275
or even higher, in the first day or two. The face is flushed, epistaxis
sometimes occurs, the headache and other pains persist, but delirium
is not common. The appetite is usually lost, thirst intense, the tongue
coated white but moist, the bowels constipated. A mild catarrhal jaun-
dice is not infrequent. Pepper states that nausea and vomiting are
prominent symptoms, the matters vomited at times containing blood.
Tenderness with pain in the epigastrium is frequently complained of.
The urine is scanty, high-colored, and frequently contains albumin
and casts ; when jaundice exists the urine contains bile-pigment and
sometimes blood.
There is no peculiar eruption in relapsing fever, but in this, as in
other fevers, erytheniata, petechias, and sudamina may be present.
The pulse is often very frequent and soft, and hsemic murmurs may
be audible.
The objective symptoms are few. They consist of the flushed face,
sometimes with slight jaundice and epistaxis, tenderness in the epigas-
trium, with moderate enlargement of the spleen and liver, and consid-
erable cutaneous hyperesthesia, with tenderness along the nerve-trunks.
Bronchitis and sometimes hypostatic congestion of the lungs, with
their usual physical signs, may be present.
These symptoms continue without much change until the fifth or
seventh day, when a decided crisis occurs. Sometimes this is deferred
until the tenth day. The temperature within twelve hours falls from
106° or 108° to or below normal ; the pulse diminishes in frequency
from 120 or 130 to 60 or 70 ; vertigo, headache, and other pains dis-
appear as by magic. The crisis is marked most frequently by a pro-
fuse sweat, sometimes by diarrhoea, epistaxis, metrorrhagia, or intesti-
nal hemorrhage. The patient now enters upon convalescence without
fever, and apparently makes rapid strides toward complete recovery.
On the seventh day from the crisis, however, a sudden relapse occurs,
with a repetition of the symptoms of the first attack. The temperature
may be higher and the febrile symptoms more severe, but the duration
is shorter — only three or four days. The spirilla, which disappeared
in the apyretic interval, are again found in abundance. A second
crisis, with its associated symptoms, now occurs. The spirilla again
disappear, and in the majority of the cases there is no further bar to
complete recovery. A second, third, and even a seventh relapse may
occur, as in a case reported by Pepper. Organic lesions are not usually
left behind, unless they have occurred as complications; but even in
ordinary cases the patient is left weak, anemic, and with poor circulation.
Examination of the Blood. Microscopical Examination. In
the blood at the height of the disease the spirillum of Obermeier is
found.
These are slender, wavy, thread-like organisms of spiral shape, seven
or eight times the length of a red blood-cell, with a very lively forward
movement in the direction of the long axis. They are from 16 to 40//
by 0.1//. Under a low power the blood may appear to be in motion,' as
the result of their movement, They have so far been found only in the
height of the febrile attacks ; but Yon Jaksch states that as long as a
relapse is to be feared the blood contains peculiar, highly refracting bodies
276 GENERAL DIAGNOSIS.
resembling diplococei, which are especially numerous before the attack ;
in some cases it has seemed to him that these diplococci at the very
beginning of an attack develop into short, thick rods, from which the
spirilla develop ; they may, therefore, prove to be spores. Staining is
unnecessary for the detection of spirilla, but cover-glass preparations of
the blood can, if desired, be stained with fuchsia or gentian-violet or
L5ffler's methylene-blue. (Plate III., Fig. 4, a.)
Serum Diagnosis. It sometimes happens that a diagnosis should
be made during the afebrile period when the organisms have disap-
peared entirely from the peripheral circulation. Lowenthal's method
is as follows : A drop of the suspected blood is mixed with one con-
taining the living micro-organisms. The mixture is sealed up with
wax between slide and cover-glass and left in the thermostat at 37°
for half an hour. Blood from a patient who has just had a paroxysm
will destroy the spirilla, so that they lose their motility and spiral curl
and accumulate in bunches. The reaction is like that of Pfeiffer's
phenomena rather than agglutinative. It is to be remembered that
the bactericidal power of the blood dies out before the next paroxsym.
Ixoculatiox. As further aid to diagnosis typical relapsing fever
can be produced by injecting the infected blood into monkeys.
The most frequent complications are on the side of the lungs, kid-
neys, and heart. Lobar pneumonia is the most frequent. The heart
becomes weakened by the very high fever and thrombosis, or sudden
failure results. Embolism is very frequent. Suppurative parotitis,
abscess of the spleen, profuse epistaxis, abortion in pregnant women,
and neuritis deserve mention.
Relapsing fever occurs at all ages, but is most common in adults.
The duration varies according to the munber of paroxysms. If
there is only one, it is about eighteen days. Under the name " bilious
typhoid " a malignant form of relapsing fever has been described. It is
characterized by intensity of the symptoms of the ordinary form, and
by bilious or bloody vomiting, jaundice, and delirium, or by collapse,
with purple nose, a small, frequent weak pulse, rigidity of the abdomi-
nal muscles, tenderness in the epigastrium, and cold, clammy skin. In
some of the cases described by Graves, intussusception of the intestines
was found after death. In other cases uraemia is an active factor.
Diagnosis. The earlier cases in an epidemic may not be recognized,
unless the blood be examined, until the occurrence of the characteristic
relapse. The diagnosis is based upon the occurrence of an epidemic,
the presence of the predisposing factors, the clinical course, and the
examination of the blood. It is most likely to be mistaken for typhus
fever, which occurs under similar conditions. The aspect of the two
diseases is very different. In typhus there is a heavy, stupid, some-
times besotted expression, with slight redness of the eyes and a con-
tracted pupil. The patient lies oblivious of his surroundings, with
low muttering delirium and ataxic symptoms. In relapsing fever, on
the other hand, the sensorium is rarely much disturbed, the spleen and
liver are enlarged, and there is hyperesthesia. Moreover, in typhus
there is a spotted eruption, later becoming petechial. In relapsing
fever this is absent.
THE DATA OBTAINED BY OBSERVATION. 277
Anthrax.
The next infectious disease, the cause of which can be determined by
an examination of the blood, is anthrax. This affection is also of his-
torical importance, and is probably the best worked out of any of the
infections common to man and the lower animals. It is also called
malignant, pustule, charbon, wool-sorter's disease, splenic fever. It is
derived principally from herbivorous animals, and characterized by the
development of a pustule or boil, with extensive brawny oedema and
subsequent toxaemia ; or toxaemia may appear first and metastatic
abscesses subsequently. The disease also attacks the gastro-intestinal
mucous membrane and the lungs.
Anthrax is caused by the anthrax-bacillus and its toxins. Outside
of the body it forms endogenous spores, which are extremely tenacious
of life, and to which infection is invariably due. They infect not only
the carcasses of animals, but also the soil, all utensils used in the care
of the animals or the soil, and they persist with infective power in the
hides, hair, hoofs, and wool (" wool-sorter's disease "). It is possible
that it may be transmitted to man by stings of insects, particularly
flies and mosquitoes.
The period of incubation varies from a few hours to several days.
In the form known as malignant pustule the patient has a pricking or
burning feeling, which may lead him to think he has been stung by
an insect at some exposed part of the body, particularly the hand, face,
or neck. At the seat of irritation, first a papule, then a vesicle, de-
velops. The vesicle may attain considerable size. The contained
fluid quickly passes from clear to bloody, and then escapes, leaving a
dark-brown or black scab (anthrax).
The original vesicle may be surrounded by a series of smaller ones.
Instead of disappearing, the base of the vesicle becomes inflamed and
indurated, the induration extending to surrounding tissue and causing
a condition of brawny oedema. A whole arm or one side of the face
and neck may be swollen. There may or may not be an associated
lymphangitis and adenitis.
The general health does not suffer at first, but in a day or two fever
sets in, accompanied by delirium, sweating, great weakness, enlarge-
ment of the spleen, severe pains in the limbs, and diarrhoea. Death,
preceded by collapse, may occur in from five to eight days (Fagge),
or the tissue occupied by the pustule may slough out.
Bollinger and others have called attention to anthrax oedema, in
which there is no pustule, but only a yellowish or greenish swelling of
the tissues. Gangrene may ensue. It is seen most frequently in the
eyelids, but may be on the head, hand, or arm.
Intestinal Form. Anthrax of the gastro-intestinal mucous mem-
brane, as described by Bollinger, presents the following symptoms :
the patient first complains of malaise, loss of appetite, pains in the
limbs, giddiness, and headache. Then vomiting may set in, and a
more or less severe diarrhoea, the evacuations often containing blood.
There may be pain in the abdomen, which becomes somewhat tumid ;
the spleen is enlarged. Dyspnoea and lividity appear, with restlessness
278 GENERAL DIAGNOSIS.
and with excitement or stupor. Epileptiform convulsions may occur,
the upper limbs may be affected with tetanic spasms, there may be opis-
thotonos, and the pupils may be widely dilated. The pyrexia is slight,
and death is preceded by extreme collapse. The duration of the disease
is usually from two to seven days, but sometimes it is scarcely twenty-
four hours.
Wool-sorter's Disease. Still another form of anthrax occurs among
the wool-sorters of Bradford, England ; it is characterized by intense
dyspnoea and a feeling of oppression or constriction. Breathing is
labored, but not much accelerated. Only a few coarse rales are to be
heard on auscultation. The expectoration may be abundant and
bloody, or absent. There is a tendency to collapse, with cold, bluish
skin, and a subnormal axillary temperature. The rectal temperature,
however, is raised two or three degrees. Death may occur in coma
and convulsions, or suddenly, the mind being clear. The duration of
the disease is from one to five days. Dr. Bell says that those who
survive for a week generally recover.
Examination of Blood. The bacillus anthracis is found in
the blood of the patient or the pus of the lesions of anthrax or malig-
nant pustule.
Morphology. A bacillus, 2 to 3^ up to 20 to 25// in length and
1 to \\{x in breadth. The bacilli are often joined end to end in long
threads, and these threads are massed together in bundles. As found
in animals they are short rods with square ends. They stain best with
Loffler's blue, but also with the basic anilines and by Gram's method.
When in the stage of spore-formation the threads look like strings of
beads.
Fig. 57.
Bacillus anthracis highly magnified, to show swellings and concavities at
extremities of the single cells. (Abbott.)
Cultures. Biological Properties. It is aerobic, non-motile,
and liquefies gelatin. (See Plate III., Fig. 2, a ; Plate VI. ; Fig. 57.)
It grows best in neutral or slightly alkaline media (gelatin, agar,
milk, meat-infusion, etc.) at 20° to 38° C. The growth-limits are 12°
and 45° C.
Cultures on agar are quite characteristic, consisting of a dense cen-
tral mass with twisting and crossing bundles all around it. In gelatin
stab-cultures a fine branching threadwork grows out alongside the
puncture. The gelatin soon liquefies and the bacilli settle in white
masses. The growth is abundant on potato, and is grayish, dry,
rough, and irregular. The virulence is attenuated by cultivation.
Drying does not kill the spores. Very toxic substances are found in
the culture-medium.
PLATE VI.
FIG. 1.
\^ ^\rA^ "*,5
.. ^ f/ *■*•
Anthrax-bacilli from Rabbit's Spleen.
(Oc. 4, ob. y'w immersion.) Drawn by J. D. Z. Chase.
FIG. 2.
*$%*?'"
Protozoa of Malaria, Intracellular and Crescentic Forms.
(Oc 4, nb. ,'., immersion.) Drawn by J. I). X. Chase.
THE DATA OBTAINED BY OBSERVATION.
279
Inoculation. "When inoculated, the organism produces the pus-
tule of anthrax. If inoculated into the abdominal wall of a guinea-
pig: or rabbit death follows in forty-eiffht hours. No reaction is seen
at the point of inoculation, but beyond this the tissues are cedematous.
Ecchymoses are seen, and the underlying muscles are pale. The
spleen is enlarged, dark in color, and soft. Cover-slip preparations
confirm the diagnosis.
Anthrax bacilli are not so numerous in human blood as in that of
the lower animals. They are most likely to be found in the spleen,
which is apt to be much swollen.
Fig. 58.
Bacillus anthracis in the blood of a guinea-pig. X 10-10. (Gibbes.)
Diagnosis. In doubtful cases a mouse or guinea-pig should be
inoculated with the blood. Carbuncle is distinguished by its tendency
to develop upon the back or shoulders and other covered portions ;
anthrax on uncovered portions. In carbuncle there is a series of open-
ings resembling a sieve, filled with pus and plugs of necrotic tissue.
In anthrax there is at first a central black crust. The boggy feeling
of carbuncle is different from that of the brawny oedema of anthrax.
Finally, in carbuncle, anthrax-bacilli are not found in the blood.
The intestinal and thoracic forms are distinguished by the occupa-
tion of the patients, the absence of other adequate cause, and the result
of the blood-examination, cultures, and inoculation experiments.
Malarial Fevers.
The next infection which we are about to consider is one of the most
common the world over. In its various forms it is recognized by direct
examination of the blood. Its clinical features are such that often but
little difficulty surrounds its recognition, but no case should be unqual-
ifiedly pronounced malaria without an examination of the blood. It
comprises a group of fevers associated with the protozoan organism of
Laveran, and is characterized by periodic paroxysms of chill, fever, and
sweat. They are not contagious, but can be transmitted by inoculation.
Malarial fevers, while most prevalent in tropical and subtropical
280 GENERAL DIAGNOSIS.
regions, are found also throughout the temperate zone, especially in
autumn and spring. In Europe their favorite habitat is Italy, and in
the United States the Southern and Southwestern States. Conditions
that especially favor their development are marshes and swamps, fed
partly by sea-water ; low ground along streams of slow current, and
freshly upturned soil. The poison is carried in the air.
The specific poison in malarial fevers is no doubt organic. The
protozoan organism described by Laveran exhibits several different
forms, which he regards as stages in the development of one organism,
but which may be different species. Golgi maintains that there are
several distinct varieties of parasites whose periodicity hi development
and sporulation corresponds with the different types of fevers.
Intermittent Fever. This is a type of malarial fever in which the
temperature remains normal between the paroxysms.
A malarial paroxysm is characterized by (1) chill, (2) fever, and (3)
sweating, occurring in the order named and in immediate succession.
The time between the beginning of one paroxysm and the beginning of
the next is called the " interval," that between the conclusion of a par-
oxysm and the beginning of the next the " intermission." The interval
varies in different forms of intermittent fever : in the quotidian there
is a paroxysm every day, with an interval of twenty-four hours ; in the
tertian there is a paroxysm on alternate days, with an interval of forty-
eight hours ; in the quartan there is a paroxysm every third day, with
an interval of seventy-two hours. In double quotidian there are two
paroxysms in the twenty-four hours, but not of the same intensity.
In the double tertian there is a paroxysm every day, the first and
third and second and fourth corresponding as to hour and intensity.
That is to say, if there be a paroxysm at 10 a.m. Monday there will
be another severe paroxysm at 10 a.m. Wednesday, while on Tuesday
and Thursday there will be milder paroxysms, but at another hour
than 10 a.m.
In the double quartan severe and mild paroxysms succeed each other
every other day, but each third day is free from any paroxysm.
While the rule is for malarial fevers to occur periodically at the same
hour, the second paroxysm may occur an hour or two earlier (anticipa-
tion) if the disease is growing worse, or an hour or two later (postpone-
ment) if it is growing better. (See Figs. 30, 31, 32.)
Quotidian intermittents are slightly more common than tertian, while
the quartan variety is rare.
The incubation-jyeriod probably varies widely, depending upon the
intensity of the poison. As a rule, repeated exposure is necessary to
develop the disease in temperate climates. During this period the
patient may suffer with headache, drowsiness, pains and aching in the
limbs and back, constipation, a coated tongue, and thirst.
The onset of a typical malarial paroxysm is marked by chilly sensa-
tions, especially along the spine, accompanied by yawning and the
development of " goose-flesh." Then a decided chill sets in, the patient
shaking violently. The face is pale and pinched, the lips blue, the
nose pointed ; as the chill becomes worse the teeth chatter, the whole
body feels cold, the skin feeling rough, dry, cold, and harsh. The
THE DATA OBTAINED BY OBSERVATION.
281
finger-nails and toe-nails are blue, the skin being wrinkled upon the
palmar and plantar surfaces. The superficial bloodvessels are so con-
tracted that a drop of blood is obtained with difficult)'. The voice is
thin and weak, almost inaudible.
The volume of blood driven from the surface leads to congestion of
the viscera, particularly the spleen, liver, and stomach. Nausea and
vomitiug are not uncommon. The spleen is perceptibly enlarged, and
frequently the liver also.
Although the surface temperature is depressed, the internal tempera-
ture is rising, and may be two or three degrees above normal. By
degrees the severity of the chill abates and the patient asks to have
the extra bedclothing removed. Reaction has set in. The surface-
bloodvessels dilate and the skin becomes flushed. The temperature
continues to rise, often reaching 103° to 106°, pulse and respiration
increasing correspondingly in frequency. The patient complains of a
throbbing, dizzy headache, and vomiting may recur. The bowels
remain constipated. The temperature now begins to fall, and the
sweating-stage succeeds. Perspiration appears first upon the forehead,
face, and neck, and gradually extends over the rest of the body. The
perspiration becomes more and more profuse, until the whole body is
drenched with it. All the subjective symptoms vanish with wonder-
FlG. 59.
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Intermittent fever.
Temperature every six hours. Morning and evening temperature
and highest at chill.
ful rapidity, and the patient, with the exception of exhaustion, seems
to be restored to complete health. The hot stage lasts from one to two
282
GENERAL DIAGNOSIS.
hours, the cold stage from three to eight hours, and the sweating-stage
from two to six hours.
In the interval between paroxysms the patient is free from fever,
but is anaemic, weak, and has impaired appetite and constipation.
During the entire paroxysm the mind remains clear.
The chief objective symptom, apart from the phenomena of chill, fever,
and sweat already described, is the occurrence of plasmodia in the
blood. (See Plate VI., Fig. 2 ; and Fig. 61.)
Examination of the Blood. The plasmodia of malaria were first
pointed out by Laveran. They have been studied in Italy, especially
by Marchiafava and Golgi, and in this country by Councilman, Osier,
and Dock. Minute amoeboid bodies are found in the red corpuscles.
These become pigmented with altered haemoglobin, and grow until
they fill nearly the whole of the cell, the pigment being arranged
chiefly in a peripheral ring. Later, the amoeboid bodies become spheri-
cal and transparent, the pigment collecting in the centre. Sporulation
now begins and a fresh crop of small, rounded parasites appears, to
begin the same cycle over again in fresh corpuscles. (Plate VI.,
Fig. 2.)
Three forms of parasites are described : 1. The tertian, which sporu-
late at the end of four hours, begin as small amoeboid intracorpuscular
bodies, gradually enlarge, produce fine brownish pigment-granules, and
finally completely fill the corpuscle. In sporulation the segments
number fifteen to twenty.
Ftg. 60.
Malarial plasmodia. (Reproduced from colored plate.) To the right two normal red blood-cells
with central depression. In addition, several others with bluish contained bodies and pigment-
sprinkled cells, which show the endogenous development of the plasmodia. Besides, two of
Laveran's bodies, one exhibiting a delicate little basket appearance. Near the centre a poly-
nuclear white cell with bluish nuclei and red granulation. (H. Rieder.)
2. The quartan, which sporulate at intervals of seventy-two hours,
are smaller ; amoeboid movement is not so marked ; when full groAvn
THE DATA OBTAINED BY OBSERVATION.
Fig. 61.
283
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The first twelve figures show the malarial Plasmodium. It is a pale amceboid body inside the
red corpuscle. It increases in size at the expense of the corpuscles. In the last four of the twelve
it is enlarged and contains pigment-granules derived from the haemoglobin. The figures of the
fourth row show progressive stages in the process of cleavage of the Plasmodium and shifting of
the pigment-granules. In the fifth row the process of cleavage is seen to be completed, and final
isolation of the spores has taken place. The dark granules are pigment-granules. The last row
shows oval parasites— Laveran's corpuscles observed in atypical cases of malaria. (From Golgi,
"Studien liber Malaria," Fortschritte der Medicin, Bd. iv. Tafel., in.)
284 GENERAL DIAGNOSIS.
the parasites are smaller, and the corpuscles tend to shrink about them
and to become a deeper greenish color. They sporulate with five to
ten segments in a very beautiful characteristic roseate appearance.
3. The sestivo-autunmal are smaller, and contain less pigment. The
period of sporulation is still hi dispute. They usually form ovoid-
crescentic or round bodies with coarse pigment-granules in the centre.
Golgi maintains that in tertian malarial fever the period between
invasion of the corpuscles and the sporulation is two days ; in quartan,
three days, the difference in cycle being due to a difference in the
parasites.
The onset of the fever corresponds in time to the division of the
parasites.
The crescentic form described by Laveran is said to be more common
in the irregular forms of malarial fever. Canalis says that it only
makes its appearance several days after the first access of fever. It is
somewhat longer than a red blood-cell, and the pigment tends to collect
in a focus about the middle of the parasite. Subsequently it becomes
oval and divides into eight or more daughter-cells.
Another form with nagella is occasionally found. Councilman says
it is most common in blood drawn directly from the spleen.
The plasmodium of malaria may be stained as follows : Cover-glass
preparations of the blood spread very thinly are dried in the air and
fixed by immersion for twenty minutes or half an hour in a mixture
of equal parts of alcohol and ether. They are then stained for twenty
to thirty minutes in concentrated aqueous solution methylene-blue, 60
parts ; J per cent, solution eosin in 75 per cent, alcohol, 20 parts ;
distilled water, 40 parts ; 20 per cent, solution potassium hydroxide,
12 drops. The cover-glasses are then washed in water, dried, and are
then ready for mounting. The red blood-cells are stained rose, the
nuclei of leucocytes a deep dark-blue, and any plasmodia a delicate
sky-blue.
Aronson and Phillips' staining method is as follows : Make concen-
trated aqueous solutions of orange G., acid rubin, and crystallized
methyl-green, leave them to settle, then mix in these proportions :
Orange G., 55 ; acid rubin, 50 ; distilled water, 100 ; and alcohol, 50.
To this add methyl-green, 65 ; distilled water, 50 ; and alcohol, 12.
Leave the mixture standing for a week. A well-diluted solution
should be used for staining purposes ; one drop of the mixture should
be added to 25 cubic centimetres of water ; the stain shoidd be left on
for twenty-four hours and the fixing of the preparations carried out at
a temperature of 120° C. In the result the red corpuscles are stained
orange, nuclei greenish blue, neutrophile corpuscles violet, and eosin-
ophile red.
The examination of the blood discloses the presence of a high degree
of aneemia. The haemoglobin is usually diminished in greater propor-
tion than the corpuscles. There is a marked reduction in the leuco-
cytes. Thus leucopenia is most marked after a paroxysm. There is
a relative diminution of the polvnuclear forms and a relative increase
in the mononuclear forms. In severe post-malarial anaemias, as Thayer
points out, the blood is characteristic of pernicious anaemia.
THE DATA OBTAINED BY OBSERVATION.
285
Irregular Form. Irregular forms of intermittent fever are more
common in Philadelphia than the typical form just described.
In the mild form the patient complains of great lassitude, irritability
of temper, and drowsiness during the day, but at night tosses upon his
bed and gets up in the morning more tired than when he went to bed.
The back and limbs ache, and the latter feel as though they would
give way under him. There is severe throbbing headache, with some
dizziness and faintness. The bowels are constipated ; the tongue
heavily coated with yellow fur. The temperature is moderately eleva-
ted and the patient has great thirst. Nausea and vomiting are absent,
though there is little desire for food. There may be a burning feeling
referred to the splenic region. The patient is worse on alternate days,
and the attacks may be preceded by slight creeping chills. On inquiry
the patient will be found to live in a low-lying district near one of the
rivers, or in a damp house over an unclean, moist cellar, or adjoining
a place where fresh soil has been upturned.
In the form known as " dumb ague" there is a periodically great
depression, with aching in the head and limbs, a sensation of coldness
rather than chilliness, but no marked fever and sweating. Nausea
and vomiting may, however, be present. Da Costa says he has seen
it manifest itself by excruciating pain over the kidney, and almost
entire suppression of urine. There may also be severe paroxysms of
gastralgia. It is more common in old residents of malarious districts.
In mashed malarial fever the poison manifests itself in an attack of
neuralgia, especially of the supraorbital nerve and gastric nerves.
Malaria may also be latent until some impairment of the resisting
power brings it to light. Hence it appears as a complication of pneu-
monia and dysentery and typhoid fever (Fig. 62), especially in the
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Abundant malarial
organisms.
Malarial fever associated with enteric fever. (Thompson.)
southern and southwestern portions of the United States. Moreover,
women who have previously had intermittent fever may suffer a recur-
rence after confinement.
Diagnosis. The essential points in the diagnosis of intermittent
fever are the periodical recurrence of paroxysms of chill, fever, and
sweating, or of attacks of dumb ague, or of paroxysms of neuralgia,
without organic lesion, associated with the presence in the blood of
pigment and plasmodia, and with enlargement of the spleen and possi-
bly of the liver. The so-called therapeutic diagnosis may be made —
286
GENERAL DIAGNOSIS.
an intermittent fever which does not yield to proper doses of quinine
in three days is not malarial. A typical malarial intermittent fever is
not likely to be mistaken for anything else. (See Fever, pages 205,
206.) It needs, however, to be distinguished from septicemic fever,
due to absorption into the blood of pus and the toxins produced by
bacteriological growth. Such fever occurs in tuberculosis, especially
in the stage when cavities form and pus collects ; in the puerperal
state, in empyema, subphrenic abscess, abscess of the liver, or, indeed,
in any form of suppuration. Here also, then, are recurring chills,
with fever and sweating, but the attacks are not regularly periodical
and intermittent ; sometimes the fever is intermittent and sometimes
remittent, the chills recur at irregular intervals, and are not so violent
as in the malarial attack. The essential difference, how r ever, lies in
the fact that a local cause can be found to explain them, tuberculosis
either of the lung or of some other viscus, or a collection of pus in an
organ or cavity, or a foetid discharge from the womb, with local ten-
derness or peritonitis ; moreover, the patient loses flesh more or less
rapidly, his blood is free from malarial germs and pigment, and quinine
does not control the fever. (Plate VI., Fig. 2.)
From the intermittent fever of hepatic origin (described elsewhere
by the author) the diagnosis is more difficult, in that physical signs of
any local trouble may be wanting. But the fever is not regularly
intermittent, is not controlled by the quinine, but may be by measures
directed to the origin of the trouble, and jaundice may be present.
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yf residence from the country to the city
predisposes to it. Those living in cities often acquire immunity, but
they may lose it upon moving elsewhere. The state of previous health
does not seem to have any influence.
The period of mcubaMon in typhoid lexer varies from four or five
day- to three weeks ; more commonly it is from one to two weeks.
During this time the patient usually is languid, becomes tired easily
19'
290 GENERAL DIAGNOSIS.
upon exertion, lias severe headache, sleeps poorly, and has bad dreams.
There is often, even thus early, a dull and listless expression of the face.
Toward the close of this period, and in severe cases, there may be
colicky pain in the abdomen, a tendency to looseness of the hovels,
cough, epistaxis, mental sluggishness, and chilliness. Dr. Pepper says
he has been led repeatedly to anticipate the approach of typhoid fever
by the unusual dulness of hearing and by the persistent occipital head-
ache coming on after a few days of general malaise.
While the disease may begin abruptly, a gradual onset is so much
the rule that it becomes important in the diagnosis from other disease-
conditions.
Invasion is not sharply marked. There may be chilliness, but a
decided chill is unusual except when pneumonia is part of the initial
process. Muscular weakness, headache, and mental sluggishness are
more pronounced, and the physician is consulted because these symp-
toms persist, or because fever is discovered. The beginning of fever
is the most constant indication of the onset of the disease, and two
very important early symptoms are cough from bronchitis and en-
largement of the spleen.
The most prominent and constant subjective symptom during the
first week is headache. Other very common symptoms are tenderness,
rarely pain, in the iliac region, more or less prostration, and impaired
appetite or loss of appetite.
The objective symptoms are therefore the most important. The face
is pale rather than flushed, and has a dull, listless, apathetic expres-
sion. The tongue is heavily coated with a white fur which later
becomes yellow. The abdomen is somewhat distended and tympanitic
on percussion. There is usually tenderness in the right iliac region,
and gurgling upon palpation is pretty constant. Constipation may
be present at first, and sometimes persists throughout the disease. A
tendency to diarrhoea is, however, characteristic of the disease. Even
if constipation exists at first, a laxative is apt to produce an excessive
effect. The number of stools varies from two or three to a dozen or
more in twenty-four hours. They are light yellow in color (resem-
bling pea-soupj, thin, watery, and offensive. The movements are not
usually attended with pain, and in severe cases may occur involuntarily.
Enlargement of the spleen is a very constant symptom. It may be
detected at the onset, increases up to the height of the fever, subsides
during convalescence, but recurs during a relapse. It covers a percus-
sion-area in the left hypochondrium of four to eight finger-breadths.
The temperature-euxxe, when not modified by treatment, shows a
gradual ascent during the first four or five days of the disease, with
morning remissions. The temperature rises a degree or two in the
evening and falls half a degree or a degree hi the morning. This
" step-ladder " ascent is very characteristic. By the end of a week a
temperature of 103°, 104°, or 105° has been reached, and it remains
continuously high, with slight morning remissions, during the second
and less frequently during the third week. In the third or fourth
week the morning fall of temperature gradually becomes greater, and
by the end of the week sinks below the normal in the morning.
THE DATA OBTAINED BY OBSERVATION.
291
The temperature in mild cases may never rise above 103° at any
time, and most of the time varies between 100° and 102°. Or it may
Fig. 64.
104°
103°
102°
101
100°
99
DAY OF DIS.
DATE
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Temperature ranges ; first week of typhoid fever. (Dock.)
be 104° from the start ; more frequently during the second and third
weeks there are marked oscillations of the temperature — a sudden fall
from 104° to 101°, or a rise from 103° to 105° or 106°. Hyperpy-
rexia is a temperature above 105°.
Fig. 65.
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The pulse is full, and in favorable cases slower than the pyrexia
would lead one to expect. It is more frequently under 110 than over
120. In the second week it is markedly dicrotic
292
GENERAL DIAGNOSIS.
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THE DATA OBTAINED BY OBSERVATION.
293
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294 GENERAL DIAGNOSIS.
The heart sounds are unchanged apart from complications, but in the
second and third weeks the first sounds often are feeble, indicating
heart weakness. A pulse of 120 or more is a graver sign in typhoid
fever than in other diseases. Therefore, when it becomes very frequent
and feeble, the extremities cool and the lips bluish, the outlook is
gloomy.
The urine is at first scanty and high-colored. A slight degree of
febrile albuminuria is not uncommon, and in rare cases the whole force
of the poison seems to be spent upon the kidneys, the urine containing,
besides the usual blood and casts, biliary coloring-matter. In condi-
tions bordering on coma the patient may have retention of urine, or,
on the other hand, he may pass it involuntarily. To obtain the diazo
reaction of Ehrlich two solutions are necessary. The first (a) consists
of 2 grams of sulphanilic acid, 50 c.c. hydrochloric acid, and distilled
water 1000 c.c. The second (6) consists of a J per cent, solution of
sodium nitrite. These solutions are kept in separate bottles. Fifty
parts of solution a and one part of solution 6 are poured into a test-
tube and an equal volume of urine added. The test-solutions and
urine are now thoroughly shaken and then carefully overlaid with 1
c.c. of ammonia. At the junction of the two a pink or ruby ring
develops. Upon agitation the foam on the top of the mixture is also
colored red. Xormal urine gives a light brown ring. This reaction
is helpful in diagnosis, but may occur in acute phthisis, tubercular
meningitis, and other diseases. According to Pepper, it is rarely
absent in measles. The reaction is fairly constant in typhoid fever
after the first week.
The respiration in uncomplicated cases increases in frequency with
the rise in temperature. It usually ranges between 24 and 36. The
slight bronchitis present in the beginning in most cases causes no
trouble ; sometimes it lasts throughout and contributes to the tendency
to hypostatic congestion, which is always present. The physical signs
are those described elsewhere in these conditions.
The nervous symptoms are often very prominent. In mild cases
they consist of hebetude and nocturnal delirium, or they may be absent
altogether. Usually, however, by the beginning of the second week,
there is some mental confusion, with nocturnal delirium. In more
severe cases, and later in the disease, the delirium is of a low, mutter-
ing character, with hallucinations of sight and sound more or less
continuous. The patient can be roused by a question, and makes an
intelligent answer, but speedily lapses into semi-consciousness. Pick-
ing at the bedclothes or efforts to catch imaginary objects are very
common. Sometimes the delirium is wild and noisy, and the constant
presence of some one is needed to keep the patient from getting out of
bed. Patients have jumped out of windows, or run long distances
before being captured. Rarely the delirium has been so active as to
simulate acute mania. Stupor may alternate with delirium. Rarely
the patient lies with wide-open eyes, apparently staring fixedly at
some object, but really unconscious (coma-vigil).
In ataxic cases the patient has marked twitching of the tendons and
jactitation. He is wakeful and restless, wearing himself out. The
THE DATA OBTAINED BY OBSERVATION.
295
hands and lips tremble, and he keeps muttering to himself all the
time.
Convulsions are rare, but may occur in children. Sometimes there
are considerable hyperesthesia and tenderness along the spine.
Fig. 68.
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Fig. 69.
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Typhoid fever in a child aged 12 years. Chart from twelfth to twenty-third day. .
Repeated crises. (Frequent mode of termination in children.)
The extent of the nervous symptoms depends upon the habit of the
patient as well as upon the height of the temperature and gravity of
296
GENERAL DIAGNOSIS.
pro-
the disease. In children and neurotic individuals they may be
nounced, with only moderate fever.
On the seventh or eight day the eruption appears. It consists of
small, very slightly elevated, rose-colored papules, which disappear
upon pressure and come out in successive crops, each papule lasting
three or four days. The spots are most common over the abdomen
and back, but are occasionally found elsewhere. They are usually few
in number, a half-dozen or dozen, but sometimes the eruption is very
copious, especially in severe cases. Sometimes it is wholly absent.
During the latter part of the second week, and through the third
week, the symptoms are apt to be intensified. The temperature keeps
up or even reaches a higher point. Delirium is more decided and con-
stant, The heart grows weak and the pulse increases in frequency.
Some degree of hypostatic congestion of the lungs is usual. Diarrhoea
may be troublesome ; intestinal hemorrhages, announced by sudden
fall of temperature and symptoms of collapse, may occur. Tympanites
may become so great as to interfere with respiration and circulation.
This is the period when ulceration of Peyer's patches in the intestine is
deepest, and when perforation is imminent. There is rarely any desire
for food, though it is taken and assimilated. Nausea and vomiting are
rare. The tongue is dry, brown, sometimes glazed and fissured, and
sordes often collect on the teeth.
Fig. 70.
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Course of temperature in a relapse beginning on the twenty-sixth day. First attack mild.
In cases ending in recovery the temperature begins to fall in the
mornings ; delirium grows less ; sleep is more refreshing. Diarrhoea
ceases, and constipation may even require treatment. The pulse does
not usually improve as rapidly as the other symptoms. There is some-
times very marked anaemia without leukocytosis (Osier). When the
THE DATA OBTAINED BY OBSERVATION.
297
temperature sinks to normal or subnormal, convalescence has set in.
This is very rapid as far as digestive symptoms are concerned, but
strength returns very slowly. It may be interrupted by a relapse, in
which the original symptoms are reproduced, with high temperature,
but the duration is shorter.
Varieties. It is now well known, as Osier forcibly states, " that
typhoid fever is no more primarily intestinal than is smallpox prima-
rily a cutaneous disease." Studies in bacteriology, promoted especially
by Chiari, Flexner, Kraus, Nicholls, and others, enables us to divide
the infection into three varieties : 1. Typhoid fever with intestinal
lesions, as described above. 2. Typhoid fever with general infection
or typhoid septicaemia. The symptoms are entirely those of an infec-
tion, and the diagnosis must rest upon the serum reaction and culture
methods. 3. Typhoid fever with more intense infection of other organs
than the intestines. The lungs, the spleen, the kidneys, and the cere-
bro-spinal meninges are the structures invaded, so that we may have a
pneumo-, nephro-, spleno-, or cerebro-spinal typhoid.
Fig. 71.
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Grave typhoid fever. Daily rigors. Death on nineteenth day. No complications.
Varieties are also based upon the severity of the disease, hence we
have the abortive, grave, and ambulatory forms.
The abortive form is so named because of the abbreviated course of
298 GENERAL DIAGNOSIS.
the disease. The symptoms are sufficiently well marked to make the
diagnosis clear, but the type is mild, and in a week or two convales-
cence is established. In rare instances an afebrile form with intestinal
s) r mptoms and eruption is seen.
In the ambulatoiy form, commonly called " walking typhoid/' the
patient, from ignorance of the gravity of his ailment or from apparent
necessity, keeps at his work until weakness and incessant headache lead
him to consult a physician in his office or at a dispensary. He may
then be well into the second week of the disease. The majority of
such cases prove fatal.
Grave forms are due to especial severity of some symptoms or group
of symptoms, such as hyperpyrexia ; profound stupor, coma, or intense
ataxia ; inability to take or retain sufficient nourishment ; profuse diar-
rhoea and intestinal hemorrhage ; great adynamia with weak heart and
a tendency to cyanosis. In other cases the gravity results from the
existence of complications.
In the malignant form there has been a large dose of the poison or
a very weak organism, or both, the result being an acute toxaemia; this
is not so common as in scarlatina and typhus fever.
In the pulmonary form the onset may be so obscured by severe
bronchitis or lobar pneumonia that the primary disease is not suspected
at first. Severe bronchitis seems to be more common in children.
Chill and initial high temperature are common in these cases.
Typhoid Fever without Intestinal Lesions. This rare form may
present the clinical symptoms of typical typhoid, or may be of spleno-
typhoid type, or of nervous type with extreme intoxication. The first
type is rare. The second type, described by Eiselt, is characterized by
an excessively large spleen, with local inflammation and remitting
fever. In the third class the symptoms of the typhoid state with sub-
cutaneous and visceral hemorrhage occur. Jaundice is more or less
common.
Complications and Sequelae. Typhoid fever may be accompanied
by a number of complications, the most frequent and important being
severe bronchitis, hypostatic congestion with oedema, and true lobar
pneumonia ; bed-sores ; parotitis ; phlebitis, especially of the femoral
vein ; peritonitis from perforation of the bowel ; meningitis, acute
mania, or mental decay ; jaundice ; myocarditis ; periostitis and oste-
itis. Secmelse are not frequent. Sometimes, however, the foundation
is laid for permanent ill health. There may be impairment of the
senses, mental weakness, and even insanity. Paralyses, neuritis, hyper-
esthesia, chorea, and epilepsy are occasional sequels.
Examination of the Blood. The infection is due to Eberth's
bacillus, the bacillus typhosus. The bacillus is found in colonies in
the spleen, liver, mesenteric glands, kidneys, and intestines. It is also
found in the feces and rarely in the urine. It may be seen in the
blood. It may be recognized by staining methods, although rarely.
It has been isolated from the blood successfully, by culture methods, by
Gwyn in a small number of cases.
Morphology. A bacillus 1 to 3// long by 0.5 to 0.8,« broad, with
rounded ends. It is motile, facultative anaerobic, does not liquefy
THE DATA OBTAINED BY OBSERVATION.
299
gelatin. It has flagella 3 to 5 times as long as the bacilli. It stains
with the anilines, best with Loffler's bine. The flagella are stained
by Loffler's special method. (See Plate III., Fig. 6, b.)
Fig. 72.
E
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Renal typhoid. Nephritis on the twenty-fifth day. Course of temperature during
three days preceding death.
Serum Diagnosis. This method of diagnosis has been more success-
fully employed in typhoid fever than in any other infection. The
methods have been previously described. The agglutinative reaction
takes place as early as the eighth day, rarely as early as the third day,
but sometimes not until the fifteenth or twentieth day, and even may
not occur until convalescence is established. By this means typhoid
fever can be distinguished from the infection due to the bacillus of
Gartner (bacillus enteritidis). (See Lancet, January 15, 1898.)
The paracolon bacillus infection, as shown by Gwyn (Bulletin of the
Johns Hopkins Hospital, 1898, vol. ix. No. 84), who studied a case
which resembled typhoid clinically, docs not give this reaction. Influ-
enza and Malta fever and forms of tuberculosis can also be distin-
guished from typhoid fever by this method.
LEUCOCYTOSIS. A determination of the number of leucocytes is of
value in the diagnosis of typhoid fever. It is one of the infections in
which leucocytosis docs not occur. In a differential count some varia-
tion from the normal is >w\\. The large mononuclear and transitional
forms are decreased ; the polvnuclear neutrophiles are decreased. The
absence of leucocytosis aids in distinguishing typhoid fever from vari-
ous septic fevers and acute inflammations. On the other hand, in a
300 GENERAL DIAGNOSIS.
case of typhoid fever if leucocvtosis occurs an inflammatory complica-
tion or mixed infection is possible. Perforation and peritonitis are
attended by leucocvtosis.
In addition to the absence of leucocytosis we find, after the second
or third week, gradual reduction of the red cells, and by the time con-
valescence is established a marked anaemia develops. Both the red
cells and the haemoglobin are reduced.
Culture Methods. The bacillus can be isolated from the blood, the
stools, and the urine.
Biological Properties. The bacillus grows readily in acid
media as well as in the neutral or alkaline media, best at a tempera-
ture of 38° C. Death-point, 60° C.
The colonies develop in twenty-four to forty-eight hours. On gela-
tin plates they are small and white, nearly spherical ; irregular, granu-
lar, and yellowish-brown.
In stab-cultures there is a whitish semi-transparent layer on the sur-
face, with sharply denned irregular edges, and along the puncture a
grayish-white growth. (See Plate VII., Fig. 5.) It develops abund-
antly in milk. On potato it forms an " invisible growth," manifested
only by increase in moisture, which is quite characteristic.
Bacteriological Diagnosis. It would be most desirable if a
means of diagnosis, that would have no element of uncertainty about
it, could be found. Bacteriologists have sought for such means, and
at present seem to have found two methods, one of which at least has
been brought to such a degree of perfection as to be of value to the
clinician. They are Eisner's culture and Pfeiffer's bactericidal serum
methods. Eisner's method 1 consists in the preparation of a culture-
medium upon which no species of micro-organism can grow except the
typhoid bacillus and the bacillus coli communis. For a description
of this complicated method the reader is referred to the recent works
on bacteriology.
Recently bacteriologists have been successful in isolating the typhoid
bacillus from the stools and the urine. Unfortunately, the methods
are too complicated for clinical work. P. H. His, Jr., recovered the
bacillus typhosus and distinguished it from members of the colon group
by a combined plate and tube method. 2
For differentiation of the typhoid from the colon bacillus the method
of Proskauer and Capaldi may be used. They employ two solutions.
In solution No. 1 the typhoid bacillus does not grow at all. The colon
bacillus grows rapidly, produces a marked acid reaction, and the blue
color gives way to red. Solution No. 2 both bacilli grow, but the
typhoid bacillus is the only one which gives an acid reaction. Note,
the solutions are neutral in reaction and colored with litmus.
Another method is that of Thoinot. He prepares a medium of
bouillon, to which he adds y^o P er cen ^- °f arsenious acid. On it the
typhoid bacilli do not grow, while the colon bacilli multiply rapidly.
1 Zeit. Hygien. und Infection kr. , B. xxi. H. 1.
2 P. H. His, Jr., "On a Method of Isolating and Identifying Bacillus Typhosus,"
etc. Journal of Experimental Medicine, vol. ii. No. 6, p. 677.
PLATE VII.
Fig. 1.
Fig. 2.
Fig. 3.
Streptococcus — Erysipelas. Streptoccocus Septicus.
Fig. 4. Fig. B.
Staphylococcus.
Fig. 6.
Diphtheria-bacilli.
I
Typhoid-bacilli. Tuberculosis-ijac illi.
THE DATA OBTAINED BY OBSERVATION. 301
Mark Richardson isolated bacilli in the urine of about 25 per cent.
of the cases of typhoid examined. They were present in large numbers
and in pure culture. They appeared late in the disease, and persisted
into convalescence. The bacilli were always associated with albumin
and casts. After disinfection of the meatus the urine is passed in two
portions into sterilized test-tubes. The second portion is used. It is
immediately plated upon plain agar. At the end of twenty-four hours
the characteristic colonies appear. Richardson relies upon the active
motility of the bacilli, which are set free in a typhoid colony by scar-
ring with a platinum needle to distinguish them from the colon bacilli.
He also used the dry serum reaction test. 1
Pfeiffer's method, while of interest and full of suggestions as to its
future usefulness, cannot be applied with sufficient ease to render it
practical for clinical work.
Inoculation. Thus far the results of inoculation have not proved
satisfactory, and are certainly not of diagnostic value.
Diagnosis. A typical case of typhoid fever ought not to be mis-
taken for any other affection, but atypical cases are numerous. The
most common sources of error are a hurried diagnosis and a willing-
ness to accept a demonstrable local affection as sufficient to account for
the condition. In this way the significance of bronchitis, pneumonia,
and diarrhoea is overlooked. In the symptomatic form there will
almost always be found a history of gradual onset and a degree of
fever and prostration greater than should attend the purely local affec-
tion. Moreover, in bronchitis and pneumonia, which are a part of
typhoid fever, there may be found tenderness with gurgling in the
right iliac region, enlargement of the spleen, and epistaxis, to aid in
the diagnosis ; while in cases in which the diarrhoea leads to uncer-
tainty, bronchitis, enlargement of the spleen, and epistaxis may coexist.
Examination of the blood, extended over a period of several days, i&
necessary to exclude the cestivo-autumnal type of malarial fever, which
often resembles typhoid fever.
New Diagnostic Sign of Typhoid Fevek. Dr. Simon Baruch
writes as follows : " As soon as the patient shows a rectal temperature
above 102.5° in the morning and 103° in the evening for three succes-
sive days, especially if this be accompanied by headache, dulness, or
apathy, he is placed in a full bath at 90°, which is reduced to 80°,
with constant friction over the body. In three hours, the temperature
still being above 102.5°, he receives another bath 5° cooler. This is
repeated until the temperature of the bath is 75°. If one or more of
these baths fail to reduce the rectal temperature 2° in half an hour, the
diagnosis of typhoid fever is almost certain, and the bath-treatment is
continued. The resistance of the rectal temperature to a bath of 75°
for fifteen minutes, with friction, is an almost certain tost of typhoid
fever." 2 Dr. Baruch considers that the diagnosis of this disease should
no longer be obscure, even in the first days of its course.
1 Richardson, M. W., "On the Presence of the Typhoid Bacillus in the Urine."
Journal of Experimental Medicine, vol. iii. No. 3, p. 349.
2 New York Medical Journal, September 2, 1893.
302 GENERAL DIAGNOSIS.
Appendicitis is more likely to be mistaken for typhoid fever than
the converse. There is usually a history of constipation, though the
occurrence of several inadequate movements a day may conceal the fact
that there is a fsecal accumulation. In appendicitis the onset is more
abrupt and the local symptoms more pronounced than in typhoid.
Pain and tenderness are prominent in appendicitis, and while they may
be general over the abdomen at first, they are found to be more acute
in the iliac region and loin. Here, in place of gurgling, we find some
increase of resistance on palpation, and a relatively dull note — a
wooden sort of tympany — or there may be a demonstrable tumor.
The patient lies with the right leg drawn up, has moderate fever, and
vomiting. In fact, the attack is often introduced by chilliness and
vomiting. Headache is not a prominent symptom, while bronchitis
and enlargement of the spleen are absent.
Acute right-sided salpingitis simulates typhoid fever. It is distin-
guished by the history of a preceding vaginitis, endometritis, or abor-
tion, by the absence of diarrhoea, of enlargement of the spleen, and of
the characteristic eruption. A digital examination through the vagina
discovers the womb pressed to one side and fixed, and a tender mass
blocking up the pelvis.
Simple continued fever is distinguished from typhoid fever of a mild
type principally by the absence of bronchitis, of enlargement of the
spleen, of epistaxis, and of the characteristic eruption of typhoid fever.
In simple continued fever constipation is more common than looseness
of the bowels, and gurgling is absent.
Typhus fever is distinguished by its sudden onset, the besotted ex-
pression of the face, with reddened eyelids and small pupils, the
absence of abdominal symptoms, and the occurrence on the fourth day
of maculae, which are subsequently converted into petechia?. It is of
shorter duration, and terminates very abruptly by crisis.
Relapsing fever differs from typhoid fever in its sudden onset with
chill, pain in the epigastrium, but absence of abdominal symptoms and
eruption ; in the absence of marked nervous symptoms, in spite of the
high fever ; the short duration and termination by crisis, and the char-
acteristic relapse at the end of a week. The conclusive test is finding
spirilla in the blood.
Acute tuberculosis of the lungs, at times, closely resembles typhoid
fever. In both the onset is gradual, with cough and fever. In the
former, however, the bronchial symptoms are more prominent, there
are apt to be recurring chills and sweats, the temperature is remittent
and irregular, emaciation is rapid, and constipation instead of diarrhoea
is the rule.
In peritoneal tuberculosis there is persistent diffused pain hi the
abdomen ; the belly is swollen. If effusion occurs, the physical signs
disclose its presence. The temperature is irregular and may be below
normal ; nervous symptoms comparable to those of typhoid are
wanting.
Meningitis before the stage of effusion exhibits exaggeration of the
reflexes and marked hyperaesthesia. There may also be muscular
rigidity. The patient is restless, easily annoyed, and " fussy " about
THE DATA OBTAINED BY OBSERVATION. 303
things that would be unnoticed by a typhoid patient. Vomiting is
often present, whereas it is rare in typhoid fever. The temperature
does not maintain so high an average range as in typhoid fever, and is
subject to greater oscillations. The pulse varies greatly, and may be
irregular.
In' septic meningitis the headache and vomiting are more persistent,
the bowels are confined, and the abdominal walls are retracted. There
may be double optic neuritis. In tubercular meningitis the knee-jerk
and other reflexes are variable, irregularly absent or present. In
typhoid fever they are always present. In the former choroidal tuber-
cles may be seen with the ophthalmoscope. In tuberculosis in all
forms leucocytosis is present ; in typhoid it is absent. Typhoid fever
must not be confounded with trichiniosis ; the peculiar muscular pain
and oedema do not occur in the former. TJrcemia may simulate typhoid
fever when it becomes chronic ; but the age, the character of the urine,
the cardio-vascular symptoms, are diagnostic, and, with the absence of
the specific typhoid symptoms, render the diagnosis easy.
Mountain Fever is an infection which has been described as pecu-
liar to the mountains of our Western States, characterized by a con-
tinued fever with intestinal symptoms not unlike those of typhoid
fever. Irregularity of the temperature-range and the occurrence usually
of constipation rather than diarrhoea make it difficult to classify the
infection from typhoid fever on the one hand and from forms of ma-
laria on the other. Recent observations of Woodruff, who studied the
serum reaction in a large series of cases, show conclusively that the
infection is typhoid fever, confirming the prior observations of Hoff,
Smart, and Raymond.
Yellow Fever.
The infection which we are about to consider is the latest of the
epidemic and contagious disorders for which a definite causal micro-
organism has been discovered. It is an acute, specific, contagious,
miasmatic disease, endemic and epidemic on the tropical and subtropi-
cal shores of the Atlantic Ocean, characterized by a sudden onset, a
duration of a week or less, a characteristic facics, a fall in the pulse-
rate preceding a fall in temperature, and by albuminuria, jaundice, and
vomiting, with a tendency to hemorrhages. The specific micro-organ-
ism is the bacillus icteroides described by Sanarelli.
Yellow fever is endemic in Havana and other seaport cities of Cuba,
and in Rio Janeiro, Brazil. From these centres it is liable to become
epidemic, and to be carried in ships and by persons and clothing to
other places. In this way epidemics have developed in the seaports
of the United States, especially iu the south around the Gulf of Mexico,
but sometimes as far north as Philadelphia and New York. The
disease becomes epidemic; in the hot season and ceases upon the appear-
ance of frost. The specific germ lias not yet been isolated.
In countries in which the disease is endemic it is the custom to
regard the native children as immune. Dr. John Guiteras, however,
is strongly of the opinion that the disease is kept alive between epi-
demics by cases among these children. He lias also shown that it
304 GENERAL DIAGNOSIS.
prevails among white children before it becomes epidemic among
adults.
The period of incubation varies from a few hours to two weeks.
Guiteras states that the cases in which it extends beyond the seventh
day are exceptional.
The invasion is abrupt, and occurs usually in the night. It is marked
by chilliness oftener than by a decided chill. The temperature rises
rapidly to 102° to 103° or 104°, not often higher in favorable cases.
The pulse is correspondingly increased in frequency at first, but very
commonly begins to fall before the temperature, so that later the pulse
is relatively slow. The face is peculiar and characteristic — it is flushed
and somewhat swollen ; the eyelids are somewhat swollen, with red-
dened edges ; the eyes are watery, glistening, and slightly but dis-
tinctly tinged with yellow ; the pupil is small and brilliant. Guiteras
says : l " The appearance of the face is often sufficiently characteristic
on the first day of the disease to warrant a positive diagnosis." " The
early manifestation of jaundice is undoubtedly the most characteristic
feature of the facies of yellow fever." He also says that these phe-
nomena are often better observed at a slight distance than on close
inspection.
The tongue is large, moist, and coated with white fur. The stomach
is irritable and the epigastrium tender. Nausea with repeated vomit-
ing occurs. The fluid is at first of a light greenish-yellow, subse-
quently becoming decidedly bilious. The bowels are constipated.
The urine almost invariably contains albumin at some time during
the first three days. Its presence may be very transient. It may be
found in the evening and not at other times. The amount of albumin
is sometimes very large, and abundant blood and tube-casts are found.
The nephritis subsides rapidly, without leaving traces. The urine
is acid in reaction and scanty in amount. It is sometimes suppressed.
During this febrile period the patient complains of headache, pains
in the back and limbs, and intense thirst. The mind, however, is
usually perfectly clear. Contrary to expectation, Guiteras asserts that
the nervous symptoms are, perhaps, more prominent in the adult than
in the child. " The loquacity, the short-cut phrases and precipitate
speech, the excitement, the show of indifference with unmistakable evi-
dences of fear — all these, that are such prominent features of the dis-
ease in the adult, are absent in the young." 2
In from two to five days the temperature falls to or below normal,
headache and pains in the limbs disappear, and the patient is cheerful
and thinks himself convalescent. This is the fact in mild cases, but
in more severe cases the period of remission or stage of calm is followed
by a return of symptoms in a few hours or at most a day or two. The
jaundice deepens, vomiting becomes more urgent and in adults is accom-
panied by much retching. It is bilious, streaked with blood, or thick
and wholly black (" black vomit ") ; the temperature may rise again
1 "Report of the Surgeon-General of the Marine-Hospital Service, 1888 ;" Keat-
ing's Cyclopaedia of Diseases of Children, 1889, vol. i.
- Keating's Cyclopaedia, loc. cit.
THE DATA OBTAINED BY OBSERVATION. 305
as high as, or higher, than in the original paroxysm, or it may remain
depressed. In any event the pulse is apt to be slow, often from 40 to
60. The urine contains albumin, blood, and casts, and may be sup-
pressed, adding uraemia to the other toxaemia. Convulsions at this
stage are usually ursemic. Hemorrhages may occur from any mucous
surface. The gums are tender, swollen, and bleed easily. There may
be epistaxis, hemorrhage from the ear, bowel, uterus, or vagina. Preg-
nant women miscarry. Ecchymoses also may form. Death may take
place in coma or convulsions. If the patient lingers beyond the fifth
or sixth day he sinks into a typical typhoid state, with diarrhoea and
marked adynamia, from which he may or may not emerge.
As in scarlet fever, the patient may be smitten down and die in a
few hours from the time he was in apparent health. In other grave
cases the temperature remains high, and rises instead of falls on the
third or fourth day. The duration of the disease is from two to five or
six days ; if a typhoid state develops, it may last ten days or two weeks.
Complications are not common. Phlebitis and lymphangitis occur,
and Guiteras says he has noticed hepatitis, insanity, and paralysis
(probably from neuritis). Second attacks are extremely uncommon.
Examination of Blood. The bacillus icteriodes is a slender rod
from two to four micromes in length. It is ciliated and motile. By
staining a drop of blood with Gram's method it is seen in more than
half the cases.
Sebum Diagnosis. Woodson and the Archinards have found agglu-
tination to take place in a large proportion of cases of yellow fever.
The blood, taken as early as the second day, gave a prompt reaction in
from 75 to 80 per cent, of all cases. Dilutions of 1 to 40 were used,
but reaction took place in dilutions as low as 1 to 5. Pothier and
Lerch report successfully upon this reaction. Cultures from the blood
produce an organism which grows on ordinary media ; does not coagu-
late milk, but ferments saccharine fluids.
Inoculation. Inoculation of dogs and monkeys produces a clini-
cal picture similar to the original infection.
Diagnosis. Yellow fever is distinguished from pernicious malarial
fever by the slow pulse, the characteristic facies, the early transient
albuminuria, the deep jaundice, the absence of diarrhoea, the occur-
rence of black vomit, the tendency to hemorrhage, and the clear mind.
If it is not practical to make a diagnosis based upon an examination
of the blood, the three important characteristics which Guiteras laid
stress upon must be borne in mind in addition to the usual data secured
for the purpose of determining the presence of an epidemic and conta-
gious disease. The three diagnostic points of Guiteras are the facies,
the albuminuria, and the slowing of the pulse, with continuance or in-
creaseof the fever. By these means the affection must be distinguished
from dengue and from various forms of malarial fever, especially the
; est i v< t-autumnal infections.
Malta Fever.
Malta fever is a remarkable infection which seems to prevail within
the limits of the Mediterranean. It is an infection characterized by
20
306
GENERAL DIAGNOSIS.
gradual onset and by repeated remissions of the fever. The alternating
febrile and afebrile periods which characterize the disease continue
from two months to two years. The most remarkable feature is the
;fi
-Iffi
js
H i "i : ;i i H. i iii!^ r 1'T f :
S 3 S 5
m
THE DATA OBTAINED BY OBSERVATION. 307
peculiar character of the temperature-range, which consists of intermit-
ting waves or undulations of fever of a distinctly remittent type.
These periods of fever last from one to three weeks, followed by an
apyretic period or a period of abatement lasting from two to ten days.
The daily temperature-range may be intermittent or remittent. The
febrile course may continue six months or more. During this time
patients grow more and more prostrated, become anaemic, and usually
suffer from constipation. Profuse sweats attend the decline of the
daily range, and in many instances we find enlargement of the spleen.
Neuralgias occur in various parts of the body ; the joints become en-
larged, and fibrous tissues may be the seat of inflammation. Hughes
— who describes the disease most accurately — describes a malignant
type lasting a week or ten days, and an undulatory type continuing
for weeks or months. Indeed, the relapses are known to occur over
a period of two years. The third is known as the intermittent type,
in which there is a daily rise of temperature without other marked
symptoms. The undulatory type is the most common variety. The
infectious micro-organism is the micrococcus melitensis.
Diagnosis. The occurrence of fever described above in the coun-
tries bordering upon the Mediterranean, whether epidemic or endemic,
should always suggest Malta fever. The possibility of its occurrence
in other tropical countries, as in the islands of the Caribbean Sea, must
not be forgotten. A positive diagnosis is made by exclusion of all
forms of malaria by an examination of the blood, and of typhoid fever
by finding the bacillus typhosus in the urine or stools of the suspected
patient. The micro-organism has not been isolated from the blood,
but the serum reaction is a valuable means of diagnosis. (See page 233.)
This reaction is performed as in cases of typhoid fever. The culture
must be carefully selected. With a 1 to 10 or 1 to 50 dilution aggluti-
nation takes place when the serum of a patient with Malta fever is
used. The serum of such a patient does not have any effect upon
the typhoid bacillus nor upon other organisms. Aldrich states that
the first reaction occurs about the fifth day.
Gonorrhceal Infection.
Although the infection is usually limited to the genito-urinary tract,
it is well known that the gonococcus may enter the blood and infect
tissues elsewhere, causing a local inflammation. We therefore see
symptoms due to the primary infection ; symptoms due to the infection
of the genito-urinary organs by direct continuity, and systemic infection.
The primary infection involves the adnexre of the genital organs in the
male and the female. Salpingitis, metritis, and ovaritis in females,
with the occurrence occasionally of peritonitis, arise from spreading by
continuity. In both sexes cystitis, ureteritis, and pyelitis occur. The
infection is usually mixed.
When the gonococcus invades the blood, symptoms of septicaemia or
pyaemia arise. The infection may be rapid and fatal, and may termi-
nate ten days after the primary lesion. The occurrence of such general
infection is suspected when the history of the primary infection can be
308 GENERAL DIAGNOSIS.
secured, and in addition the micro-organism can be recovered from the
blood, as was successfully done by Thayer.
In other infections the joints become involved and we have the
phenomena of gonorrheal rheumatism (see Joints), the course and
symptoms of winch are discussed elsewhere. Endocarditis may result
from gonorrhoeal infection, and can only be distinguished from other
forms of endocarditis by the history and the finding of micro-organ-
isms in the blood. Myocarditis (Councilman) and pericarditis may
also occur.
Diagnosis. Thayer and Blumer and Thayer and Lazear have suc-
ceeded in recovering the gonococcus from the blood in this form of
septicaemia. The blood is withdrawn from the median basilic vein by
a sterilized syringe. A large quantity is secured. It is mixed with
melted agar and immediately plated. The medium should contam
at least one-third blood. This is practically the medium which Wer-
theim recommends. After forty-eight hours colonies appear half the
size of a pin-head, granular, but with irregular borders. Cover-slip
preparations of the colonies, if the case is gonorrhoea, will show the tinc-
torial and morphological characteristics of the gonococcus. (See Plate
III., Fig. 3, B. The diagnosis is further established by finding the
gonococcus in any purulent discharge, as of the urethra or vagina. (See
Chapter XXI. — Exudations, etc.)
CHAPTER XX.
THE DATA OBTAINED BY OBSERVATION— (Contin ued).
FEVER. THE INFECTIOUS DISEASES.
Infections Recognized by the Examination of Excretions and
Secretions or by the Products of the Infectious Inflammation.
The following infections are disclosed by the examination of the
products of the infection found in the inflammatory areas (pus) ; in
the excretions and secretions of the body ; in the sputa ; in the voni-
itus ; in the fseces or in the urine. The reader should refer to the
sections describing the method of the examination of pus, sputum,
and secretions bacteriologically. They are as follows : Erysipelas,
pneumonia, tuberculosis, influenza, cerebrospinal meningitis, diphtheria,
septico-pycemia, glanders, cholera Asiatica, dysentery, bubonic plague,
leprosy, actinomycosis, tetanus, trichinosis.
Erysipelas.
The fever of this infection, particularly in a first attack, is very
marked. It rises suddenly to a considerable height and may antedate
the eruption. It resembles the course of a pneumococcus infection.
It is an acute, specific, contagious, and infectious disease, character-
ized by a sudden onset, with a bright-red eruption, which usually begins
on the face near the nose or mouth and spreads over the entire face
and scalp. It is attended with burning heat of the skin and great dis-
figurement from swelling.
The specific cause of erysipelas is the streptococcus erysipelatosus.
It is carried to a slight extent by the air, and still more in the dis-
charges, especially those of the nose. Repeated attacks occur in per-
sons with chronic nasopharyngeal catarrh, carious teeth, or a sinus. It
is apt to attack persons with open wounds (surgical erysipelas), and
puerperal women, producing in these cases sloughing and septicaemia.
One attack does not protect against another ; on the contrary, if there
is any focus in which the streptococci linger, one attack actually pre-
disposes to another.
The period of incubation is usually from three days to a week. On
close inquiry a history of sore-throat and some enlargement of the
cervical lymphatics is usually found to precede an attack of facial
erysipelas. The invasion is sudden and is marked by chill. The tem-
perature rises to 104° or 105°, and in the next two or three days may
rise still higher.
Coincident ly with the rise in temperature the portion of the shin to
be affected burns, tingles, is tender to the touch, and may be seen to be
310 GENERAL DIAGNOSIS.
reddened. The redness increases in intensity and extent, while the
skin is swollen and slightly cedematous. The part of the face to be
affected is usually the cheek in close proximity to the nose, less fre-
quently near the mouth and ear. Vesicles and blebs often form when
the inflammation is very intense. The redness disappears upon press-
ure, but quickly returns ; sometimes it has a dusky, purplish hue.
A marked characteristic of the disease is its tendency to spread. In
ordinary cases it involves one cheek, eyelid, and ear, and travels across
the bridge of the nose to the other side. The inflammation is most
intense when it is spreading ; the advancing margin is raised, tense,
and brawny ; the line is thus sharply drawn between healthy and in-
flamed tissue. The loose tissue about the eyes swells enormously, both
eyes are closed, the entire face swollen, red, and disfigured with vesi-
cles and blebs here and there. Curiously the chin escapes. The red-
ness and swelling begin to subside in the part first attacked, before the
process has reached its height on the opposite side. As a rule, facial
erysipelas does not extend beyond the face, the scalp and neck being
spared. The scalp, however, is more frequently affected than the
neck ; occasionally erysipelas leads to extensive cellulitis of the scalp,
with the production of a septic constitutional condition and much
local sloughing. The submaxillary glands are more or less enlarged,
sometimes so much so as to prevent the taking of solid food.
When on the body the eruption spreads over a greater extent than
when primary on the face, hence its name, " the red runner." It may
pass from the heel to the thigh, and over the trunk, lasting for weeks.
"While the erysipelas is extending the fever continues, and is some-
times alarmingly high. The pulse is frequent and soft. Leucocytosis
is present. Xocturnal delirium is not uncommon in severe cases, and
sometimes nausea and vomiting are frequent. The bowels are usually
constipated. The urine is high-colored, frequently contains a small
amount of albumin, and actual nephritis sometimes occurs.
In favorable cases of facial erysipelas the process is at an end in
a week or less. It may be prolonged to two weeks, subsiding by crisis
or lysis, and convalescence is usually rapid. The vesicles or bulla? dry
up into yellowish crusts and the epiderm is shed in large or small
pieces according to the intensity of the process.
Pneumonia and nephritis are the most frequent complications. Men-
ingitis, pericarditis, and endocarditis also occur. Erysipelas may extend
inward and involve the fauces, pharynx, and larynx, producing oedeina
and death from suffocation.
Sequelae. If the scalp has been involved the hair falls out. The
cervical adenitis may result in abscess ; chronic nephritis may result.
Otitis media occurs occasionally, and so do keratitis and abscess of the
eyelids.
* On the other hand, erysipelas is credited with causing the disappear-
ance of lupus, chronic eczema, and sarcomata.
Diagnosis. Bacteeiological Diagnosis. Examination of pus
or discharge from the nose or thorax will disclose the presence of the
streptococcus. (See Plate TIL, Fig. 1. and Chapter XXI.)
Herpes zoster of the face and forehead is distinguished from erysipelas
THE DATA OBTAINED BY OBSERVATION. 31 1
by the fact that vesicles appear first, followed by erythematous redness,
and that they are limited by the median line, and are preceded and
accompanied by sharp neuralgic pain, whereas erysipelas affects both
sides of the face, and vesicles appear at the height of the disease ; the
pain is much less in erysipelas. It is distinguished from dermatitis of
various kinds mainly by the sharper febrile reaction, the raised border
of the eruption, which begins on one side and spreads to the other.
Erysipelas is rarely equally intense upon the two sides. Dermatitis
frequently is. The latter often exhibits a rough surface, whereas, until
vesicles appear, erysipelas is smooth and shiny.
Chronic erythematous eczema occurs in the middle-aged and old per-
sons, is afebrile, accompanied by little swelling but a great deal of
itching, and runs a slow course.
Lobar Pneumonia.
The Pneumococeus Infections. In typical cases of the infection we
are about to consider the course of the fever is of great diagnostic sig-
nificance. Its sudden rise to a great height, preceded by a rigor, is of
itself suggestive. During the succeeding days of the disease the morn-
ing and evening temperature varies but little. When associated with
hurried respiration and the intoxication symptoms attending this infec-
tion, even though no physical signs are present in the lungs, pneumonia
can reasonably be suspected. The termination of the febrile course is
characteristic of the infection. The sudden fall to normal or a subnor-
mal temperature — known as the crisis — brings to an abrupt end the
usually alarming symptoms.
Acute pneumonia, croupous or lobar pneumonia, is an infectious
inflammatory disease excited by the micrococcus lanceolatus (diplococ-
cus pneumonia?, pneumococeus) involving the vesicular structure of the
lungs, and followed by choking of the alveoli with the products of
inflammation ; it is attended by severe constitutional symptoms due to
the toxines of the infecting organism.
Symptoms. Mode of Onset. The invasion of pneumonia is usually
sudden, and is marked by a chill. The temperature rises rapidly, and
may reach 104° or 105° in the first twelve hours after the chill. With
the fever, the patient complains of severe headache and pain in the
side, and has a short, quick cough and sometimes vomiting. The pulse
is moderately accelerated, and the respiration either is or soon becomes
very frequent. The face is apt to be flushed, and there may be a circum-
scribed red spot on the cheek. The skin is hot and dry. On physical
examination, within the first twenty-four hours, a small patch of con-
solidation is detected, which may subsequently extend over a large
area.
While this i> the picture of an ordinary pneumonia in its early stage,
all cases are by no means so clear. In some the course resembles that
of a general fever in which the pulmonary disease is a local manifesta-
tion. In such cases there may be prodromata, consisting of headache,
general malaise, a slight bronchitis, and digestive disturbance. Then
follows the chill. Central 'pneumonia. The fever may he high for
312 GENERAL DIAGNOSIS.
several days before there is any discoverable consolidation of the lungs,
and during this time cough may be wholly, or almost wholly, absent.
The respirations increase gradually in frequency, and finally a well-
marked pneumonia can be made out. It is customary to account for
these cases by the supposition that pneumonia developed in the interior
of the lung and consolidation gradually extended to the surface. In
some cases the patient presents no more definite symptoms for three
or four days than high fever, intense headache, and moderately accel-
erated respiration.
Later Stages. At the end of forty-eight hours, or, at the most,
of four days, the patient is found lying in bed in the dorsal position,
or on the affected side. The face is flushed, and countenance anxious,
the respiration hurried, the alse nasi play vigorously. The tempera-
ture varies little from the first day's rise ; the chest pain has subsided,
and the short, dry cough is now attended by viscid expectoration. The
respiration continues hurried, the pulse full and bounding. During
this time the physical signs of consolidation continue and increase.
After a period of five to ten days the termination takes place by
crisis, the pain in the chest abates, the cough becomes looser, and the
expectoration more free, but the other symptoms persist. In addition,
in some cases, delirium occurs, the pulse softens and becomes dicrotic,
the urine becomes albuminous.
Respiratory Symptoms. Chest-pain, cough, hurried respiration
of a peculiar type, and expectoration are characteristic. The chest-
pain is sharp and stabbing or lancinating. It is increased by breath-
ing. It is seated about the nipple or in the axillary region, at the
angle of the scapula or below the diaphragm. Its seat always indicates
the side affected. Cough is short and dry, smothered and painful ;
it soon becomes softer and painless as the expectoration becomes free.
It may be absent in the feeble, in the aged, in alcoholic subjects, or in
persons with brain disease, including insanity.
Characteristic symptoms of pneumonia are the increased frequency
and the type of the respiration. The rate in adults reaches 40, 50, or
even 60 per minute, and in children 80 and 100 are not very un-
common.
The pulse, on the contrary, does not increase in frequency in the
same proportion ; hence, the normal ratio of respiration to pulse of 1
to 4 ceases, and becomes 1 to 3 or 1 to 2.
Inspiration is short, expiration quick and often attended by an expi-
ratory noise or grunt. The long pause may take place after inspira-
tion instead of expiration. In children both are so short that unless
the epigastrium is inspected it may be difficult to distinguish the two.
In ordinary cases which run a normal course the cough is followed
by expectoration, which is at first viscid mucus, but gradually becomes
reddish-brown from admixture of blood — the rusty sputum of pneu-
monia. This sputum is characteristic, almost pathognomonic. It is
expelled with difficulty from the mouth, clinging to the lips or to the
mustache. It cannot be removed from the spit-cup by turning it
upside down. It continues to be rusty, and as the crisis approaches
becomes purulent and is discharged with ease. In typhoid pneumonia
THE DATA OBTAINED BY OBSERVATION.
313
it looks like prune-juice (See Sputum.) It contains blood, alveolar
epithelium, the specific micrococcus, and later pus and small fibrinous
casts.
Fig. 74.
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Pneumonia from first day. Pseudo-crisis on fourth day. Crisis began on fifth.
314 GENERAL DIAGNOSIS.
The Fever. The chill that precedes the fever is pronounced and
is always a warning to look for a pulmonic inflammation. In children
a convulsion is rarely absent in frank pneumonias. During its occur-
rence the body-temperature rises. In twelve hours it reaches 104° to
105°. (See Figs. 74 and 75.) It remains at this point, obeying the
laws of diurnal variation. The hot, dry skin, the parched lips, the dry
tongue, the thirst, the anorexia, the hurried breathing, the occasional
delirium, the loaded urine attest its presence. At the end of the third,
or more frequently the fifth, seventh, or ninth day, crisis takes place ;
the fall is abrupt, and the normal or a subnormal temperature may
be reached in from five to fifteen hours. Pseudo-crisis, as the accom-
panying chart indicates, may precede the true crisis by twenty-four or
forty-eight hours. The decline may take place by lysis, however. Pro-
tracted fever indicates delayed resolution or the occurrence of a compli-
cation.
Cerebral Symptoms. In some cases, especially in children, the
onset of the disease may be marked by a convulsion. This is said to
occur more frequently in apical pneumonias than in pneumonias of the
base. Headache and delirium are so pronounced in some cases as to
simulate meningitis. This is most likely to be the case in severe apical
pneumonia in children, and in double pneumonia either in children or
in adults.
Delirium may occur during the height of the fever, and occasionally
is maniacal. Xocturnal delirium may be a constant symptom in very
grave cases. In drunkards it may simulate delirium tremens, and
may be pronounced, without much fever. In the later stages of grave
or fatal cases a low form of delirium, with a tendency to coma, is
common.
The Heart and Pulse. The pulse is small at the time of the chill,
but becomes full and bounding during the fever ; later it may become
dicrotic. The pulse-respiration ratio has been referred to. The pulse
varies in frequency and in character with the type of the disease. In
healthy adults it is rarely over 110. In the debilitated it may be very
frequent, small, and feeble ; in the aged, frequent and dicrotic. Exten-
sive consolidations reduce the amount of blood in the general circula-
tion, cause rapid action of the heart and a small pulse, and favor death
with the heart in asystole.
The heart-sounds are clear. A murmur low in pitch is often heard
in the mitral and pulmonary areas. The left ventricle acts forcibly.
The pulmonary second sound is accentuated. If dilatation and failure
of the right heart takes place, the area of dulness may extend beyond
the right edge of the sternum, an epigastric impulse be noted, tur-
gescence of the veins in the neck become marked, but, above all, the
previously accentuated pulmonic second sound may become weak or
disappear.
Gastro-intestinal Symptoms. Vomiting frequently occurs in chil-
dren at the onset, and both in them and in adults may persist and mask
pulmonary symptoms. The appetite is lost. The tongue is furred.
It may become dry and brown. The bowels are constipated except
when complications occur. The spleen is enlarged. The vomiting and
THE DA TA OBTAINED B Y OB SEE VA TIOX. 31 5
epigastric pain may be so pronounced as to mask the pulmonary symp-
toms. The occasional presence of jaundice has caused it to be mistaken
for hepatitis, congestion of the liver, and even for gallstones. I saw
a case of pneumonia, said to be appendicitis and peritonitis because of
the characteristic pain, colic, and vomiting, followed by great abdomi-
nal tenderness hi the upper abdomen.
The Blood. Leucocytosis is a marked accompaniment of pneumonia,
especially in cases ending favorably. The white cells mav be increased
from 12,000 to 40,000. They fall with the crisis, or probably a day
after the termination of the fever. In malignant forms there may be
no leucocvtosis. Increase in the fibrin network causing the " buffv
coat " of older writers is commonly seen.
Cutaneous Symptoms. Herpes on the lips, the nose, or the geni-
tals is of common occurrence. Sweating occurs with the crisis, or if
heart failure is imminent.
The Urine. The urine is scanty and high-colored, and may contain
a small amount of albumin. In some cases the chlorides are found to
be absent. This is determined by acidulating the urine with a drop
or two of nitric acid, and then adding one or two drops of a 10 per
cent, solution of silver nitrate. If chlorides are present a heavy white
cloud of chloride of silver is thrown down. The chlorides are not
invariably absent, or even diminished in pneumonia, hence their reap-
pearance, which is said to indicate beginning convalescence, loses its
value as a prognostic sign.
Physical Signs. (See Diseases of the Lungs, Plate XIX.) Con-
solidation. Diminution in the amount of air, increase of solid con-
tents. On inspection, diminished movement. If extensive consolidation,
enlargement of the affected side. On palpation, inspection confirmed
and increased vocal fremitus discovered. Both are more marked at the
height of consolidation. Percussion. In first stage, impaired resonance
or Skodaic resonance. In stage of hepatization, dulness or flatness, but
without any wooden quality or marked resistance.
Auscultation. In the early stage, that of congestion, the respira-
tory murmur is suppressed and crepitant rales are heard at the end of
inspiration. On full inspiration or after cough a broncho-vesicular
respiration is brought out. When consolidation has taken place the
respiratory murmur is bronchial. Rales, if present, are moist snbcrep-
itant rales from associated bronchitis, or a few crepitant rales may still
persist, and a friction-sound be heard.
When resolution sets in the crepitant rale reappears, quickly followed
by moist subcrepitant rales, heard both on inspiration and expiration,
while dulness gradually yields to impaired resonance. The respiration
loses its bronchial character and again acquires a vesicular element
before becoming completely normal. It may be a week or two, <>r
many months, even in uncomplicated cases, before the percussion-note
becomes perfectly clear, and rales wholly disappear.
The physical signs are modified by the intensity of the inflammation
in the lung structure and by the pleural complications. In massive
pneumonia, for instance, the auscultatory signs are absent. On percus-
sion, the lung is absolutely flat. There i- no fremitus or tubular breath-
316 GENERAL DIAGNOSIS.
ing. The physical signs resemble those of pleurisy with effusion. In
the central pneumonia the physical signs may be delayed until the third
or fourth day. A few rales or febrile breathing oyer a small area inay
be the only indication of a possible lung process. In the aged the
physical signs are obscure. In patients with laryngeal disease or marked
obstruction in the nasopharynx the physical signs may be indefinite.
Bronchial breathing may not be heard unless the patient takes a full
breath or coughs. In this class of cases, as well as those with feeble
respiratory moyement, as the aged, the Aveak, and those suffering from
some other disease, as tuberculosis, the physical signs are not made out
because of the deficiency of respiratory movements. The mdefiniteness
of the physical signs makes the diagnosis all the more difficult, because
it is this class of subjects in which the general symptoms of infection
are very slight. Increased respiration may be the most suggestive
sign. Slight elevation of the temperature and more or less stupor may
be the only other clinical symptoms.
Duration and Course. The duration of the disease is from one to
two weeks. It may subside by crisis on the third, fifth, seventh, or
ninth day, or gradually by lysis. Crisis is marked by a critical sweat,
a copious discharge of limpid urine, or sometimes by a few loose move-
ments of the bowels, accompanying a fall of temperature to or below
normal.
Instead of clearing up, the pneumonia may progress to suppuration,
abscess, or gangrene. These conditions can be made out by the char-
acter and range of temperature, the general condition of the patient,
the sputum, and the physical signs. Termination in abscess or gan-
grene is rare.
In cases proceeding to a fatal issue the strength fails, respiration
becomes more labored, and expectoration increasingly difficult. The
number of respirations often diminishes, but the pulse continues fre-
quent and often becomes small and irregular. Physical examination
shows diffuse bronchitis with oedema. The heart's action is irregular
and rapid. The sounds are weak and feeble ; the first becomes short
and snappy like the second, and later both are weak or indistinct. Death
may occur abruptly from convulsion, or more frequently from asphyxia,
due to oedema of the lungs, which in turn sets in on account of weak-
ness of the heart or the development of heart-clot from cardiac asystole.
Varieties. Migratory pneumonia. Sometimes, with the reappear-
ance of abundant rales and increased expectoration, the fever continues
high, or, if the temperature has fallen to normal, again rises, the
patient is disinclined to take food, has a dry, brown tongue, and is often
delirious. In such cases the pneumonia is probably extending in the
lung already involved, or has attacked the other lung.
Typhoid pneumonia is an unfortunate name for an adynamic form of
the disease with typhoid symptoms. If it arises in the course of or
complicates low fevers, it is usually of the typhoid type ; but it occurs
also in those much exhausted, in depraved health, or exposed to unhy-
gienic surroundings. It is found also in cases of septicaemia, in Bright' s
disease, in drunkards, and in the negroes in the southern part of the
United States.
THE DATA OB TA INED B Y OBSEB VA TION. 3 1 7
The characteristic features of this form of pneumonia are the great
physical prostration and the weak heart-action. The fever is high, the
respiration and pulse frequent, and delirium and vomiting are more
frequent than in the ordinary form. The skin sometimes has a dusky
hue ; the tongue is heavily coated, or may be dry and brown, and
sordes collect on the teeth. The sputa may be rusty, and sometimes
pure blood is expectorated. The disease may prove fatal rapidly, or
may linger for a long time, the patient only gradually coming out of
a low typhoid state. It is always dangerous.
Bilious pneumonia is the name given to a type of pneumonia occur-
ring in persons who are already suffering from malarial poisoning.
The initial chill lasts longer, and the pain in the side, from coincident
pleurisy, is more marked that in ordinary pneumonia. The fever is
more remittent, and jaundice and vomiting are present.
Pneumonia in infants is characterized by nervous symptoms. Re-
peated convulsions and active delirium may be most pronounced, fol-
lowed by torpor and coma. There is no sputa and but little cough.
The apex of the lung is affected.
Pneumonia in the aged is characterized by latency of symptoms.
There is but little cough and expectoration. A tendency to the typhoid
state, however, is pronounced. The physical signs are obscure.
Pneumonia in alcoholic subjects also develops insidiously and may be
masked by the symptoms of delirium tremens. The temperature may
be the only indication of infection, as there is no pain, no cough, no
expectoration, and no dyspnoea.
Pneumonia ivith Other Infections. The staphylococcus and strepto-
coccus pyogenes, the colon bacillus, and the bacillus pneumonia? (Fried-
lander) are often found with the pneumococcus, and may predominate,
inducing a mixed infection. The micro-organisms which cause diph-
theria, typhoid fever, influenza, and the plague may cause a pneumonia
which resembles that of lobar pneumonia in the extent of the consoli-
dation. The micrococcus lanceolatus is found in increased numbers in
the sputum of these cases. There is not the same intensity of pulmo-
nary symptoms, however. The respirations are not so hurried. The
physical signs, while extensive, are obscure, and indicate rather a heavy
lung (congested) than one greatly consolidated. There is impaired reso-
nance, feeble breathing, and a few rales in a large number of cases.
It is this form of lobar pneumonia which it is difficult to distinguish
from bronchopneumonia or catarrhal pneumonia — an infection which
usually begins in the upper air passages. This form of local infection is
considered in the chapter on diseases of the lungs.
Diagnosis. The diagnosis is based upon the aggregation of special
symptoms. The mode of onset, the chill, the course of the fever, the
pain in the chest, the cough, the peculiar expectoration, the dyspnoea,
the abnormal pulse-respiration ratio, the peculiar character of breath-
ing, the physical signs, and leucocytosis are the phenomena of the symp-
tom-complex. It must be remembered that in children, in the aged, in
drunkards, in cases of chronic disease, the type is different. In drunk-
ards cerebral symptoms are more marked. In children the cerebral
symptoms are more prominent, the expectoration often absent. In the
318 GENERAL DIAGNOSIS.
aged, the cough, the expectoration, and the fever are not pronounced ;
the former may be absent ; the onset is insidious. The same onset and
course occur in wasting diseases, as cancer, phthisis, Bright' s disease,
diabetes, and organic heart disease. In this class of cases a small patch
of pneumonia, difficult to determine on physical examination, may be
attended by the gravest general symptoms. In all of the above cases,
if there is fever without cause, although no pulmonary symptoms are
present, the lungs must be examined repeatedly. In many such cases
the physical signs are obscured because respiratory action is enfeebled
by the primary condition.
Pneumonia must be distinguished from other acute inflammatory
affections of the lung and pleura and from acute tuberculo-pneumonic
phthisis. The evidence for each is considered in the respective sections.
The presence of leucocytosis serves to distinguish it from acute tubercu-
losis and from typhoid fever, meningitis, and influenza. To distinguish
pneumonia from pleurisy with effusion, the aspirator may be used.
Bactebiological, Diagnosis. Staining and microscopical exami-
nation of the sputum reveal the characteristic micro-organism. Care
must be taken to secure the sputum from the lung. By inoculation of
rabbits with the sputum the disease is readily reproduced. The organ-
ism is not readily found in the blood. (See the Sputum.)
Pneumonia may be distinguished from cerebrospinal meningitis by
the results of spinal puncture alone ; from acute tuberculous pneumonia
by the examination of the sputum. The diagnosis in the latter instance
may be postponed, as tubercle bacilli are sometimes not foimd until the
tenth or twelfth day. (See Tuberculosis.) Typhoid fever sometimes
resembles pneumonia, and must be distinguished after the first week
by the results of serum diagnosis.
Pneumococcus Septicaemia. The account Ave have just given of
pneumonia represents but one phase of the pneumococcus infection.
This infection may be attended by very grave symptoms, especially
those of a toxic nature, with but little if any involvement of the lung
tissue. It is well known that we may see the chill, fever, rapid pulse,
and hurried respiration with but little evidence of consolidation in the
lung, but with nervous symptoms paramount. Delirium, stupor, coma
with the phenomena of the ataxic or the typhoid state may prevail. (See
pages 199 and 200.) In the ataxic state the symptoms resemble those
of mania. In the typhoid form they are not unlike those of uraemia.
In either instance death ensues in coma or from heart failure with its
attending symptoms. Preceding the cardiac failure the urine is dimin-
ished in amount and the secretions generally suppressed.
In other forms of this infection the localization of the process is in
the pleura, as in empyema, in the pericardium, in the endocardium,
and in the cerebral meninges. Pneumococcus inflammation of these
structures is very common. It may develop at the same time that the
lungs are affected, independently of the process in the lungs, or subse-
quent to it. These forms will be considered in a discussion of the
various local inflammations just referred to.
It is important to remember that in pleural, pericardial, and cerebro-
spinal infections the nature of the infection can be determined by aspi-
THE DATA OBTAINED BY OBSERVATION. 319
ration and bacteriological examination of the fluid removed from the
respective serous cavity. The pneumococeus infection can be positively
diagnosticated in tins manner.
These complications, which occur in the course of the disease, modify
the clinical picture and obscure the diagnosis.
Tuberculosis.
The infection discussed in this section prevails to a greater degree
than that of all the others combined. In some forms, as pointed out
in the clinical description, fever is one of the gravest symptoms. In
other forms the febrile process may not be pronounced. It must be
remembered that the fever may be due to the specific micro-organism
or its toxin, or it may be due to a mixed infection. Staphylococcus
and streptococcus infections are common attendants upon the tubercu-
lous infection. This secondary infection may disappear or may become
the most prominent infection. In many instances a terminal infection
ensues, causing mortal symptoms. Infection by the pneuniococcus is
the most common of these terminal infections. (See page 228.)
Tuberculosis is an infectious disease, the course of which may be
acute or chronic. It is caused by the bacillus tuberculosis. This
micro-organism sets up a specific inflammation characterized by the
development of nodules or tubercles, or by a diffuse growth of tuber-
culous tissue. Either anatomical product may undergo caseation or
sclerosis, and in either instance ulceration or calcareous degeneration.
Invasion of the body by the micro-organism may give rise to general
infection, with an eruption of miliary tubercles in most of the organs
and structures of the body, or to a local infection. General tubercu-
losis is acute ; local tuberculosis may be acute or chronic. In acute
tuberculosis the serous membranes, the lungs, liver, kidneys, lymphatic
glands and spleen, the bone-marrow, and choroid coat of the eye may
be invaded in whole or in part. In chronic tuberculosis the lymph-
glands, the lungs, the serous membranes, the tissues and organs of the
alimentary canal, the liver, the organs of the genito-urinary system,
and the brain and cord are individually invaded.
Diagnosis. The diagnosis of any form of tuberculosis is aided by
the determination of the chief factors in its etiology, where this is
possible.
Bacteriological Diagnosis. First. The discovery of the bacillus
tuberculosis in any inflammatory area, or any product of inflammation,
as serum, blood, pus, or the secretion from any gland or mucous mem-
brane invaded by the disease, establishes at once the diagnosis of this
condition. The method of determining the presence of this micro-
organism is fully detailed in the various descriptions of tuberculosis in
the discussion of local diseases, and in the accounts of the examination
of the sputum and of exudations and transudations. Inoculation of
inflammatory products, as of a gland or of fluid which has been sedi-
mented, is a positive mode of diagnosis. Guinea-pigs are selected for
this purpose.
Second. As tuberculosis is an infection- disease, discovery of the
infection is an aid in the diagnosis. Infection takes place by means of
320 GENERAL DIAGNOSIS.
the inhalation of the sputum or other secretions, which when dry float
about in the air. It implies in a measure more or less contact with
individuals previously infected. In rare cases such contact is produc-
tive of the disease by means of direct contagion. The second source of
infection is the food-supply. This may occur from the consumption
of milk secured from a cow infected with tuberculosis. The eating of
meat of tuberculous animals may possibly lead to infection. Direct
inoculation is another but rarer source of infection. This usually
occurs accidentally only.
Third. It is possible that tuberculosis may be inherited. A more
prominent etiological factor, which aids in the diagnosis of the disease,
is the presence of a certain type of structure which is a marked heredi-
tary characteristic in families, on account of which feeble resistance is
offered to the invasion of the tubercle-bacillus. The phthisical and
phthisinoid chest which belongs to this type has been described else-
where, and the tuberculous and scrofulous states have been outlined.
(See page 67 and Part II., Chapter II.) These anatomical conditions,
which are inherited, undoubtedly favor the development of tuber-
culosis.
It is a mistake to lay much stress in the diagnosis of tuberculosis
upon the age or the occupation of the individual. Tuberculosis may
occur at any age. It is true, however, that at certain periods of life
the tubercles are distributed more commonly in one group of organs,
while in other periods they affect another group. Lymphatic, joint,
and meningeal tuberculosis is most common in the first decade of life.
The mesenteric glands are particularly open to invasion at this period.
The diagnosis of tuberculosis, whether local or general, is further
aided by a complete knowledge of the phenomena that attend the
entrance of the virus into the body and the mode of diffusion through-
out the body after infection has taken place. The phenomena at the
point of entrance of the micro-organism are nearly always distinct.
The general invasion is associated with symptoms like those of specific
fevers. The local secondary effects upon the tissues are always decided.
It must be borne in mind that after the exposure, which may lead to
infection, either an acute form of tuberculosis of a general character
may be set up, with or without marked local symptoms, or acute local
tuberculosis alone may arise. In local tuberculosis the disease is con-
fined to one organ or to the lymphatic glands and the organs in the
lymphatic distribution, as the bronchial glands, which are primarily
affected, and to the lungs. In these structures the entire process of
nodular formation, caseation or sclerosis, ulceration or calcification,
may take place. The disease remains primarily local. On the other
hand, it may be spread by continuity of structure through the lymph-
atics throughout the remainder of the organ affected, leading to its
ultimate destruction and the death of the patient ; or general infection
of the system may take place from the primary local area. The pri-
mary seat of infection may be the lungs, the larynx, the alimentary
tract, or the genito-urinary organs. Primary tuberculosis of the serous
membranes, of the lymph -glands, of the bones and joints, may take
place.
THE DATA OBTAINED BY OBSERVATION.
321
The symptomatology and diagnosis of the various forms of tubercu-
losis are detailed in the section devoted to the special diseases of the
various organs of the body.
The Tuberculin Test. The physical signs and clinical symptoms
may point to an inflammatory process in one of the many structures of
the body which may be invaded by tubercle bacilli. On the other
hand, failure in health, loss of weight, ansemia, and moderate fever may
alone occur. The nature of the inflammatory process may be obscure.
To determine more accurately whether the inflammation is tuberculous
or not, or the "decline" due to tuberculosis, we can resort to the use of
tuberculin. Since the researches of Koch, who introduced tuberculin
as a remedy in tuberculosis, he himself as well as a number of other
observers, has employed this preparation to determine the presence of
tuberculosis in the body. In this country Trudeau has been the earliest
and most earnest exponent of this means of diagnosis. After the injection
of tuberculin a group of phenomena follows, known as the tuberculin
reaction, if tuberculosis existed anywhere in the body. It was thought
the occurrence of this reaction was necessary to bring about a cure.
As a therapeutic measure its value has not been upheld by experience.
The invariable production of the reaction has led it to be used as a
diagnostic medium.
Phenomena of Reaction. About twelve hours after the injec-
tion of tuberculin the temperature rises rapidly. In the course of a
few hours it has risen two or three degrees. This elevation of tem-
Fig. 76.
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perature is attended by malaise, pains in the head, back, and legs, and
sometimes nausea or vomiting. The maximum temperature is main-
tained for two or three hours, and then a gradual decline to the norm til
takes place. The normal temperature is reached in from twenty-four
21
322 GENERAL DIAGNOSIS.
to thirty-six hours. The whole period of the reaction, from the time of
the injection until the termination of the fever, is about forty-eight
hours. With the fall of temperature to normal the constitutional
symptoms subside. The accompanying chart (Fig. 76) shows the
course of the fever in a typical reaction.
Method. Twenty-four to forty-eight hours preceding the test the
patient's temperature should be taken every two hours to determine
the range at this period of the disease. The injection should be made at
a time when the reaction could be observed — i. e,, during the period
of normal or subnormal temperature. This, of course, can only be
selected if the temperature of the disease is intermittent. The hour of
day selected to inject the tuberculin should be such that the reaction
may be conveniently observed during the waking hours of the patient.
Bedtime or the early morning hours are the most convenient.
The site of the injection is not material. Usually the interscapular
space is selected. The amount of tuberculin employed is of the greatest
importance. The initial dose should never exceed five milligrammes,
and it is better to use less than this, and an increasing quantity in-
jected every second or third day. The maximum dose should not ex-
ceed ten milligrammes. For children one-twentieth to one-tenth of a
milligramme may be the initial dose. The crude tuberculin should be
diluted at the time it is used with 1 to 2 per cent, solution of carbolic acid.
At the point of injection a little redness and infiltration, with tender-
ness to the touch, is observed. This local reaction may also be seen at
the site of former negative injections when the larger dose produces
reaction. In pulmonary tuberculosis in which physical signs are
obscure some auscultatory phenomena which were previously absent
may be found during the period of a reaction. This test also enables
one to detect tuberculosis in the pleura, pericardium, peritoneum,
genito-urinary tract, and lymphatic glands, the meninges, bones, and
the skin. The test is of special value in cervical adenitis.
It must be remembered that a negative result with large doses of
tuberculin is of more value than a positive one. In the former instance
one can affirm that tuberculosis is absent, as well as that there is no
old focus in any of these organs. It must also be remembered that
the test should only be employed after all other means have failed to
make a positive diagnosis.
Acute m Mary tuberculosis has been spoken of elsewhere. (See Part II.,
Chapter II.) Its course may resemble typhoid fever, septicaemia, or
malignant endocarditis. It usually develops in the course of tubercu-
losis in some other organ of the body. The typhoid form has been
described in the section indicated. It must not be forgotten that the
diagnosis is rendered positive by the demonstration of the presence of
tubercle-bacilli in the blood, or of the occurrence of choroidal tubercles
in the eye-ground. Another form is attended by marked pulmonary
symptoms. This is the type seen in the bronchial pneumonia that occurs
in children following measles and whooping cough. (See Catarrhal Pneu-
monia.) Of the pulmonary symptoms dyspnoea is the most prominent.
Cyanosis is marked. The physical signs are not prominent, and may
be those of bronchitis alone. Although there is impaired resonance
THE DATA OBTAINED BY OBSERVATION.
323
at the base of the lungs, areas of hyper-resonance are observed above and
in front of the chest. Collapse of the lung may cause tubular breathing.
The temperature rises to 102° or 103°. An inverse type may be seen.
The diagnosis of acute tuberculosis is determined by the history of
infection from extraneous sources or from local tuberculosis in some
portion of the body, and by the presence of bacilli.
The following conditions should point to the possibility of chronic
tuberculosis in some portion of the body : (1) Emaciation, not otherwise
explained ; (2) chlorosis or anaemia ; (3) weakness without cause ; (4)
fever — the temperature should be taken every two hours during night
and day ; (5) causeless sweats ; (6) gastro-intestinal catarrh ; (7) morn-
ing nausea ; (8) signs of local inflammation in some organ of the body.
Influenza.
High temperature out of proportion to the local signs of inflamma-
tion in the lungs or other structures characterizes this infection. The
fever may be continuous, remittent, or intermittent.
Fig. 77.
F
106"
105°
104°
103°
102
101
100
99'
98
97"
DAY OF
DISEASE
M
E
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—36
Temperature in influenza— interrupted crisis. (Wilson.)
324
GENERAL DIAGNOSIS.
Fig. 78.
pr
105'
104'
103'
102'
101'
100'
99=
98°
97 :
DAY OF
[USEASE
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Influenza— intermittent type. (Wilson.)
Fig. 79.
F
104
103'
102
ior
100
99°
97
DAY OF
DISEASE
M
E
M
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M
E
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-38
Influenza— remittent type. (Wilson.)
THE DATA OBTAINED BY OBSERVATION. 325
Influenza is a specific contagious febrile disease, occurring in wide-
spread epidemics, having a very short period of incubation, and charac-
terize! by great prostration, marked nervous symptoms, and catarrhal
inflammation of the respiratory or gastro-intestinal tracts, or both.
There is great liability to relapse, and to complications, which are gen-
erally pulmonary or nervous.
The disease generally begins with the ordinary symptoms of coryza ;
but the headache over the eyes and root of the nose is more severe, and
may be so agonizing as to mask all other symptoms. The lacrymation,
rhinitis, and tormenting cough are all usually worse than in ordinary
coryza. Physical weakness, weariness, and depression of spirits are
almost invariably present, and they sometimes reach an extraordinary
degree. Fever is usually moderate (100° to 102°), but may be 104° to
105° for several days, and then gradually subside. It may terminate
by crisis (Fig. 77), or may assume an intermittent or remittent type
(Figs. 78 and 79). In ordinary cases the patient seeks relief first for
the headache, severe aching pain in back and limbs, and extreme
weakness ; if these are relieved he is apt to complain most of incessant
racking 1 cough, often due more to a tracheitis than to bronchitis.
Nausea and vomiting are not uncommon, especially in the morning, at
which time also the patient frequently feels worse than he does later
in the day. Sleep is broken and restless, and may be accompanied by
drenching perspirations. Severe neuralgic pains are common.
In some cases the disease attacks the stomach and bowels especially,
and vomiting with diarrhoea are the prominent symptoms. In others
the predominant symptoms are nervous, and great pain with prostra-
tion masks any catarrhal symptoms. Torpor and delirium may be
present. Sometimes a prolonged and severe attack of asthma marks
infection in susceptible persons.
The duration of the disease is from a few days to a few weeks.
Convalescence is remarkably tedious, and is characterized by persistent
weakness. Sweats are often annoying during this time. The heart
often continues for some time to beat too frequently and to be easily
excited by exertion. Relapses are common.
Diagnosis. Bacteriological Diagnosis. This is possible when
the characteristic bacilli are detected by the means described in the
section on sputum. Influenza in the great majority of cases is easily
recognized. In certain cases, however, it is to be differentiated from
'pneumonia, typhoid fever, and cerebrospinal meningitis.
Cases in which the disease sets in with high fever and marked
chest-symptoms are very apt to be mistaken for pneumonia ; but the
headache and prostration are more intense, while the respiration is not
so frequent. Sweats are common, and albumin and casts in the urine
are by no means rare. Physical exploration shows that botli lungs
are involved, though often not to the same degree. Resonance is .im-
paired, and auscultation shows moist crepitant and subcrepitant rales,
which seem to be due to an oedematous condition of the lung-tissue,
associated with a diffuse bronchitis. A true lobar pneumonia is rarely
I ) resent even as a complication.
If diarrhoea is one of the symptoms, typhoid fever lass t<> be excluded.
326 GENERAL DIAGNOSIS.
This is extremely difficult in the first two or three days. As a rule,
headache, backache, nausea, and sleeplessness are at this time greater
in influenza, the spleen is not so much, if at all, enlarged, the diarrhoea
can be checked, and tenderness and pain in the right iliac fossa are absent.
It can be distinguished from cerebrospinal meningitis by noting the
fact that it begins with coryza, "whereas cerebro-spinal meningitis
often sets in with chill, vomiting, and faintness ; the headache in the
former is usually frontal, in the latter occipital, and accompanied by
stiffness of the back of the neck. Further, in cerebro-spinal menin-
gitis there are often swellings of the joints, delirium alternating with
coma, and in young subjects convulsions are common.
Finally, it may be said that the pronounced diagnostic feature is the
preponderance of general symptoms over local inflammations. The
occurrence of undue exhaustion, extreme general neuralgias and myal-
gias, high fever, and profuse sweats, without intense catarrh or inflam-
■mation to account for or co-ordinating with them, is of the highest
diagnostic significance. The presence of an epidemic, the contagious
nature of the affection, the sudden onset, and the bacteriological diag-
nosis, all point to influenza.
Epidemic Cerebro-spinal Meningitis.
In this infection more than all others the course of the temperature
is without diagnostic significance unless it be that this want of a char-
acteristic course is significant. Its extraordinary irregularity is most
striking when a large number of charts are examined. The fever may
have the course and exacerbation of a typhoid temperature, but it is
more similar to that of tuberculosis. It is often of very short dura-
tion, followed by a prolonged subnormal temperature. It may be high
from the immediate onset of the disease, or remain below 100° for
several days, and then suddenly rise to a great height. Remissions
and exacerbations may attend many of the cases. The most marked
feature, apart from the irregularity of the temperature, is the inequality
between the pulse and the temperature. In some instances the pulse
is rapid, and the temperature is normal or subnormal, while later in
the disease the pulse may be slow when the temperature rises to a con-
siderable height.
Concerning the temperature, then, it may be said that it may be in-
termittent, remittent, or continuous ; it may be intermittent at one
period, continuous at another ; it may be afebrile ; it may be afebrile
at one period and continuous at another.
Cerebro-spinal meningitis, also known as spotted fever, is an acute,
specific, infectious, and mildly contagious disease, endemic and epi-
demic, characterized by evidences of systemic infection, and generally
also by symptoms depending upon inflammation of the cerebral and
spinal meninges — particularly intense pain in the back and head, hyper-
esthesia, retraction of head and neck, delirium, coma, convulsions, and
vomiting.
It is most common in cold weather, and in children under fifteen
years of age. Xone of the epidemics show a continuous extension. The
THE DATA OBTAINED BY OBSERVATION.
327
period of incubation is unknown, but is probably short. It is free
from symptoms. The invasion of the disease is abrupt, although in
some instances the patient may complain of rheumatoid pains in the
limbs or a joint, and headache and weakness. Usually the first
Fig. 80.
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Cerebro-spinal meningitis, showing irregularity of pulse and temperature. (Councilman.)
symptom is a severe chill, which may awaken the patient from sleep.
In other cases the initial symptom is a convulsion. Then quickly
follow repeated vomiting, intense headache, sometimes accompanied
by backache, retraction of the head, delirium, and extreme prostration.
The rise in temperature is moderate, and the pulse is as often slow
as frequent. The face is pale and livid, expressing suffering, and the
patient may toss from one side of the bed to the other, begging some
relief for his headache. Simple stiffness of the muscles of the neck
may prevail. The pain in the head may be occipital or frontal. The
pain in the back becomes more severe, and root-pains dart in all direc-
tions, but especially into the limbs or joints, which may be swollen and
tender to the touch ; in fact, the whole skin is hypersesthetic and the
reflexes are increased. The spinal muscles become rigid, and the head
is often retracted. Less frequently the back is arched and trismus
occurs. Delirium is common at night. It may develop very early or
appear at a late period of the disease. It is sometimes violent or low
and muttering. It is often of a sportive type, the patient making
absurd remarks, cracking jokes, or singing snatches of a comic song.
Delirium may alternate with tonic or clonic convulsions and with
stupor. The appetite is poor, the bowels constipated. A remission
may occur on the third day, with temporary improvement of the
symptoms.
As the attack progresses there may be strabismus, which is usually
divergent, inequality of the pupils, nystagmus, ptosis, and optic neu-
ritis. Vertigo, tinnitus, anosmia, and photophobia are common.
328 GENERAL DIAGNOSIS.
Hyperesthesia and delirium persist. Facial paralysis, a monoplegia,
a hemiplegia, or a paraplegia may occur. The pulse becomes more
frequent and the fever continues. In favorable cases improvement
now begins, the headache and root-pains abating, and delirium and
spasms becoming less frequent. In unfavorable cases the convulsions
may become more severe and end in fatal coma, or the patient may
sink into a typhoid condition, with nephritis as a complication. Coma
may come on in the beginning and continue until death.
The skin eruptions, which explain the name " spotted fever," are
not always present and exhibit no constant character. Herpes and
petechise are the most frequent ; in other cases the eruption is a pur-
plish mottling, or is macular, or the eruption resembles that of measles.
Herpes is most common on the nose and mouth, then on the cheek,
forehead, eyes, and ears. The blood shows a leukocytosis, the increase
being due to the polynuclear leucocytes.
' In the malignant (fulminating) form of the disease death occurs in
a few hours, or two or three days. Such cases are apt to arise early in
an epidemic. The patient has a violent chill ; delirium occurs early ;
the headache is less intense, or at any rate gives way rapidly to stupor
and coma. The pulse is frequent and feeble ; there may be no rise of
temperature, the skin being cool, clammy, and cyanotic. Local or
general convulsions may occur. The eruption may be purpuric, and
eccliymoses may even occur. The urine is scanty and contains albu-
min and casts.
Mild cases usually occur late in epidemics. They are characterized
by severe aching in the head, back, and limbs, nausea, vomiting,
vertigo, and prostration. They closely resemble the nervous type of
influenza, and would escape recognition except during an epidemic.
An abortive form, ending in recovery in two or three days, and an
intermittent form, with exacerbations on alternate days, have been
described.
The duration of the disease is from a few hours to two or three
months. In ordinary favorable cases there is decided improvement
toward the end of the first week, and convalescence is established in two
weeks. It may become chronic and last for weeks, and, as already stated,
may be fatal in a few hours. Relapses are common in some epidemics.
The most frequent complications are on the part of the lungs and
heart, particularly pneumonia and endocarditis or pericarditis. Pneu-
monia often occurs so early that it is difficult to decide whether it is
primary with marked nervous symptoms, or is only a complication of
the cerebro-spinal fever. Nephritis also occurs.
The most frequent sequels are deafness, blindness, headache, and local
palsies.
Diagnosis. The diagnosis in the presence of an epidemic is not diffi-
cult, although an absolute diagnosis can only be made by lumbar jmnc-
ture. The fluid withdrawn is more or less cloudy if the patient has
meningitis. If it is the epidemic form, microscopical examination of
stained cover-slips and cultures will expose the diplococcus. In some
cases fluid cannot be secured, either because the spinal canal is filled
with membrane or the fluid is retained in the lateral ventricles.
THE DATA OBTAINED BY OBSERVATION.
329
The fluid is turbid in the early part of the disease. In some cases
a purulent sediment forms in the bottom of the test-tube at once. In
others, the fluid is simply turbid, and after standing contains consider-
able fibrin and many cells. The fluid secured at the first puncture may
be more turbid than that secured later, although the symptoms may be
more severe than at first. If the acute symptoms subside the fluid may
be clear, and no cells may be found. In the intermittent cases the
fluid may be clear during the interval that the patient is without
symptoms. In chronic cases there may be no turbidity.
The cells in the spinal fluid are chiefly polymorphonuclear leuco-
cytes — " pus corpuscles." Small lymphoid cells and large endothelial
cells may be present. The latter are phagocytic, and have large oval
or round nuclei. They may contain leucocytes and blood-corpuscles.
In the pus corpuscles or leucocytes the diplococci are found ; they are
rarely found outside of the cells. Late in the disease the pus corpus-
cles do not stain sharply and are degenerated. In chronic cases the
fluid contains a few pus corpuscles which are smaller than usual, and
like lymphoid cells.
Bacteriological Diagnosis. This disease is due to the diplococcus
intracellular is. This micrococcus appears in diplococcus form as two
hemispheres the size of the ordinary micrococcus. It stains with the
ordinary stains for bacteria. It is decolorized by the Gram method.
The staining is sometimes irregular, some being brightly stained, others
faintly. There is some variation in the size of the organisms. Both
variation in size and staining are apparently due to degeneration. The
two organisms are sharply separated usually, though sometimes they
seem to be united. (Figs. 81 and 82.)
Fig. SI.
Fig. 82.
Fig. si. Pus cells containing diplococci from the meninges. A few diplococci are in the exudate
outside of the pus cells. Between the pus cells there are delicate (ibrillae of fibrin. The drawing
is an accurate representation of a group of cells in the field of the microscope. (Councilman.)
Fig. 82. Pus cells from an alveolus of the lung in a case of diplococcus pneumonia. The cells
are swollen and contain immense numbers of diplococci. Both figures from stained cover-slips.
The organisms do not grow profusely. The blood-serum mixture
of Loftier as prepared by Mallory is the best medium. It is often
difficult to make cultures unless a large quantity of material is used.
330 GENERAL DIAGNOSIS.
Transfers must be made daily to keep cultures going. The growth
on the serum mixture forms round, white, shiny viscid-like colonies
with smooth outlines. They do not liquefy the blood-serum. In
the tissues the diplococcus is found in the interior of the polynuclear
leucocytes.
Cultures. Cultures should be made at the time of puncture. In the
majority of cases a growth of the diplococcus is found, although even
in acute cases rarely they may not grow. In chronic cases a growth
is only rarely obtained. (Plate VIII.)
This form of meningitis must be excluded from pneumococcus men-
ingitis, tuberculous meningitis, and streptococcus meningitis. In the
pneumococcus form the symptoms are comparatively slight and are
usually preceded by pneumonia. In the streptococcus form the clini-
cal history is like that of ordinary forms of meningitis. The evidence
of an infection elsewhere is usually present. Tuberculous meningitis is
, recognized by the methods employed to detect tuberculosis elsewhere
in a patient suffering from the usual symptoms of cerebro-spinal men-
ingitis. The most positive method of distinction of the various forms
is by lumbar puncture. (See Chapter XXI.)
Keknig-'s Sign (Kernig, 1884; Netter, 1898). This sign is of
value in the diagnosis of meningitis, but is present in any form. It is
determined by placing the patient in the dorsal decubitus, with the legs
relaxed and fully extended at the knees. When the child is raised in
a sitting posture the knees are flexed, and cannot be extended on
account of contracture of the posterior muscles of the thigh. In adults,
if the patient is propped up, or seated on the side of the bed, and an
attempt made to extend the leg on the thigh, there is contraction of the
flexures. The test can be equally well performed by flexing the thigh
on the abdomen until it makes a right angle. When an attempt is
made to extend the leg it will be found that the limb cannot be fully
stretched out if meningitis is present.
Diphtheria.
In this infection the temperature-range is variable. The infection
may be intense, and yet the temperature remain subnormal, especially
if the fever is due to the toxin, and not, as is frequently the case, to a
mixed infection.
Diphtheria is an acute, specific, infectious, and contagious disease,
sporadic and epidemic, occurring especially in children from one to six
years of age, and characterized by insidious or abrupt onset, with mod-
erate fever, and the development upon the fauces or upon any abraded
surface of a grayish-white false membrane, which has a tendency to
extend, especially to the larynx. The subsequent phenomena are
those of stenosis of the larynx, or toxaemia, with or without superadded
ursemia or marked cardiac weakness ; it is further characterized by the
liability to paralysis as a sequel.
Diphtheria is spread by inhaling the expired breath of a diphtheritic
patient, or breathing air which has been contaminated by the clothing
of the patient or the discharges from his nose and throat. It may also
PLATE VIII.
Fig. 1.
Fig. 2.
Cerebro-Spinal Meningitis. (Councilman.)
Fig. i. Forty-eight-hour culture of diplococcus intracellular on Loeffler's blood-serum mixture.
Fig. 2. Abundant growth in twenty-four-hour culture on fresh blood-serum. The colonies are
minute, very numerous, and somewhat resemble similar cultures of the pneumococcus.
THE DATA OBTAINED BY OBSERVATION.
331
be transmitted directly, as when a fragment of membrane is ejected by
coughing and infects the mouth or eye of physician or attendant.
Moreover, it is contained in the sewers of large cities where the dis-
ease is endemic, and it persists in damp cellars if they have once been
infected. Hence sewer-gas and cellar-air may carry the disease.
There is reason also for believing that a similar disease affects birds,
fowls, and cats at times, and from them may be transmitted to man.
These facts must be borne in mind in making the diagnosis.
The specific poison is the Klebs-Loffler bacillus and its toxin.
While children from one to six years of age are especially liable to
it, no age is exempt — neither the newborn babe nor the very aged.
One attack does not protect a person completely against a subse-
quent attack.
The period of incubation varies from a few days to two weeks, or
perhaps longer in exceptional cases. As a rule, it is less than a week.
It is shorter when the poison is virulent, and when infection has been
upon abraded surfaces.
The onset in mild cases is deceptively free from positive symptoms.
The child is languid, perhaps slightly chilly, and has a little fever,
with thirst, impaired appetite, and discomfort in swallowing. Unless
the nature of the trouble is suspected the child is not thought ill enough
to be kept in-doors. The throat is slightly inflamed, especially about
the tonsils. The child may protest that there is no pain on swallow-
ing. In from twelve to twenty-four hours from the onset, sometimes
later, a grayish pellicle will be found upon the tonsils, and the cervical
glands will be swollen.
Fig. 83.
102
101
ioo c
9'J
98 C
DAY OF DIS.
PULSE
RESP.
DATE
•
.
1
^
F
l -
A a
l\
a.
If
Bacillus of bubonic plague: A, iu pus from suppurating bubo; B, the bacilli very much enlarged,
to show peculiar polar staining. (Abbott.)
" This organism is described as a short, oval bacillus, usually seen
single, sometimes joined end to end in pairs or threes, less commonly as
longer threads. It stains more readily at its ends than at its centre.
It is sometimes capsulated ; is non-spore-forming ; is aerobic, and is
non-motile. It is found in large numbers in the suppurating glands,
and in much smaller numbers in the circulating blood. (See Fig. 89.)
" It is demonstrable in cover-slip preparations made from the pus
THE DATA OBTAINED BY OBSERVATION. 349
and in sections of the glands by the ordinary staining methods. Yersin
states that it retains its color when treated by the method of Gram,
while Kitasato says that it at one time stains by this method and at
another it becomes decolorized. Aoyama observed that those bacilli
within the suppurating glands were decolorized, while those in the
blood retained the stain when treated by Gram's method."
The duration is from six to ten days. If there is much suppura-
tion, convalescence is prolonged.
Leprosy.
A chronic, specific, infectious disease, characterized by the develop-
ment of tubercles, anaesthetic patches, and neuritis, and followed by
ulceration and destruction of tissue. The disease occurs especially
from puberty to the thirtieth year, and oftener in men than in women.
It develops slowly and insidiously. Sometimes the first skin lesion is
a crop of bullae, suggestive of pemphigus. More commonly there
appear reddish or violet-colored patches, varying in size from a quarter
of an inch to two or three inches in diameter, and becoming of a darker
hue later. The next step is the formation of nodules, which are char-
acteristic of the disease. These may develop upon the patches already
described, or hi other places. They vary in size from a pea to a bird's
egg or larger. They are most common upon the face and extensor
surfaces of the arms, legs, fingers, and toes. The tubercles consist of
an infiltration into the true skin ; they are raised, firm, relatively pain-
less, and vary in color from red to copper. The face is characteristi-
cally distorted into a fierce expression (leontiasis). The tubercles may
become absorbed and leave atrophic areas, but generally they break
down into eroding ulcers, which slowly burrow and increase in extent,
eating off a portion of the nose, fingers, hands, and feet, and exposing
muscles, tendons, nerves, bloodvessels, and bone. Tubercles form also
upon nerve-trunks, and ulcers upon the mucous membranes. (See the
Nose and Larynx.)
In other cases, or in combination with the tubercles, especially upon
the limbs and trunk, there are anaesthetic areas. Ulcers may follow
without the previous occurrence of tubercles. With the anaesthetic
patches are associated crops of bullae, and neuritis.
The further peculiarities of the disease are : its long duration, its
slow progress interrupted by apparent healing of some of the ulcers ;
its afebrile course (the temperature is generally subnormal) ; its com-
parative painlessness, and the slight impairment of the general health.
Death results from gradual wasting, or is hastened by some intercur-
rent affection.
Diagnosis. The specific cause of the disease is probably the bacillus
leprae of Hansen. It is found in the thin pus of the ulcers and in the
lesions themselves. It consists of rods 4 to Q/i long and \fi broad, closely
resembling tubercle-bacilli. They stain in alkaline fluids, but do qo1
bleach after exposure to acids. Staining cover-slip preparations with
the Ziehl-Neelsen fluid and decolorizing in acid and alcohol bring
them out, They may be distinguished by yielding their color more
350
GENERAL DIAGNOSIS.
readily, and by taking easily aniline-dyes in simple watery solution
(Yon Jaksch). (See Plate III., Fig. 4, b.)
The diagnosis from a tubercular syphilide is made by the history of
the case, the possibility of infection, the bacteriological examination,
the slow progress, and the inadequacy of specific treatment. The pres-
ence of anaesthesia and of neuritis points to leprosy.
Actinomycosis.
The general symptoms attending this infection are like those due to
suppurative infections. The fever is irregular, often intermitting.
It is a specific infectious disease of cattle, occurring occasionally in
man, attacking especially the lower jaw, lungs, and intestines, and
characterized by a long duration, by the development of tumors and
metastatic growths, and by pycemic symptoms.
It is due to the actinomyces, or ray-fungus (see Fig. 91), which pro-
duces in cattle the disease known as big or lumpy jaw and swelled
head. The fungus is conveyed in the food or drink, and gains entrance
to the body through abrasions in the mouth or a decayed tooth, or is
inspired into the lungs. Israel, Ponfick, and Bostrom have given us
the greatest amount of information in regard to this parasite. It was
discovered in 1845, in human beings, by B. v. Langenbeck, and in
1877, in cattle, by Bollinger.
Fig.
Case of actinomycosis.
At the seat of invasion a slowly growing, slightly painful tumor
develops. Bones are affected as well as soft tissues. These become
swollen and suppurate, the fungus being at all times obtainable. The
THE DATA OBTAINED BY OBSERVATION. 351
fungous masses appear to the unaided eye as particles of yellow sand,
and are greasy to the touch.
Pulmonic Form. Actinomycosis of the lung may be divided into
three stages : a latent stage, when the lung proper is affected ; an active
stage, when extension to the pleura and chest wall takes place ; and a
final or chronic stage, when perforation and the formation of a thoracic
fistula occur and the adjoining organs become affected. The symp-
toms of the first stage are those of chronic bronchial catarrh, with
later the occurrence of the physical signs of consolidation, especially
in the mamillary and axillary regions of the chest, in the middle zone
of the thorax. The apices and bases are rarely affected primarily.
The symptoms of the second stage are those of pleurisy, with adhesions
and with or without effusion. At this time the disease may extend
downward to the liver and peritoneum, or the pericardium may become
infected. Fever and pain accompany these processes. On physical
examination, in addition to the signs of the pulmonary and pleural
conditions above mentioned, swelling of the thoracic wall will be ob-
served, not unlike that of an empyema which is about to perforate.
The swelling, which is at first dense, and hard, and red, becomes softer
in small areas, and may fluctuate. Fluid, which is mucopurulent and
shows the parasite, may be removed by aspiration. Repeated dry taps
may occur before the needle secures the serous or sanguino-serous exu-
dation in the pleura. The sputa at this time may accidentally show
the parasite, although this is rare. The expectoration is mucopuru-
lent, but it is said to never contain elastic fibres. The course of the
disease at this time may extend over many months, in contradistinction
to empyema on the one hand or carcinoma on the other. In the final
stage ulceration of the swelling is seen in many places, fistula forms,
and the disease extends to adjacent structures. Secondary infection
may occur and symptoms of pysemia develop.
The masses which form upon the intestinal mucous membrane may
lead to suppuration and perforation of the intestine. Metastasis to any
organ may occur, with resulting local symptoms. The duration depends
upon the organs involved in metastases. If metastases do not lead to
early death, that result is brought about at the end of months or years by
slow pyaemia, with resulting amyloid degeneration and its consequences.
It is usually associated with chronic inflammation and the produc-
tion of pus. The pus is peculiar. It is thin and viscid. Small
nodules of gray or yellow color, the size of a poppy-seed, can be seen
by the naked eye when it is spread out on a glass. With a low power
these particles are aggregations of spherules, which with a, higher
power are seen to be arranged in masses radiating from a common
centre. Each separate spherule is pear-shaped. They have high re-
fractive power. In the centre of the masses a network of fibres is
seen. If the mass be broken up numerous club-shaped forms in the
periphery are seen, while at the centre a sort of detritus alone is <>!>-
served. The micro-organism belongs to the class of fission-fungi, and
the club-shaped bodies are the degenerated forms. (See Fig. 91.)
Gram's method of staining brings out the threads of the network
most distinctly. The centre is made up of a network of minute spheri-
352
GENERAL DIAGNOSIS.
cal organisms, with converging constituent threads. The whole is sur-
rounded by a delicate envelope. The pear-shaped bodies may be
denned by Weigert's process. Make a solution of 20 c.c. of absolute
alcohol, 5 c.c. of concentrated acetic acid, 40 c.c. of distilled water, and
sufficient French extract of litmus to color it ruby-red after repeated
filtering. In this solution the cover-glass preparations are allowed to
remain for an hour, and then rinsed with alcohol rapidly and placed
Fig. 91.
Actinomyces.
in -a 2 per cent, gentian-violet solution for three minutes. The fluid
should be boiled before use and filtered after cooling. The fungous
threads are stained a ruby-red, while the central mass of actinomyces
is colorless.
Diagnosis. Simple microscopical examination is usually sufficient
to determine the nature of the fungus. The recognition is more posi-
tive if we bear in mind the peculiar character of the pus in which the
nodules and the club-shaped forms are seen. It must not be mistaken
for the radiating leptothrix threads found in the mouth. Pure cultures
have been obtained resembling macroscopically the cultivation of the
tubercle bacillus.
Tetanus.
Tetanus is an acute, infectious disease of the nervous system, the
essential characteristic of which is persistent tonic spasm of the muscles
of the jaws (lockjaw) and of the spinal and trunk muscles. The disease
begins with the stiffness of the jaw, which steadily increases until,
within a few hours, there is complete tonic spasm of the jaw. The
neck-muscles, and then those of the spine and trunk, become rigid, so
that the body is arched backward and may rest upon the heels and
head (opisthotonos). The facial muscles share in the spasm, and by
their contraction produce a horrid, grinning countenance (rims sar-
donicus). The contracted muscles become painful, and there is also
epigastric pain. The rigidity is persistent, but is interrupted by ex-
acerbations in which the phenomena already described are exaggerated,
and, in addition, respiration is embarrassed, the face becomes livid, the
skin bathed in sweat, and the patient is further distressed by increased
THE DATA OBTAINED BY OBSERVATION. 353
pain in the affected muscles. The body may be bent forward (empros-
thotonos) or laterally (pleurosthotonos). The temperature is not con-
stant. It may remain normal, be moderately elevated, or hyperpyrexia
may be present, especially toward and after the end in fatal cases. The
spasm ceases during sleep, but subsequently returns.
The cause of the disease is the bacillus of tetanus, which produces
the convulsive poison tetanin. The bacillus is seen as a delicate, slen-
der rod, with a terminal spore. It stains with aniline dyes and Grain's
fluid. Cultivations may be made with the pus. It should be smeared
over the surface of slanted agar-agar or blood-serum in a sterilized
tube, placed at 37° C, for twenty-four hours, then heated to 80° C. in
a water-bath from forty-five to sixty minutes. At the end of this time
gelatin plates or Esmarch tubes are to be made from the growth in the
heated tube ; these are to be kept in an atmosphere of pure hydrogen
at 20° to 22° C. Growth is favored by the addition to the gelatin of
2 per cent, of glucose. If the inoculation be made as a stab in a tube
about three-quarters filled with gelatin, growth is seen only to within
about 2 cm. of the surface of the media. Faint radiating striae or
thorn-like processes are seen. The development is rapid in agar-agar.
After an exposure of thirty hours to a temperature of 37° C. the
spores make their appearance. On gelatin the colonies are dense at
the centre, with a more delicate periphery. The preparation becomes
fluid, and gas is evolved. It is strictly anaerobic. The accompanying
illustration from Abbott's work on Bacteriology shows its appearance.
Fig. 92.
a
J
Tetanus bacillus, a. Vegetative stage, from gelatin culture, b. Spore-stage, showing
pin-shape. (Abbott.)
Tetanus frequently follows an injury. Trismus neonatorum and
puerperal tetanus are names given to special varieties which occur in
new-born children and in puerperal women. Tetanus is much more
common in men than in women, and Gowers states that three-fourths
of the cases occur between the ages of ten and forty. It is much more
common in hot than in cold countries, though cold is an exciting cause.
In traumatic and puerperal cases the disease usually develops in
from a few days to two weeks from the time of injury or childbirth or
abortion. In new-born children it occurs usually during the first week.
It lasts from two to six weeks, but may be fatal much earlier, or, in
rare cases, last even longer.
Tetanus must be distinguished from strychnine-poisoning. In the
latter the jaw-muscles are never involved early, if at all, and the nms-
23
354 GENERAL DIAGNOSIS.
cles are relaxed between the paroxysms. It is distinguished from tetany
by the history and the distribution of the spasm, which in tetany is
confined to the extremities. Bacteriological methods should be re-
sorted to.
Trichinosis.
Until recently fever was not looked upon as an attendant of the
gross parasitic invasion which is considered below. The study of a
large number of cases shows that fever is present in various forms. In
not a few, it is true, it may be very slight for a few days, and then
fall to normal, and even, especially in convalescents, be strikingly
subnormal. In other instances the temperature curve may be markedly
intermittent. The chart from Osier's monograph shows this peculi-
arity. (See Fig. 93.) Finally, the fever-range is not unlike that of
typhoid fever in many instances. Strumpell observes that the fever is
seldom continuous for any length of time, and that its course is inter-
rupted by frequent and prolonged intermissions. Kiemeyer compares
the curve to that of typhus, and Eichhorst to that of typhoid fever.
The infection is acute, caused by absorption of trichinae spiralis, and
characterized by fever, gastric and intestinal irritation, followed by
pain and stiffness in voluntary muscles, oedema of the eyelids, face,
and feet, by profuse sweating, and by death or tardy convalescence.
The trichinae are absorbed by human beings through raw or imper-
fectly cooked food, often in the form of sausage. The trichinae are
encysted when absorbed, but within forty-eight hours they are liber-
ated in the intestine and can be found adherent to the mucous mem-
brane. In the course of six or seven days each liberated female worm
produces about 180 embryos, which immediately penetrate the walls
of the intestine and travel or are carried to all parts of the body,
becoming in turn encysted.
Swallowing of trichinous flesh does not necessarily produce symp-
toms ; the trichinae may be destroyed in the stomach, or, if calcified,
may pass through the intestine unchanged. When symptoms result
the severity depends upon the number of trichinae which become liber-
ated. The symptoms are sleeplessness, lassitude, anorexia, nausea,
vomiting, tenderness over the abdomen, and diarrhoea. Headache is
a constant and marked symptom of invasion. Colicky pains attend
the gastro-mtestinal symptoms. These symptoms may not be marked
in the beginning of the disease ; or they may be so severe as to cause
death in two or three days. If the patient survive, toward the end of
the week the voluntary muscles become stiff, painful, and contracted.
The muscles feel hard and swollen. The eyelids, face, and sometimes
the feet become oedematous. Depending upon the muscles involved,
there are interferences with the eye-movements, contractions of the jaw-
muscles, difficulty in breathing or in swallowing, etc. The calves of the
legs are especially involved. Recurrent oedema over the affected muscles,
eyelids, and face is very common and characteristic. Profuse sweating
also is very common, and at times there are severe neuralgic pains.
The fever is usually moderate, but it may be high. It follows the
types described above. It is accompanied by malaise, with pains in
THE DATA OBTAINED BY OBSERVATION.
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356 GENERAL DIAGNOSIS.
the joints and muscles, preceding the true local muscle pain. The pulse
is very frequent if trichinae reach the heart. The later stages in fatal
cases are marked by insomnia, delirium, stupor, and coma.
The duration varies from a few days to four or five weeks, or even
longer. Muscular pains may persist for months after recovery. Death
results from exhaustion, or from some complication, as pneumonia or
ulceration of the large intestine.
The Blood. Brown, in studying Dr. Osier's cases, found an increase
in the leucocytes, and on a differential count a great increase of the
eosinophiles. The leucocytes were increased to 17,000 per c.mm.
The eosinophiles increased from 2 per cent., the normal, to 37 per cent.,
and at one time to 68.2 per cent. In subsequent cases their average
increase was as high as 48 per cent.
Diagnosis. The diagnosis is based upon the history, the peculiar
muscular pains and swellings, the localization of the oedema, and the
leucocy'tosis and eosinophilia. The muscles are swollen and hard,
painful on pressure, and contracted. There is no involvement of the
joints, an important point in the diagnosis. The oedema (see Chapter
XL) is seen in the eyelids and over the eyebrows. It is of common
occurrence over the swollen and tender muscles. It is distinguished
from typhoid fever by the presence of vomiting, and oedema of the face
and eyelids, the development of muscular troubles, by the absence of
hebetude, delirium, and other typhoid symptoms, and absence of the
characteristic eruption and enlargement of the spleen.
Muscular rheumatism is distinguished by being limited to one part,
as the lumbar region, arm, or chest ; by its appearance following ex-
posure to draught ; and by the fact that it is not preceded by nausea,
vomiting, and diarrhoea, nor accompanied by oedema.
CHAPTEE XXI.
THE DATA OBTAINED BY OBSERVATION— {Continued).
Exploratory puncture or aspiration for diagnosis: Instruments. Preparation of instru-
ments. Preparation of skin. Point of puncture. —Exudations (Pus. Seropus.
Gangrenous debris. Blood. Serum. Chyle): Pus. Blood-corpuscles Bac-
teria. Protozoa. Vermes. Crystals. — Chemical examination: Seropurulent
exudations. Putrid exudations. Hemorrhagic exudations. Serous exudations.
Chylous exudations. Pleural effusions. Transudations. — The contents of cysts:
Hydatid, ovarian, renal, pancreatic.
THE EXAMINATION OF EXUDATIONS, TRANSUDATIONS,
AND CYSTIC FLUIDS.
Exploratory Puncture or Aspiration for Diagnosis. The presence
or absence of fluids in the natural cavities of the body, as the peri-
cardium, the pleura, or the abdomen, or in the gall-bladder, must
frequently be ascertained by means of puncture or aspiration. The
fluid is secured at the same time by the puncture for examination.
The fluid of tumors or cysts is likewise withdrawn to complete a diag-
nosis by determining its chemical, microscopical, or bacteriological
character. Certain rules of procedure are necessary, and, as the}' are
common to the method in whatsoever situation employed, may be con-
sidered in this section.
The Instruments. If it is the desire of the observer to determine
the presence of fluid, an ordinary grooved needle may be used. If,
however, fluid is to be obtained for examination, a syringe or aspirator
must be used. An ordinary hypodermatic syringe, or the syringe of
Pravaz, may be used if the needles are long enough. A special aspi-
rator made for diagnosis by instrument-makers is the best. The
needles are sufficiently long, the barrel large enough to hold sufficient
fluid for any method of examination. If the diagnosis is to be fol-
lowed by treatment by aspiration, the apparatus of Dienlafoy, or any
equally perfect apparatus, may be used at once.
Preparation of Instruments. The instruments should be ster-
ilized in a steam sterilizer, or boiled. This does not apply to the
needles alone, but every portion of the instrument should be cleansed,
because, for instance, the contents of the barrel of the syringe pass
through the needle. After sterilization they should be carried to the
patient in sterilized test-tubes plugged with cotton-wool. When not
in use the needles should be kepi in absolute alcohol and the syringe
in carbolic acid solution, 1 : 20. Before using, the carbolic acid should
be washed from the syringe and needle with boiling water ; they are
then to be sterilized as described. Unless the carbolic acid is removed
from the syringe its presence may serve as an antiseptic or disinfectant.
358 GENERAL DIAGNOSIS.
and thus interfere with the culture-tests, to which the material drawn
is to be subjected.
Preparation of Skin. The skin should first be cleansed with
soap and water, then with alcohol, then with a solution of carbolic acid,
1 : 20, or of the bichloride of mercury, 1 : 1000. After thorough
cleansing the parts should be kept covered with a towel soaked in
bichloride solution until the time of operation. At the time of punc-
ture the surface should be made anaesthetic by ethylene chloride, the
rhigolene spray, by ice and salt, or, in adults, by the Schleich method
of subcutaneous anaesthesia. Care must be taken, if the patient is
aged or poorly nourished, or the skin oedematous, not to freeze the skin
too much, on account of the danger of local gangrene.
The Point of Puncture. The points selected for aspiration
depend upon the cavity to be explored or the situation of the cyst.
The Pleura. To withdraw the fluid within the pleura it is best
to select a point for aspiration in one of the lower interspaces of the
chest, because the fluid is more likely to accumulate in this position
and because complete aspiration can there be performed if necessary.
The sixth or seventh interspace in the anterior axillary line, or the
eighth or ninth interspace in the posterior axillary or scapular line,
may be selected. On the right side the upper interspace of the two
should be chosen on account of the position of the liver. If the con-
tents tend to point or break out at any particular spot on the surface
of the chest the puncture may be made in this area. In suspected
loculated empyema or effusions the point of puncture should be at the
site of greatest dulness and least fremitus.
The Pericardium. For aspiration of the pericardium three points
of election have been recommended : First, the usual position of the
apex-beat, in the fifth interspace, inside of the midclavicular line ;
second, the space between the ensiform cartilage and the left seventh
cartilage, the point advised by Roberts ; third, Rotch has tapped the
fifth right interspace a number of times on the cadaver, and thinks
that this situation is a proper one on the living subject. The writer
has aspirated the pericardium in several instances inside of the normal
position of the apex. Care must be taken to insert the needle slowly
and with the point directed downward and toward the left axilla when
this position is selected.
The Abdomen. It should be remembered that no attempts at
puncturing the abdomen should be made if pus is suspected, unless
preparations have been made to perform laparotomy at once. Indeed,
this exploratory operation is performed with so little detriment to the
patient by modern surgeons that, on the whole, it should be advocated
instead of puncture. There are times, however, when the latter must
be resorted to. The writer has performed it in a number of instances
— always refusing to do so in cases in which pus was probably present
in the peritoneal cavity, or in tumors, or in organs the seat of suppura-
tion — without any danger having ever arisen. Explorations of this
character are probably more feasible in connection with diseases of the
liver. It does not appear to be harmful to insert needles into that
organ, and valuable information is often gained thereby.
THE DATA OBTAINED BY OBSERVATION. 359
In aspiration of the abdomen, to determine the character of perito-
neal contents, the median line should be selected for the puncture. The
bladder must be emptied and a point midway between the umbilicus
and pubes selected.
The Vertebral Canal. Spinal or Lumbar Puncture. Proposed
by Quincke, the procedure has been carried out by many clinicians and
has proved to be a means of corroborating and even establishing a diag-
nosis. Cerebral lesions are diagnosed and intracranial pressure relieved
because of the continuity of the spaces in the brain and the spinal canal.
(See Cerebro-spinal Meningitis.)
Method. The patient should lie on the right side, with the knees
drawn up and the left shoulder turned forward. The puncture is made
by an antitoxin needle or the needle of a large hypodermic syringe,
which may then be used to withdraw the fluid. The syringe itself
may be removed and the fluid allowed to ooze through the needle drop
by drop. A needle 4 cm. in length and 1 mm. in diameter is suitable
for infants ; a longer needle for children over ten and adults. The
point selected for puncture is midway between the third and fourth or
fourth and fifth lumbar vertebra?, below the spinous process, a little
to one side of the median line. The thumb of the left hand of the
operator placed between the spinous process may be used as a guide.
If the needle is inserted to the right of the median line, preferably on
this side, it should enter 1 cm. from the median line, on a level with
the thumb, and be directed slightly upward and inward. At a depth
of 3 or 4 cm. in children and 7 or 8 cm. in adults the canal is entered.
The fluid oozes drop by drop, and should be collected in a sterilized
test-tube. It should not run down the sides of the tube. Five to
fifteen cubic centimetres should be withdrawn.
The fluid is examined chemically, bacteriologically, and microscopi-
cally. Sugar has been found in brain-tumor and not in meningitis ;
albumin is said to be less hi the former than in the latter. In tubercu-
lous meningitis the fluid is usually clear and limpid ; in other forms
cloudy and turbid. Pus has been withdrawn in leptomeningitis. Blood
may be found in hemorrhage into the lateral ventricles. The respective
affection is distinguished by the results of bacteriological examination.
Cover-glass preparations are made of the fluid and cultivations taken
at once. In purulent meningitis streptococci, staphylococci, the pneu-
mococcus, and the meningococcus (diplococcus intercellularis) may be
detected. In tubercular meningitis tubercle bacilli have been found,
especially after sedimentation. After the fluid has been twenty-four
hours in a conical glass the fine clot which forms should be examined
for bacilli. The absence of bacilli does not exclude tuberculosis. The
positive result, however, is diagnostic.
Inoculation, as in a case by Lafleur, will cause tuberculosis in a
guinea-pig, and is diagnostic. A clear fluid does not exclude purulent
meningitis; usually, however, the fluid is purulent, turbid, or rich in
leucocytes.
Sometimes, although the canal is entered, fluid is not secured, be-
cause the needle enters pseudomembrane, thick pus, or gelatinous fluid,
or because fluid is retained in the lateral ventricles.
360 GENERAL DIAGNOSIS.
Cysts or tumors, with fluid contents, should be punctured over the
point which presents externally, at which place it is evidently hi closer
proximity to the external wall.
The Spleex. The spleen has been punctured for therapeutic and
diagnostic purposes. If the organ is hard, as in chronic malaria, it
may be done without danger ; but if it is enlarged and soft, as in infec-
tious diseases, such as typhoid fever, it is hardly justifiable to puncture
it, because of the danger of subsequent rupture. Risks attend the
puncture of other organs, as the kidney. The writer has seen a serious
hemorrhage follow such puncture, and, of course, septic inflammation
may arise. Exploratory operation is more suitable for determining its
condition.
The Examination of Fluids and Discharges. While the fluids to
be examined can be obtained by the above-mentioned method, it some-
times happens that they are discharged spontaneously, as in the case
of an empyema.
The following general methods apply to the examination, in what-
ever way material is obtained. When derived from the natural cavi-
ties they are known as exudations or transudations. Fluids are also
obtained from cysts, but do not require different methods of exami-
nation.
The naked-eye appearances are first noted ; then microscopical ex-
amination with and without staining is resorted to. Chemical exami-
nation is also required. Often culture-preparations and inoculations
must be resorted to, as hi the case of pus or of serous exudation.
The Exudations.
They may be composed of pus, seropus, gangrenous debris, blood,
or pure serum or chyle. When pus, seropus, or putrid fluid is with-
drawn, it implies absolutely an inflammatory origin. Blood and serum
may be associated with inflammation, simple or infectious ; but may
also point to impediments in the general or lymphatic circulation.
Blood or bloody serum is thought to be of tuberculous or cancerous
origin. Its absence does not imply the absence of either disease. A
chylous exudation is usually due to obstruction of the lymph-channels.
Purulent Exudations.
Pus ranges in color from gray to greenish-yellow. It is turbid, of
high specific gravity, and alkaline. It varies in consistence. When
standing after removal it separates into two layers ; the upper layer is
light yellow and transparent, and the lower opaque. Pus may be
mixed with blood, and is then reddish-brown. (See Abscess of the
Liver.) When it has undergone decomposition it is thin, green, or
brownish-red, of a penetrating odor.
Microscopical Examination: White Corpuscles. If the speci-
men is fresh the cells exhibit the movements that are common in
leucocytes. If a solution of iodine and iodide of potassium is added
to them they change to mahogany color. If the pus is old and the
THE DATA OBTAINED BY OBSERVATION. 361
cells are dead, they are shrunken and granular. Enormous giant-cells
and cells loaded with fat are seen in pus.
Red Corpuscles. In fresh pus red corpuscles are also seen along
with blood-pigment or haematoidin-crystals.
In addition to the corpuscles free fat-globules and fat-particles are
seen. Epithelium is rarely seen. In the pus from the pleural cavity,
if cancer is present, the vacuolated epithelial and endothelial cells
sometimes seen in cancer may be observed.
Bacteria. Micro-organisms are always detected with the aid of
staining-methods. (See Chapter XVII., Bacteriological Diagnosis.)
The micro-organisms are usually the determining cause of the suppu-
ration. Suppuration, however, may be caused by chemical substances,
although this is at least of rare clinical occurrence. Of the various
fungi found the micrococci and bacilli are the most numerous. The
commonest of these are the staphylococcus pyogenes aureus and strep-
tococcus pyogenes ; the amoeba dysenterica, in abscess of the liver and
secondary abscess of the pleura and lung. It was found in an abscess
of the jaw by Flexner. For further description of the pyogenic micro-
organisms, see below and Chapter XVI., The Infections.
The Pyogenic Bacteria. 1. Staphylococcus Pyogenes Aureus.
This micro-organism is found in acute abscesses and boils, sometimes
also in infectious osteomyelitis and ulcerative endocarditis. In addi-
tion to other portals it may enter the tissue through abrasions or the
hair-follicles.
Morphology. In cover-glass preparations they appear as small
round bodies scattered among the pus-cells, rarely within them, single,
in pairs or in clusters. They stain readily with the basic aniline dyes.
(See Fig. 94.)
Biological Properties. It is aerobic, facultative anaerobic, grows
in milk, meat-infusions, gelatin, or agar at 18° C. Death-point is 56°
Flo. 94.
(TO
Pus with staphylococcus. X 800. (FlOgge.)
to 58° C. after ten minutes' exposure. Growth. Make plate-cultures
on agar-agar. After twenty-four hours in the incubator the plate will
be studded with yellow or orange-colored colonies, round, moist, and
glistening. In a gelatin stab-culture liquefaction occurs in thirty-six
to forty-eight hours along the puncture, forming a funnel. The whole
mass gradually liquefies. At the bottom of the funnel the microbes
362 GENERAL DIAGNOSIS.
collect as an orange-colored mass. On potato it grows as a brilliant,
orange-colored, somewhat lobulated layer. The growth gives off an
odor of sour paste. (See Plate VII., Fig. 3, and Plate III., Fig. 2, 6.)
2. Staphylococcus Pyogenes Albus. It is also found in acute
abscesses, but less often than the " aureus," and is less virulent.
It is morphologically identical with the " aureus," but develops no
pigment. The surface-cultures are milk-white, and the mass at the
bottom of the liquefying gelatin is white.
3. Staphylococcus Epidermidis Albus (Welch) closely simulates
the staphylococcus pyogenes albus. It is the most common micro-
organism on the surface of the body, and is often present in parts of
the epidermis too deep for disinfection, save by heat. It is supposed
to be the usual cause of " stitch-abscess."
4. Streptococcus Pyogenes. It is found in acute abscesses, ery-
sipelas, otitis media, puerperal metritis, infectious endocarditis, pseudo-
diphtheria,- scarlatinal angina, and most purulent inflammations of a
phlegmonous character. It is the organism most commonly found in
inflammations having a spreading tendency.
Morphology. Cover-glass preparations show spherical cocci of
varying sizes, which form chains of four to twenty elements, the chains
often forming tangled masses. It is stained by the basic anilines or
by Gram's method. (See Fig. 95.)
Biological Properties. Grows in most media at a temperature
of 16° to 37° C. (best 30° to 37°), but not on potato. It is facultative
anaerobic, and does not liquefy gelatin. On plates it forms a flat,
transparent disk of about one-half millimetre diameter. In stab-cul-
tures it grows all along the puncture and forms a white opaque granu-
lar column. The death-point is 52° to 54°, ten minutes' exposure.
(See Plate VII., Figs. 1 and 2.)
Fig. 95.
Streptococcus pyogenes in pus. X 800. (FmJgge.)
Inoculated, it causes erysipelatous or phlegmonous inflammation.
5. The Tubercle Bacillus. This is seen at tunes in pus removed
from phthisical cavities, and the pus of abscesses, particularly about
glands. It may be detected by methods of staining adopted in the
examination of the sputum. Pus may be of tubercular origin, and the
micro-organisms may not be detected by the usual microscopical
methods. Its absence, therefore, does not imply the absence of tuber-
culosis. Culture-methods and inoculation should be resorted to, partic-
ularly the latter.
THE DATA OBTAINED BY OBSERVATION. 363
6. The Bacillus of Syphilis. The pus under these circumstances is
usually derived from ulcers or inflammations, or from secretions about
the vulva or prepuce. The actual relationship to syphilis has not been
demonstrated.
Lustgarten's method is as follows : After immersion for twenty-four
hours at the ordinary temperature in the gentian-violet fluid of Koch-
Ehrlich, the cover-glass preparation is removed and washed for a few
moments with absolute alcohol. It is then placed for ten seconds in
a 1 per cent, or 2 per cent, solution of permanganate of potash ; a
watery solution of pure sulphurous acid is then poured over it, after
which it is washed in water. If the preparation still shows its color,
it must be reimmersed for a few seconds in the potash solution and
then in the sulphurous acid, and again washed with water.
7. Actinomyces.
8. The Bacillus of Glanders.
9. The Bacillus of Anthrax.
10. The Bacillus of Leprosy.
11. The Bacillus of Tetanus.
12. The Bacillus of Influenza. (See Sputum.)
13. The Micrococcus Lanceolatus. The Pneumococcus. The
pneumococcus is often found in the pus of empyema and pericarditis,
whether from the pleural cavity or after it has burrowed from this
situation. It occurs in cerebro-spinal meningitis. It is easily detected
by the usual staining-methods (for which see Sputum).
14. The Bacillus Coli Communis. The bacillus coli communis is
found more commonly in infections within the abdominal cavity. (See
Fseces.)
15. The Gonococcus. It is constantly present in virulent gonor-
rhceal pus, usually within the pus-cell or attached to the surface of
epithelial cells. Morphology. Micrococci, usually joined in pairs or
fours, flattened and separated, when stained, by an unstained intercel-
lular space. Stains easily with anilines — not by Gram's method.
No other cocci are of the same shape, and at the same time within
the cells, except one which, however, stains by Gram's method. (See
Plate III., Fig. 3, b.)
Growth. Does not grow readily on ordinary media, but can be
cultivated on blood-serum and other special media, such as urine, agar,
etc. ; 30° to 40° C. is best, and a moist atmosphere is needed. Growth
is slow and often fails. Forms a thin, scarcely visible layer, with
smooth, shining surface, grayish-vellow bv reflected light — is aerobic.
(See page 308.)
Protozoa in the Pus. Cercomonads have been observed in the pus
of an empyema, probably from the lungs. Flexner has found the amoeba
dysenterica in the pus of an abscess of the jaw. It is found in abscess
of the liver and secondary abscess of the lung. (See Sputum and Fieces.)
Vermes. Filaria have been found in abscess of the liver. In the
suppuration of hydatids the pus contains membrane and booklets.
Crystals. Crystals of cholesterin are found in the pus from cold
abscesses, suppurating ovarian cysts, and foetid discharges. They are
similar to the crystals described under sputum.
364 GENERAL DIAGNOSIS.
H^matoidiist-crystals indicate a previous hemorrhage ; they are
most frequent in suppurating hydatid cysts. (See Fig. 96.) Fatty
needles are found in old pus and gangrenous exudates. (See Fig 97.)
Triple phosphates are frequently seen in pus, and are of the same appear-
ance as the phosphates hi the urine. The carbonates and phosphates
are seen in foetid pus.
Fig. 96. Fig. 97.
Pus from putrid empyema. (Eye-piece
Rhombic crystals of bsemin. (Charles.) III., obj. 8, A. Reichert.) Shrunken leu-
cocytes. Fat-crystals. (Von Jaksch.)
Chemical Examination of Pus. This does not yield any informa-
tion of diagnostic value.
Serum-albumin, globulin, and peptone are detected by methods em-
ployed in the examination of urine. Fresh pus contains sugar. After
being boiled with an equal weight of sulphate of soda and filtered the
filtrate is examined by the reagents used in examination of urine for
sugar. Pus also contains bile-pigments and biliary acids, cholesterin
and salts of sodium and the fatty acids in jaundice. Von Jaksch has
found acetone in pleural exudations.
Seropurulent Exudations. They resemble purulent discharges,
chemically and morphologically. They point to antecedent inflam-
mation.
Putrid Exudations. The exudations are brown or brownish-green
in color. The odor is penetrating and offensive. They are usually
alkaline in reaction. On microscopical examination old leucocytes and
crystals of fat, cholesterin, and hsematoidin are seen ; fission-fungi of
various forms are seen. (See Figs. 96 and 97.)
Hemorrhagic Exudations. Hemorrhagic exudations contain red
blood-corpuscles and haemoglobin in large amount. Fatty endothelial
cells are found. Quincke states that when the glycogen-reaction is
shown, if the fluid is from the pleura, carcinoma is probably present.
A positive diagnosis depends upon the discovery of the epithelial cells
(see page 364), which are seen in cases of cancer. Hemorrhagic exuda-
tions in the pleura are due most frequently to cancer, to tubercle, or to
scurvy. To determine its exact nature (as to tubercle), inoculation
and cultures are sometimes necessary.
THE DATA OBTAINED BY OBSERVATION. 365
Serous Exudations.
The fluid is clear and light yellow or straw-colored. On standing a
white fibrinous clot is deposited. On microscopical examination, red
blood-corpuscles, leucocytes, fatty globules, and endothelial cells are
found. They may be bunched in groups or scattered about. The
micro-organisms, if present, are detected with difficulty. If ulcerating
tuberculosis of the pleura is present the bacillus may be found, but
tuberculous pleurisy may exist without ulceration, and hence the fluid
is clear of the bacillus. Cholesterin-crystals are found in old serum.
On chemical examination the fluid contains more than 3 per cent, of
serum-albumin and globulin ; peptone is absent in pleural exudations ;
sugar in small amount and acetone are found.
The specific gravity of the fluid is above 1018.
Chylous Exudations. True chyle is found in fluids of low specific
gravity. Such an effusion is rich in fat and is due to leakage of
lymphatics into the peritoneal cavity. It is known as a chylous effu-
sion. Chyliform effusion is a term applied to the second variety of
effusions mentioned in this section. The fluid has the property of
chyle. Sometimes in peritoneal exudation, particularly if the patient
has been upon a milk-diet, the fluid contains fatty matter, which gives
it a milky appearance. The same character of fluid is seen in obstruc-
tion of the thoracic duct.
Special Effusions. Effusions in the Pleura. It is of the
greatest importance to distinguish the various forms of infection.
Bacteriological examination is often necessary. In purulent exuda-
tion, if micro-organisms are absent (staphylococcus and streptococcus),
it is probably tuberculous ; serofibrinous exudations are usually free
from fungi. AVhen the micrococcus lanceolatus is found it is of favor-
able prognostic omen.
To distinguish the effusion of inflammation from that of transudation
(obstruction) the specific gravity is of service. In the inflammatory
effusions the specific gravity is high ; they also contain a large amount
of fibrin and more than 3 per cent, of albumin.
Transudations.
This class of fluids is serous, bloody, or chylous. The specific grav-
ity is lower than in inflammatory effusion. The color is light and the
reaction usually alkaline. On microscopical examination but little is
found. In pleuritic effusions there may be considerable endothelium,
which, if mixed with blood, may be due to carcinoma. Serum contains
albumin and sugar, the former in great excess. Peptone is always
absent. The fluid coagulates with difficulty on boiling.
Runeberg 1 lays stress upon the diagnostic importance of the amount
1 Runeberg (J. W. ) : On the Diagnostic [mportance of the Amount of Albumin in
Pathological Transudations and Exudations. Berliner klin. Wochenschrift, L897,
No. 33.
366
GENERAL DIAGNOSIS.
of albumin in pathological transudations and exudations. His experi-
ence warrants the following statements :
1. Inflammatory processes, 4 to 6 per cent, of albumin.
2. Venous stasis, 1 to 3 per cent, of albumin.
3. Marked hydremic conditions, as in amyloid degeneration or
nephritis, 0.1 to 0.3 to 0.5 per cent.
4. Combination of two or three of the above causes, 0.2 to 6 per
cent.
In group two, even without inflammatory complications, a high per-
centage may occur in old transudations.
Contents of Cysts.
In aspiration of the abdomen and of the pleura cysts are sometimes
evacuated, the nature of which is often determined by an examination
of the fluid. It is within the province of this work to discuss hydatid
cysts, pancreatic cysts, and the cystic kidney. As tumors of the ovary
so frequently resemble tumors in other situations, it is well also to
discuss in this section the nature of the fluid withdrawn from them.
Hydatid Cysts. The fluid of hydatid cysts is clear, alkaline, and
of a specific gravity of 1010. It contains chloride of sodium in ex-
cess, grape-sugar in small amount, and very little, if any, albumin.
Fig. 98.
Contents of an ovarian cyst. (Eye-piece III., obj. 8, A. Reichert.) a, squamous epithelial cells ;
b, ciliated epithelial cells ; c, columnar epithelial cells ; d, various forms of epithelial cells ; e, fatty
squamous epithelial cells ; /, colloid bodies ; g, cholesterin-crystals. (Von Jaksch.)
On microscopical examination booklets are found, as in the sputum
from hydatid cyst of the lung, as well as portions of membrane. The
membrane is recognized by its peculiar transverse striation and the
granular appearance of its inner surface. The heads or scolices are
sometimes found. Two circles of booklets and four disks on the ante-
THE DATA OBTAINED BY OBSERVATION. 367
rior aspect cross the head, which is separated from the hinder part by
an annular constriction. (See Sputum and Faces.) If suppuration has
taken place the original nature of the cyst cannot be made out unless
hooklets are found. After the fluid has been standing in a conical
glass vessel the bodies may be found in the sediment.
Ovarian Cysts. The fluid from an ovarian cyst is of high specific
gravity, 1026, of alkaline reaction, contains but a small amount of
albumin, and does not coagulate. On microscopical examination vari-
ous forms of epithelial cells are seen, colloid bodies, and cholesterin-
crystals. If hemorrhage has taken place in the cyst the color of the
fluid is correspondingly changed, and beside the squamous, columnar,
and ciliated varieties, some epithelium in the stage of fatty degenera-
tion and red and white blood -corpuscles are seen. In colloid cysts
the usual concretions are found. (See Fig. 98.)
In dermoid cysts, in addition to the above, squamous epithelium,
hairs, and fatty-, haematoidin-, and cholesterin-crystals are detected.
Ovarian fluid contains albumin and niethsemoglobin, or paralbumin.
The latter is detected by mixing a portion of the fluid with three times
its bulk of alcohol. It is then allowed to stand for twenty-four hours,
when it is filtered. The precipitate is removed and suspended hi water.
After filtering the filtrate is seen to be opalescent, and is tested as
follows :
1 . On boiling no precipitate is formed, but the fluid becomes turbid.
2. There is no change with acetic acid alone.
3. The fluid becomes thick and of a yellowish tint when treated with
acetic acid and ferrocyanide of potassium.
4. There is a change to a violet color when treated with concentrated
sulphuric and acetic acids.
Some observers differ from the above statement in their description
of the fluid of an ovarian cyst ; all agree as to the large number of cell-
elements. At one time it was thought that the fluid contained a special
cell, but this view has been abandoned. In rare cases the specific
gravity may be lower than that of the fluid of ordinary ascites. A
fluid of low specific gravity, with a small amount of albumin, is said
to be characteristic of a cyst of the broad ligament.
Cystic Kidney. The fluid from a cystic kidney can be recognized
by the properties it derives from the renal secretion. Urea and uric
acid in large amounts point to its true source. Renal epithelium is of
the greatest diagnostic value. (See Urine.) If epithelium from the
urinary tubules can be detected after the fluid has settled the diagnosis
is absolute. (See Hydronephrosis.) It must not be forgotten that both
urea and uric acid may be found in other cysts, as in those of the
ovary, if they communicate with the urinary tract.
Pancreatic Cysts. The fluid from cysts of the pancreas is of a
specific gravity of 1012, but may be as high as 1028. It contains
cholesterin-crystals in abundance, and blood or pigment. Seruin-
albumin is present, but metalbumin is not found. Three diastatic
ferments are present :
(1) If on examination for sugar the latter is found to be a maltose,
its presence is of diagnostic significance.
368 GENERAL DIAGNOSIS.
(2) The most pronounced property of the pancreatic fluid, and that
by which we are enabled to distinguish it from other fluids, is the
power of digesting albumin without the presence of an acid.
Boas (Deutsche med. Wochensehr., 1890, Bd. xvi. p. 1095) developed
the method of examination. The fluid is to be added to milk. After
the casein is precipitated the biuret-test is applied, as follows : Heat
the substance with caustic potash and add drop by drop a 10 per cent,
solution of sulphate of copper. If digested albumin is present the fluid
assumes a reddish-violet color. No other cystic fluid can dissolve
albumin in alkaline solution.
It is not necessary that albumin or fibrin should be employed in
performing this test, as it is sufficient to add milk to the secretion ;
when in such cases the casein of the milk is precipitated, and the
biuret test is applied to the resulting filtrate, and the test compared
with a control-milk from which the casein has been removed (this can
be done by adding very dilute acetic acid with constant stirring), the
digestive property of the liquid under examination may be with cer-
tainty determined. The peptone would not be precipitated with the
albumin, and as all albumins give the same reaction as peptone with
the biuret test, the albumin should be removed before applying the
test. It is removed from the filtrate by a saturated solution of ammo-
nium sulphate. Then test the resulting filtrate with the .biuret test.
Then compare with the control-test as above.
(3) The pancreatic fluid also emulsifies fats. In large cysts, however,
particularly if of long standing, the physiological properties of the
pancreatic juice are sometimes wanting. 1 In the case referred to by
Boas and reported by Karewski, the old age of the cyst modified the
character of the fluid, and hence rendered its nature doubtful. More-
over, in the exploratory puncture the stomach was penetrated. For
two reasons the author advises against exploratory puncture. First,
the age of the cyst is not known, hence an analysis would be mislead-
ing. Second, the danger of puncturing other organs is too great. Ex-
ploratory laparotomy is preferable.
1 In a case operated on by Penrose the analysis of the fluid was as follows : Sp. gr.
1025; reaction slightly alkaline ; serum-albumin; no metalbumin; diastatic ferment
absent ; maltose absent. By Boas' method, power to digest albumin appeared to be
great ; but when the albumin remaining in the filtrate was removed from the pan-
creatic fluid, it failed to show that peptone was formed. The method, therefore,
appears to be fallacious in this class of cases. The cyst was old, and the fluid no doubt
lost its physiological properties. Cholesterin was present in enormous amount ; tyrosin-
crystals were very scarce.
CHAPTER XXII.
THE BLOOD.
The blood is a tissue, the origin, growth, and decay of the elements
of which has been the source of the greatest interest. It was the tissue
held responsible in days gone by for many diseases, the origin of which
was not known, so that skin eruptions, scrofula, and other affections
were known as blood diseases. At present we hold such affections
only blood diseases which show a demonstrable change in the physical
or morphological characteristics of the blood. There is either diminu-
tion of the red cells, increase or diminution of the white cells, or dimi-
nution of the haemoglobin. Strictly speaking, most of the blood dis-
eases now so called are really diseases of the blood-making organs — the
lymphatic glands or the spleen. It is interesting to note that as late
as 1866, J. Hughes Bennett included under diseases of the blood leu-
cocythaemia, chlorosis and anaemia, diabetes, the infectious diseases,
rheumatism, gout, and scurvy. The most recent text-book divides the
blood diseases into anaemia, with two subdivisions, and leuJccemia. Of
course, no one thinks of considering the infectious diseases blood diseases
any more than we think of considering typhoid fever an ulceration of
the intestine.
Although the blood diseases are thus limited, it is none the less true
that the blood may be the only tissue by an examination of which we can
determine the ailment from which the patient suffers. As has been
previously related, many infections are recognized in this manner only.
The symptoms of blood affections are due to the physical change hi
the blood and the effect of this altered blood upon the function or the
nutrition of the organs. Many functional symptoms thus arising may
be the first indications of blood disease, as dyspnoea or palpitation,
both very common symptoms. The symptoms may be subjective or
objective, or both. The recognition of the former comes from the
history of the disease and the complaints of the patient. The latter,
or the objective symptoms, are 'determined by the physical examination
of the patient and the examination of the blood.
We recognize scarcely any condition at the present day due t<> an
increase of the bulk of the blood or of the red cells. Plethora is hardly
a clinical identity. The symptoms of blood diseases, therefore, are the
symptoms of ancemia. In like manner, all the data obtained by inquiry
are those which belong to some form of anaemia.
THE DATA OBTAINED BY INQUIRY.
The Social History. Generally speaking, women, patients of
early age, who have been subjected to want or had unusual care, or
faulty nutrition, are those most liable to anaemia. No family predis-
24
370 GENERAL DIAGNOSIS.
position exists to a marked degree apparently, although it is well
known that " pale people " are a family class. The previous history
and the data to be elicited in investigating it are best appreciated by
turning to the classification of the cause of anaemia in succeeding pages.
The history of the disease is usually that of gradual onset, although
sudden fright or any cause producing profound shock is said to cause
acute anaemia. But the reader must again be referred to the para-
graphs just mentioned.
The subjective symptoms are general. Languor, debility, and
fatigue are complained of. The patient with anaemia may have one
group of symptoms preponderate. Thus headache, vertigo, restless-
ness, noises in the head, and neuralgias may be the most prominent
symptoms. Agam, dyspnoea and air-hunger may be the most dis-
tressing, or cardiac palpitation may be the earliest symptom, with or
without cardialgia. Then gastro-intestinal symptoms are suggestive,
although not pathognomonic. The peculiar appetite of chlorosis is
well known. The causeless vomiting of many forms of anaemia has
often been described. The bowels may be constipated or loose, varying
more particularly because of the difference in the cause of the anaemia.
Ringing in the ears has been referred to, and flashes of light, spots
before the eyes, and other visual phenomena may be complained of, and
show their origin in the state of the blood. Other alteration of the
special senses are not marked in the course of any of the anaemias.
These symptoms may occur singly or are combined in varying degrees.
THE DATA OBTAINED BY OBSERVATION.
While diseases of the blood, and especially forms of anaemia, are
recognized by an examination of the blood, much information can be
secured by general physical examination. It is true no disease would
be pronounced a blood affection unless that tissue is examined by the
modern means of research.
An examination of a case of anaemia includes a study of the appear-
ance of the patient, the color or hue of the surface, and the occurrence
of oedema. Both these subjects are carefully considered in the chapters
devoted to them respectively. Examination of the eye-grounds should
always be made, when the findings discussed in the Chapter on the
Eye may be present, if the case is one advanced in its course. No
•consideration of anaemia can be made, however, without an examination
of the organs thought to be engaged in the blood formation, hence the
state of the glands and the size of the spleen are inquired into.
Finally, as evidence of the presence of anaemia, we observe frequently
cardio-vascular phenomena. The murmurs that are heard in the heart
and bloodvessels in this disease are fully discussed in the Chapter on
Diseases of the Heart, to which the reader is referred.
Examination of the Blood.
Normal Blood. Before a consideration of the examination of the
blood, it may be well to review the elements of which the blood is
composed.
PLATE IX.
Fly. 1.
- : -
Blood from Case of Pneumonia, showing Leucocytes.
Fig. 2.
@
:
O
^0
©
(•>/ -
.
Normal Blood, showing Rouleaux and Leucocytes.
THE BLOOD. 371
The blood consists of corpuscles and serum. The corpuscles are
four : (1) Red blood-cells or erythrocytes ; (2) nucleated red blood-cells ;
(3) blood-plaques ; (4) leucocytes.
The ordinary red blood-cells measure -g-joif mcn J * ne leucocytes,
2To"o mcn - I n an adult man the red cells number from 5,000,000 to
5,500,000 to the cubic millimetre ; in an adult woman the number is
usually less, being from 4,500,000 to 5,000,000. There are 8000 to
10,000 leucocytes in a cubic millimetre of blood, or 1 to 350-600 red
blood-cells.
Varieties of Leucocytes. In the normal blood there are found the
following varieties of leucocytes : 1. Small mononuclear forms, which
are cells about the size of a red blood-corpuscle, and have a round,
large, deeply staining nucleus, surrounded by a narrow rim of non-
granular protoplasm. These are known as lymphocytes. 2. Large
mononuclear leucocytes several times as large as the foregoing. They
have a round or oval nucleus, with a relatively larger amount of non-
granulated protoplasm. 3. Transitional forms, which resemble the last
named, except that the nuclei are indented or S-shaped. 4. Poly-
nuclear leucocytes. These are usually about the size of the foregoing
variety, but they may be somewhat smaller. The nuclei are long and
irregular and stain deeply. The protoplasm contains granules that
stain by a combination of both basic and acid dyes, but by neither
alone. The cells are therefore called " neutrophiles." 5. Leucocytes
similar to the last form, except that their protoplasm contains highly
refractive granules that are stained by acid dyes alone. For this
reason they are usually called "eosinophiles." The proportion of each
variety in the normal blood is fairly constant ; lymphocytes, 15 to 25
per cent. ; poly nuclear, 65 to 80 per cent. ; mononuclear and transi-
tional forms, 6 per cent. ; and eosinophiles, 2 per cent, or less. (See
Plate IX.)
Physical Appearance. For the purpose of examination of the blood
a drop or two is quite sufficient. In olden times much stress was laid
upon the physical character of the blood drawn in bulk. The signifi-
cance of the " buffy coat" was dwelt upon by all clinicians, not alone
because of its value from a therapeutic stand-point, but also because it
was held to indicate the type of the disease that was present. At pres-
ent, however, we rely very little upon the results of the naked-eye
examination. By this examination we may be able to distinguish
bright-red arterial blood from darker venous blood, and also when
arterial blood has become deficient in oxygen from any of the causes
of venous engorgement and cyanosis. In chlorosis and hydremias the
blood is pale, as though mixed with water, while in severe leukaemias
it has a slight milky tinge. On the other hand, in carbonic-oxide
poisoning the blood becomes of a brighter red, while in poisoning with
chlorate of potash and aniline, and in grave cases of poisoning with
nitrobenzol and hydrocyanic aeid, it is brownish-red or chocolate-
colored.
For accuracy in diagnosis reliance must be placed upon instruments
of precision. These are the microscope, the luemoglobinometer, the
hsemocytometer. By this examination we determine (1) the size and
372 GENERAL DIAGNOSIS.
shape of the red cells ; (2) the morphological characteristics of the
white cells ; (3) the number of the red cells ; (4) the number of the
white cells ; (5) the presence of new elements as nucleated red cells
and myelocytes ; (6) the presence of parasites ; (7) and the amount of
haemoglobin.
Method. A drop of blood for this examination may be taken from
the lobe of the ear or the finger-tip. The surface should be thoroughly
cleansed with alcohol, and dried carefully. If the finger is used, it
should not be unduly constricted. The puncture should be made
forcibly and quickly, in order that the drop of blood may ooze freely.
If it is difficult to secure the blood, it is well to allow the first or
second drop to escape before any is collected. AVlien the flow is started
and the finger cleansed the succeeding drops are gathered on cover-
slips. If the lobe of the ear is selected, it should be steadied with the
fingers of the left hand, which at the same time stretches the skin. It
may be necessary to puncture to the depth of one-eighth of an inch, or
even more if the skin is bloodless. The puncture should be made on
the lower surface or edge of the lobe. A surgical needle, a small lancet,
or the bayonet-pointed instrument devised for the purpose, should be
used. The nib of a new steel pen, one-half of which has been broken
off, answers fully as well.
It is well to remember the precaution insisted upon by all who ex-
amine the blood frequently, to beware of "bleeders." It sometimes
becomes a very serious matter when hemorrhage is started hi a patient
who is the subject of haemophilia.
Mode of Examination. As soon as the blood flows freely, without
pressure, the apex of a drop may be touched by the cover-glass, which
has been previously prepared. The cover-glass should not touch the
skin, and as soon as it is covered by the blood it should be placed face
downward upon the slide, or if cover-slip preparations are to be made,
upon a corresponding cover-glass. The precaution must be taken to
have the slide and cover thoroughly cleansed. It is well to keep them
in alcohol or in a weak acid solution after they have been previously
cleansed with soap and water, and when removed from the alcohol
solution they should be thoroughly polished with a clean handkerchief.
The blood will then spread evenly over the surface with the slightest
pressure upon the cover-glass. If the slide and cover are warmed
slightly before using, it will not be necessary to use the pressure just
referred to.
Blood collected in this way may be examined fresh or be put aside
for staining and future examination.
Examination of Feesh Blood. By the examination of fresh
blood we learn of the presence of parasites and of the occurrence of
rouleaux formation. In a general way we can learn the number of
red and white cells respectively, the degree of coloring of the red cells,
the shape and size of the red cells, and the presence of blood-plates.
An unusual increase in leucocytes may be detected, and the diagnosis
of leukaemia made without further investigation.
Cover-sKp preparations. For the purpose of future study, and
particularly in order to determine the differential count of the white
THE BLOOD.
373
corpuscles, cover-slip preparations are made. The covers are cleansed
and the blood secured in the manner previously described. The cover-
glass, which has been touched to the summit of the drop, is let fall
upon another somewhat diagonally. (See Fig. 100.) The drop
Fig. 99.
Fig. 100.
Proper method of holding a cover-glass. (Cabot.)
Illustrating the position of cover-
glass during the spreading of hlood
films (Cabot.)
spreads over the adjoining surfaces of the cover-glass. As soon as the
spreading ceases, slide the glasses off, but do not lift them apart. Dr.
Manson introduced the use of tissue paper drawn over a slide, with
the object of getting a more uniform thickness of film. Pakes uses
this method applied to cover-glasses, which should be not less than 1^
inch by f inch. The cover-glasses are held in a clip and smeared by
means of cigarette paper cut into strips across the direction of the rib.
The cover-slip should be dried in a gas or alcohol flame at once, by
means of which the preparation is fixed.
" Fixation" may also be done by alcohol and ether, or by corrosive
sublimate solution. The cover-glass should be immersed for one-half
hour in equal parts of alcohol and ether. After such fixation malarial
organisms and nucleated red corpuscles are more readily found.
Fixation with formol is quickly secured. Dilute one part of formol
with nine times its volume of water ; dilute one part of this mixture
with nine times its value of alcohol. The resulting fluid will fix im-
mersed specimens in one minute.
Fixation of heat is best when the white cells are to be studied. By
this method it is best to put the cover-slips in a dry-heat sterilizer at
a temperature of 110° or 115°. If this cannot be done, place the
cover-slips on the end of a copper plate at least a foot long, the other
end of which is heated by a Bunsen burner or a gas flame. The cover-
slips should be placed on the plate at that point on which water boils
when dropped upon the surface of the copper. They should be placed
face downward and kept there from fifteen to twenty minutes. When
they cool they are ready for staining.
Staining. The greatest care should be taken to have a perfectly
clean, dry cover-glass, which should be handled with forceps, to avoid
moisture and soiling. (1) The prepared cover-glass, arranged as above,
should then be immersed for a few minutes in a solutii f eosin :
374 GENERAL DIAGNOSIS.
Eosin 0.5
Alcohol (70 per cent. ) 100.0
This solution should be diluted one-half before using. (2) The
cover-glass should then be dried and stained for three or four minutes
in a saturated aqueous solution of methylene blue, also diluted one-half
before using (Chunzinsky-Plehn's mixture). Or, instead of the latter,
stain for half an hour to several hours in Delafield's hematoxylin. This
hsematoxylin-stain is made in the following manner : To 400 c.c. of a
saturated solution of ammonia alum add 4 grammes of hsematoxylin-
crystals dissolved in 25 c.c. of strong alcohol. Leave this exposed to
the light and air in an unstoppered bottle for three or four days.
Filter and add 100 c.c. of glycerin and 100 c.c. of methylic alcohol.
Allow the solution to stand until the color is sufficiently dark. Then
filter and keep in a tightly stoppered bottle. The stain should ripen
for at least two months before using. For blood-work the solution
is used in its full strength. By this double stain, a modification of
JEhrlich's hcemdtoxylin-eosin mixture, the red corpuscles are stained red,
the nuclei blue, the bodies of the leucocytes light lilac and their nuclei
darker, the eosinophile granules a brilliant red.
Ehrlich' s Tri-acid Stain. The Ehrlich tri-staining mixture is the
best that can be selected for staining. Thayer says the following is a
satisfactory modification of Ehrlich's formula :
Saturated aqueous solution of acid fuchsin . . 2
Water 3
Saturated aqueous solution of orange-G. . . 6.25
Saturated aqueous solution of methyl-green . . 6
To be added, drop by drop, while shaking the solution :
Water 15
Alcohol 10
Glycerin ........ 5
The stain is spread over the cover-glass specimen with a glass rod,
and in from one to five minutes washed off with water. If the cover
glass has not been heated very long it will not be necessary to keep
the stain long in contact with the blood, although specimens which are
heated an hour require at least five minutes for the stain to take.
After the specimen is stained and washed in water it should be dried
between layers of filter paper and mounted in balsam. It can then be
examined at leisure with the twelfth oil-immersion with diaphragm
open.
Specimens heated for one or two hours stain better than those which
have been treated only a short time. The red cells appear orange or
buff, the nuclei of the colorless corpuscles green or greenish-blue, the
neutrophilic granules a violet or lilac color, the eosinophilic granules a
deep red. The nuclei of nucleated red corpuscles, when present, are
stained an intense deep green, almost black. 1
Another method much used and urged by Hewes is as follows :
The blood, after fixation, is subjected for four minutes to the modified
Ehrlich stain, which is made as follows :
1 Thayer, loc. cit.
THE BLOOD. 375
Ehrlich-Biondi-Heidenhain three-color mixture . . 1.7 grammes.
Acid fuchsin 0. 05 "
Absolute alcohol . . . . . . ". . 2 c.c.
Distilled water . . . . . . . . 18 c. c.
After immersion wash the specimen in water and then subject it
from one-half to ten seconds to Loffler's solution of methylene-blue.
Again wash the specimen, dry, and mount in balsam.
L5ffler's solution is saturated alcoholic solution of methylene-blue,
30 c.c. ; potassic hydrate (1 : 10,000 solution), 100 c.c.
The Red Corpuscles or Erythrocytes. In thickly spread blood
the cells are arranged in the form of rouleaux. If such rouleaux are
absent in a preparation thus poorly spread it is an indication of great
reduction in the red cells.
In thinly spread films the red cells are recognized by their color and
shape. They vary from 6 to 9// in diameter. The lighter colored
centre, due to the biconcavity of the corpuscle, sometimes causes con-
fusion. It must be remembered, too, that the corpuscles readily become
crenated, an appearance which may be confounded with pigmentation
or other abnormal change. In them, too, a slight molecular movement
is sometimes seen, which must not be confounded with the amoeboid
movements in dying cells or with the rapid motion of malarial pigment.
Poikilocytosis. The variations in size and shape are indications
of disease. In forms of anaemia the red cells may be larger than nor-
mal ; they may be irregular in shape, or they may be smaller than
normal. Large cells are known as macrocytes, small cells as microcytes.
Cells that are irregular in shape are known as poikilocytes. They may
be oval, pointed, angular, or reniform.
Achromia. When the red cells are stained the haemoglobin takes
the orange-G. of the tri-colored mixture of Thayer, causing the red
cells to be brilliant yellow or pale orange in tint. An idea of the
amount of haemoglobin can thus be obtained. When the haemoglobin
is diminished the centre is pallid, although in extreme poverty of
haemoglobin the colored rim may be a faint outline only (achromic
forms).
Nucleated Red Cokpuscl.es or Blasts. They contain one or
more nuclei. The stroma takes the golden acid stain and the nucleus
the pure basic stain. They are divided in accordance with their size,
and the depth of the color of the nuclei, into three varieties :
(1) The normoblast. It is the size of a normal red blood-corpuscle.
The stroma is golden in color ; the one or more nuclei are deeply
bluish-black, homogeneous. The nucleus occupies one-fourth to three-
fourths of the whole corpuscle. It is deeper in color than the nuclei
of the white blood-corpnscle. It is the parent cell of the red blood-
corpuscle.
(2) The megaloblast. They are larger than a red blood-corpuscle.
The color of the stroma is less intense than that of the normoblast, and
the nucleus is blue rather than black, and not compact and homoge-
neous. The nucleus is more compact and more clearly defined than the
nucleus of a white blood-corpuscle. It is found on the marrow of the
embryo.
376
GENERAL DIAGNOSIS.
(3) The microblast. They are smaller than the normal. There is
but little stroma, and the nucleus is deep black
Blasts are found in anaemia. An excess of normoblasts indicates
very active regeneration of blood.
Polychromatophiles. These are red blood-corpuscles in which
the stroma takes not only the normal acid staining elements but also
the blue basic or purple neutral stain. They are degenerate forms of
red blood-corpuscles.
Degenerate Forms. The coloring matter is irregularly distrib-
uted and the stroma appears disintegrated.
When thus stained we can readily find nucleated red cells, but the
fibrin or blood-plates, as a rule, are destroyed.
Counting the Corpuscles. It is of the greatest clinical impor-
tance to be able to estimate the number of red cells in a given quantity
of blood, in order that approximately at least we may know of its
globular richness. For this purpose hsemocytonieters are used.
The hgemocytometers, or blood-counters, most frequently used in
this country are those of Gowers and Thoma-Zeiss.
Gowers' instrument (Fig. 101) consists (1) of a small pipette, A,
which, when filled, holds exactly 995 cubic millimetres ; it is for meas-
FlG. 101.
Ha?mocvtometer of Gowers.
uring the diluting fluid ; (2) a capillary tube, B, graduated for 5 cubic
millimetres ; (3) a small glass jar, d, in which the dilution is made ; (4)
a small glass stirrer, e, for mixing the blood and diluting fluid in the
jar ; (5) a small lancet, f ; ((3) a brass stage-plate, c, carrying a glass
slip on which is a cell one-fifth of a millimetre deep. The bottom of
the cell is divided into one-tenth millimetre squares. On the top of
the cell rests the cover-glass, which is kept in place by the pressure of
THE BLOOD.
377
two springs proceeding from the ends of the stage-plate. 995 cubic
millimetres of the diluting fluid are measured and blown into the
mixing-jar ; then 5 cubic millimetres of blood are added and the two
thoroughly mixed. A small drop of the mixture is then placed upon
the cell, the cover-glass gently adjusted and held in place by the two
springs. From five to ten minutes should be allowed to elapse, so
that the corpuscles will have time to settle to the bottom of the cell.
The stage-plate is then placed under a microscope, and the number of
red blood-cells in ten squares counted. This number multiplied by
10,000 gives the number in a cubic centimetre of pure blood. It is
better to count a large number of squares, take the average, and multi-
ply by 100,000. This number is the product of the dilution (200) by
the square surface of the cells, 100 (10 X 10), and again by 5, the
depth of the cell : 200 X 100 X 5 = 100,000. To facilitate seeing the
fine lines marking the squares, a soft black lead-pencil should be
gently rubbed over them before the drop of diluted blood is placed on
the cell. Counting of the white cells is made much easier if the
diluting fluid is colored a pale violet with a very small quantity of
gentian-violet. The white cells then appear a distinct blue, while the
red cells are unaltered. As diluting fluids, a 1 per cent, solution of
common salt, or a 2| per cent, solution of bichromate of potash, as
recommended by Daland, may be employed ; or Toison's fluid can be
used.
Toison's Fluid. It is made up as follows : Distilled water, 160 c.c. ;
glycerin, 30 c.c. ; sulphate of soda, 8 c.c. ; chloride of soda, 1 gramme ;
methyl-violet, .025 gramme.
Another hsemocytometer is the Thoma-Zeiss (Fig. 102). It is pre-
ferred by most clinicians. It consists of a heavy glass slip («), in the
Fig. 102.
l r D |
0.100 mm.
1 fT7% I
totj mm.
1 ^j
Thoma-Zeiss blood-counting apparatus.
middle of which is a cell (B) exactly T \ millimetre in depth. The cell
is limited at the periphery by a circular gutter to prevent fluid placed
upon the cell from flowing beyond it between the slip and cover-glass.
The floor of the cell is ruled into squares whose sides are ^ nun.
Double lines mark out large squares, each containing sixteen small
378
GENERAL DIAGNOSIS.
squares. Thick, carefully ground cover-glasses (Z>) are provided in
the case. The ordinary Potain melangeur (S) is used to measure and
mix the blood. It consists of a capillary tube, the upper portion of
which is blown into a chamber (E) holding 100 c.mm. The stem of
the tube is graduated at 0.5 and at 1 c.mm.
To use the instrument, a drop of blood is obtained from the finger or
lobe of the ear, the point of the capillary tube is inserted into the drop,
and blood sucked up to the mark 1 c.mm. The point of the tube is
then quickly wiped free from excess of blood and inserted into the
diluting fluid, which is drawn up to the level of the mark 101. The
proportion of blood and diluting fluid is then 1 to 100 c.mm. The
blood and diluting fluid are now thoroughly mixed. The diluting fluid
in the stem of the melangeur is now blown out and a drop of the
blood-mixture placed on the cell. The cover-glass is adjusted carefully
to avoid bubbles and to prevent the escape of the fluid between it and
the slip. The cover-glass is now pressed firmly down until Newton's
color-rings appear, and then the slip is allowed to stand for five or ten
minutes, until the corpuscles have settled to the bottom of the cell.
The cell is ruled into 400 small squares, groups of sixteen squares
being separated by double lines. The surface of a square is T ^ square
millimetre, and the depth of the cell be-
millimetre, the space overlying
Fig.
103
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Appearance of blood in the Thoma-
Zeiss cells.
each square is 4 qVo" °^ a cu bic millimetre.
In estimating the number of corpuscles in
a cubic millimetre of blood, multiply the
number of corpuscles counted in all the
squares by 4000 and the product by the
dilution, which is 1 to 100 or 1 to 200,
according as 1 or 0.5 c.mm. of blood has
been used. The last product is now to be
divided by the number of squares which
have been included in the count, the quo-
tient being the number of corpuscles in a
cubic millimetre of blood. The results
are accurate in proportion to the care
exercised in the measurement of the blood and diluting fluid, and espe-
cially in proportion to the number of squares counted.
In the estimation of white blood-cells the pipette made by Zeiss is
employed. In this instrument the blood is diluted ten times by a
solution of one part of a J per cent, acetic acid solution to ten parts of
distilled water. By means of this solution red cells are dissolved and
the nuclei of the white cells are rendered distinct and easy of recogni-
tion. Toison's fluid, mentioned above, may also be used. The ordi-
nary Thoma-Zeiss slide is employed, and the average number of white
cells in each small square is multiplied by 40,000. To obtain accurate
results four entire fields should be counted.
The hcematokrit is an instrument devised for the estimation of the
percentage-volume of red corpuscles by means of centrifugal force. In
Daland's article will be found a full description of the instrument, and
from the same article the following: method of using it is abstracted :
THE BLOOD. 379
' ' The finger or ear and apparatus are prepared as above. An incision
is made deep enough to produce a good-sized drop of blood. This is
drawn into a hseniatokrit tube by means of suction through an attached
rubber tube, one finger being placed over the free end when the rubber
tube is removed, to prevent the loss of blood. The filled tube is then
placed in the frame of the hsematokrit and a second prepared exactly
as the first. The larger wheel is then rapidly rotated for two minutes
at seventy-seven turns of the handle-crank per minute (giving alto-
gether 20,000 rotations of the frame), and the result read from the
scale multiplied by 2 gives the percentage-volume. It has been found
by experimenting that each division upon the scale of the haematokrit
tube represents 100,000 corpuscles." This procedure is not available
for the determination of the volume of leucocytes unless the number
exceeds 20,000, at and above which number an approximate estimate
may be readily determined. A distinct white band appearing between
the red cells and the clear fluid, having the width of one line, may
be considered as representing from 15,000 to 20,000 leucocytes.
Number. The normal number of red cells — as stated previously —
is approximately 5,000,000 per cubic millimetre. They may be
reduced to 500,000. A reduction below 3,000,000 indicates grave
anaemia. When the reduction is less than 1,500,000 the anaemia is said
to be pernicious or malignant. It must be remembered that temporarily
the red cells are reduced during menstruation and lactation. At
puberty there is also a reduction. On the other hand, when the blood
is concentrated by profuse sweating or exhaustive diarrhoea, the num-
ber of red cells is increased, while they are lowered when the blood is
diluted by large draughts of fluid or by subcutaneous injections of fluid.
A cold bath may temporarily concentrate the peripheral blood, and
thereby increase the number of cells. Red cells are ahvays lessened in
the aged, and are reduced in number after great exertion. They arc
increased in number after fasting, and diminished after a meal, particu-
larly if much fluid is taken.
Oligocythemia. Oligocythemia is the name applied to a dimi-
nution in the number of red blood-cells, from whatever cause. It is
usually associated with olic/oehromcemia (deficiency of haemoglobin),
which, however, in idiopathic anaemia is absolute, not relative. Marked
oligocythemia can be detected with the microscope alone, and can be
estimated accurately with the hsemocytometer or hsematokrit. (See
Fig. 102.)
The White Corpuscles. The white or colorless corpuscles are
recognized by their absence of color, by their irregular shape and their
size, which is larger than that of the red, and by the amoeboid move-
ments which they undergo, particularly if placed on a warm stage
They number from 8000 to 10,000 per cubic millimetre. They are
readily recognized by the peculiar affinity which they have for various
aniline dyes. They appear as granular nucleated cells in stained
specimens. The method of staining has been described, and the vari-
eties of leucocytes found in normal blood indicated on page 371. In
addition to determining the number by counting, as described in the
paragraph which gives the method of counting the red cells, a so-called
380 GENERAL DIAGNOSIS.
differential count is made. This count enables us to determine the
proportion of the many varieties of leucocytes.
In counting the white blood-corpuscles, Phear advises the use of the
camera lucida. The most convenient form is the Zeiss- Abbe drawing
camera, used with the stage of the microscope in a horizontal position.
The image of the field is projected on a piece of paper or card-
board lying horizontally on the table immediately to the right of the
microscope stand. The ruled squares on the floor of the hseniocytoni-
eter cell are accurately marked out on the cardboard. The image of the
corpuscles which lie on the unruled part of the cell floor is thrown
by means of the camera on the cardboard, and the corpuscles which
appear to lie over each square are enumerated and included in the
count. It is convenient to use a mechanical stage. It is essential
that the eye-piece, objective, and tube-length used during the count
should be the same as on the occasion of marking out the squares on
the cardboard. For the dilution of the blood, that recommended
by Sherrington, 1 consisting of distilled water, 300 cubic centimetres ;
sodium chloride, 1.2 grammes ; neutral potassium oxalate, 1.2 grammes,
and methylene-blue, 0.1 gramme, is excellent. The blood-corpuscles
are not stained, but their shape aud color are preserved. The nuclei of
the white corpuscles are in every instance stained, facilitating the dis-
tinction of the white from the red corpuscles. For the differential
count of the white corpuscles it is desirable to work with an immer-
sion lens.
Differential Counting. After the specimen is carefully stained with
the triple solution it is ready for differential counting of the white cells,
as well as determining the presence of nucleated red cells. To make
the differential count a large number of leucocytes should be studied.
The best plan to pursue is to begin at the upper left-hand corner of the
blood film and count across the film to the right-hand corner. Then
move the slide so that an adjacent field comes into view, when the pro-
cess is to be repeated. In this manner the entire field is covered. In
ordinary leucocytosis a thousand leucocytes can be seen in a seven-
eighth inch cover-glass specimen. We may find an abnormal variety
of leucocytes ; an abnormal proportion of some one of the normal
leucocytes ; an abnormal number of all the leucocytes.
Fluid Preparations. Dr. A. G. Phear lays stress on the advan-
tages of fluid preparations over the cover-slip method. In the cover-
slip method leucocytes are inevitably flattened and distorted in the
process of making and fixing the film ; some are washed away during
the staining ; others obscured by the red corpuscles. In the fluid
preparation the white cells are fixed and preserved as approximately
spherical bodies ; camera lucida drawings and measurements of them
could be relied on as accurate. A solution of methylene-blue (0.2 per
cent.) in 40 per cent, alcohol is used for diluting the blood. The red
corpuscles are laked so that the white cells alone remain conspicuous.
" A small quantity of the diluting solution is added to a drop of blood
on a glass slide and the two are thoroughly mixed by directing a cur-
1 Proceedings of the Koyal Society, vol. lv.
THE BLOOD. 381
rent of air through a pipette on to the surface of the fluid. The fluid
is allowed to spread as a thin film under a cover-glass and the edges
then sealed with vaseline." The contour of the normal polymorpho-
nuclear cells is rounded. Their diameter vary from 9 to 10//. The
complex nucleus can be made out by changing the focus, the nucleus
being, in fact, " an undivided elongated body, in places deeply con-
stricted, elsewhere bulged into rounded lobes." The lymphocytes and
the large hyaline cells represent the extremes of cells, differing in the
amount of protoplasm around the nucleus ; all grades are readily
found. The nuclear diameter is fairly constant in these cells, varying
only between 4.5 and 5.5//. Large oval cells, as much as 14//. in
length, with the nucleus large and irregular, usually reniform, are
seen. The protoplasm becomes rapidly and uniformly stained an
opaque blue color with methylene-blue. The coarsely granular or
eosinophile cells (diameter from 9.5 to 10.5//) are at once recognized
in the film prepared with methylene-blue solution, notwii hstanding
the absence of an acid dye ; the large refractile granules are tinged
with a greenish color. The cells containing basophile granules (diam-
eter about 8//) have a characteristic appearance. The protoplasm con-
tains granules of medium size, many of which are aggregated in one
or more deeply stained clumps near the surface of the cell. The non-
granular part of the protoplasm is stained a peculiar mauve or purple
color. The nucleus is usually massed at the centre of the cell, and
stains a slate or grayish-blue color.
Separate counts over different areas of one preparation gave uniform
results, showing that the blood was evenly mingled with the diluting
fluid. Not less than 500 cells should be enumerated at a time ; the
more the better. It was desirable to use a mechanical stage and to
work with an immersion lens. The blood should always be procured,
if possible, before the first meal of the day is taken, since this is the
time at which the influence of meals is least likely to be evident.
Leucocytosis. Leucocytosis is a temporary increase in the number
of white blood-cells of the same morphological varieties as in health,
with an excess of the polynuclear forms (neutrophile leucocytosis).
Such increase may be physiological or pathological, as indicated in the
following :
Physiological Leucocytosis. (1) Pregnancy (14,000 and up-
ward) ; (2) during digestion (from 1000 to 7000 above normal ; more
in children) ; (3) new-born (12,000).
Pathological Leucocytosis. An excess of leucocytes occurs in
the following diseases: (1) Leukaemia; (2) pernicious anaemia; (3)
chlorosis; (4) diseases of lymphatic glands; (5) disease accompanied
by exudations, as pleurisy, 'pericarditis, meningitis, polyarthritis, and
especially croupous pneumonia; (6) inflammatory condition associated
with exudation, as appendicitis, pyonephrosis, perinephritic abscess,
tonsillar and retropharyngeal abscess, acute pancreatitis, cholangitis;
(7) many acute infectious diseases, as varicella, variola, vaccinia, epi-
demic cerebrospinal meningitis ; cholera, typhus fever, trichinosis, glan-
ders, diphtheria, scarlet fever, erysipelas, pyaemia and septicaemia,
rheumatism, abscesses, and gangrenous inflammation ; (8) after bemor-
382 GENERAL DIAGNOSIS.
rhage and (9) just before death, leucocytosis of agony. On the other
hand, leucocytosis is not found in uncomplicated cases of (1) influenza
{Boston Medical and Surgical Journal, March 22, 1894) ; (2) uncom-
plicated cases of typhoid fever • (3) tuberculosis when not associated
with cavity-formation or hyperplasia of lymphatic glands (Stein and
Erbman, JDeutsch. Archiv. f. klin. Med., Bd. 56) ; (4) many forms of
carcinoma and sarcoma, gastric ulcer and benign pyloric stenosis
(Schreuger, Zeitschr. f. klin. Med., 1895, 27, 475), although it may be
present in gastric carcinoma.
Leucopenia. Diminution of the number of leucocytes is seen (1)
in starvation, as in cancer of the oesophagus ; (2) the latter weeks of
typhoid fever ; (3) leukaemia complicated by infection.
Diagnostic Value. The value in diagnosis of determining the
presence of leucocytosis is great. Its absence excludes the first series
of cases ; its presence the last. If leucocytosis is present in the course
of, or convalescence from, typhoid fever, it pomts to a complication, as
thrombosis. A post-febrile rise, due to a complication, may be distin-
guished from a true relapse by an increase of the white cells.
It is best determined with a hsemocytometer. Dry preparations,
according to Ehrlich's method, are necessary for a study of the various
forms of leucocytes. (See under Leucocythaemia, page 396, and
Plate X.)
Increase of Special Leucocytes. Lymphocytosis. A relative
increase in the lymphocytes, with or without a total increase of leuco-
cytes, is seen in infants, and is a common accompaniment to rickets
and hereditary syphilis. In some forms of scurvy it is also found.
In adults lymphocytosis occurs in chlorosis and pernicious anaemia and
in secondary ansemia of syphilis and typhoid fever. It occurs in haemo-
philia, in adenitis, and splenic tumors. Cabot states that it is also
found at the end of scarlet fever and measles, in pneumonia with de-
layed resolution, and in some forms of phthisis. The larger forms of
leucocytes are seen. Absolute lymphocytosis occurs in lymphatic
leuksernia.
Eosinophilia. An increase in the percentage of eosinophiles, with
or without leucocytosis, is seen in many affections of the bones, in affec-
tions of the skin, and in diseases of the genital apparatus in females.
It is also seen in certain disturbances of the sympathetic nervous
system, as in cyanosis and vasomotor troubles associated with menstru-
ation and pregnancy. The bone diseases in which the eosinophiles are
increased are osteomalacia, sarcoma, carcinoma, and in those affections
of the bone and marrow with which pernicious ansemia and splenic
myelogenous leuksernia are seen. The skin diseases are urticaria,
pellagra, herpetiform, dermatitis, and pemphigus, in herpes, eczema and
prurigo, psoriasis, lupus, and nryxoedema. In the eruption of scarlet
fever and syphilis they are increased, but not in measles or smallpox.
In various affections of the uterus and ovary, in functional disorders
connected with the same, the eosinophiles are increased. They are
also increased in gonorrhoea and prostatitis. They are increased in
those infections in which Neusser's granules are found. Thayer, in
Osier's clinic, has found marked increase in the eosinophiles in trichi-
PLATE X.
FIG. 1.
*\ uch as
tuberculosis, syphilis, cancer, rheumatism, scrofula, scurvy, rickets,
Bright's disease, chronic catarrhal gastritis, and others. The anaemia
here may be due to the malnutrition and interference with digestion
392
GENERAL DIAGNOSIS.
brought about by the disease, or, as iu the case of Bright's disease,
in part to the direct loss of albumin, and in dyspeptic conditions to
inability to take and assimilate food.
In many cases of simple symptomatic anaemia the spleen may become
progressively enlarged, probably secondarily. In other cases there is
an enlargement of the spleen in Hodgkin's disease. In no case is
there a primary splenic anaemia.
V. Anaemia of Malnutrition. Anaemia may also be the result of
malnutrition from deficient or improper food, or from the poisonous
influences of unsanitary surroundings.
Chlorosis.
Chlorosis, or chloro-anaeniia, is a form of anaemia occurring especially
in young girls about the period of puberty, and characterized by great
pallor of the skin and mucous membranes, with a greenish tint of the
skin, a pearly eye, languor, weariness, suppression or irregularity of
Fig. 107.
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Chlorosis. Straight lines, number of red cells: small dots, percent, of haemoglobin; large dots,
number r>f white cells.
menstruation, venous hum in the vessels, dyspnoea, palpitation, dizziness,
neuralgias, and an unstable condition of the nervous system. In spite
of the extreme pallor there is usually but little loss of flesh. The skin
PLATE XI.
o *& .*£• «%»
©0
Blood from Case of Chlorosis, showing slight Staining of the Red
Blood-eorpuscles, and presence of Mononuclear Leucocytes.
(Oc. 4. ob. J 1 * immersion.) Drawn by J. D. Z. Cbase.
FTG. 2.
o °
o
O
Blood in Pernicious Anaemia, showing Macrocytes
and Mierocytes.
(Eosin stain, oc. 4. i>b. ^ oil immersion.) Drawn by J. D. Z. Chase.
THE BLOOD. 393
may be pigmented, especially around joints. The bowels are usually
constipated ; the urine abundant, pale, and of low specific gravity.
The digestion is disturbed, the appetite capricious, and the patients
sometimes crave unwholesome things, such as earth, slate-pencils,
vinegar, and the like. Hyperacidity of gastric juice is commonly
present. A systolic murmur over the base of the heart is common.
Gastralgia is more common than in other forms of anaemia.
The changes in the blood are very important. There is always a
marked reduction in the haemoglobin, the percentage falling sometimes
to 30 or 25 per cent, of the normal. The red blood-cells are usually
also reduced, but not in the same proportion as the haemoglobin. For
example, there may be 4,000,000 red cells, but only 30 per cent, of
haemoglobin. Sometimes there is no diminution in the number of red
cells ; the latter, however, appear pale (achromia), vary considerably in
size, microcytes and occasionally poikilocytes are present, and, in severe
cases, nucleated red corpuscles are found ; occasionally macrocytes
occur, but in general the size of the red cells is below that which is
usually found. The number of leucocytes varies but little from the
normal, but there may be a slight increase. Occasionally there is a
rise of temperature, but it is probably due to some complication.
(See Plate XL, Fig. 1.)
The cause of chlorosis has not been determined satisfactorily. Vir-
chow has established the existence of congenital narrowing of the blood-
vessels. Sir Andrew Clark thinks it is due to the absorption of
poisonous matter from the intestine ; the great benefit that follows
saline purgatives in many cases indicates that faecal toxaemia is a factor
in these cases. Forchheimer 1 also looks upon it as intestinal in origin.
Sex and puberty are predisposing causes ; but chlorosis may occur
in boys, and appear in girls before puberty, and in young women con-
siderably after that period. The prognosis is favorable ; it may, how-
ever, be complicated with gastric ulcer, chorea, tuberculosis, and endo-
carditis. Kecovery is often slow and interrupted by relapses.
Pernicious Anaemia.
Pernicious or idiopathic anaemia is a form in which the diminution
of red blood-cells reaches an extreme degree. It occurs without ade-
quate known cause, and runs a progressive course with remissions ; it
usually terminates in death.
The disease usually develops slowly and insidiously, the patient pre-
senting the ordinary symptoms of anaemia — pallor, weakness, shortness
of breath, palpitation, venous murmurs, loss of appetite, and impaired
digestion. As the disease progresses the skin becomes of a pale Lemon
hue, weakness and dyspnoea increase, the patient has attacks of dizzi-
ness, faintness, and ringing in the ears ; there may be slight (edema,
and hemorrhages from the nose, the bowels, and into the retina occur.
The hemorrhages are small and distinct in the skin and mucous mem-
branes. The urine is of low specific gravity, and usually contains an
increased amount of uric acid. According to Hunter, the mine should
1 Trans. Assoc. Amer. Phys., 1893.
394
GENERAL DIAGNOSIS.
be dark and contain a pathological amount of urobilin, some renal
epithelium, a few casts containing blood-pigment, and an increased
amount of iron. The bowels may be disturbed by diarrhoea.
A peculiarity of the disease is the occurrence of fever of an irregular
type. The temperature rarely rises higher than 102° or 103° in the
evenings, and is followed by a morning remission. It is not usually
present in the early stages of disease, may be absent for weeks at a
time when the disease is fully developed, and may cease entirely in the
later stages. 1
In spite of extreme exhaustion, anaemia, and wide-spread functional
disturbance, there is no emaciation ; the patient appears well nourished.
The blood appears pale and watery to the naked eye ; there is diffi-
culty in obtaining by puncture a sufficiently large drop for examina-
tion. The specific gravity is lowered, often being 1028 instead of
1055. It has been found deficient in fibrin, iron, and nitrogen.
The blood-changes in idiopathic anaemia are characteristic, and are
essential to the diagnosis of the disease. In brief they are : (1) Very
great reduction in the number of red blood-cells ; (2) an absolute dirni-
Fig. 108.
85'-'
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-— •
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Pernicious anaemia. Straight lines, number of red cells ; small dots, per cent, of haemoglobin ;
large dots, number of white cells.
nution in the amount of haemoglobin, but as compared with the number
of red cells there may be a proportionate increase ; (3) considerable
- 1 See "Idiopathic Anaemia: A Report of Three Cases." Musser, Phila. Co. Med.
Soc. Trans., 1885.
THE BLOOD. 395
variation in the size of the cells, the average size of the cells probably
being larger ; (4) poikilocytosis ; (5) nucleated red blood-cells ; (6)
degenerative cells. (See Plate XI., Fig. 2.)
Redaction in the number of red blood-cells (oligocythemia) reaches
a more extreme degree in pernicious anaemia than in any other disease ;
the number often falls below 1,000,000, and in one case reported by
Quincke 1 the number was only 143,000 per cubic millimetre. The
shape of many of the cells is altered ; they are oval, elongated, bent,
or have projections of their substance (poikilocytosis). The size of the
cells varies ; there are microcytes and megaloblasts ; but the occur-
rence of a distinct proportion of large nucleated red blood-cells (megal-
oblasts) is regarded by Ehrlich as almost diagnostic. The average
size of the red cell seems to be increased, and so is the proportionate
amount of haemoglobin in each cell. The latter is a very character-
istic symptom (the only one, according to Hunter). There are also
red corpuscles which are stained by methylene-blue ; these are regarded
as degenerative by Ehrlich. The leucocytes are " usually diminished
in number, showing a relative increase in the small mononuclear ele-
ments (lymphocytes, small transparent forms), while the multinuclear
elements are relatively diminished, sometimes being under 50 per
cent." 2
The blood condition is not constant, but is subject to wide varia-
tions. Von Noorden has recently found that in a very short time a
change in the form of the blood, a ' ' formal " crisis, may occur. A
"formal" overflow of the blood with polynuclear leucocytes and
nucleated red blood-cells takes place before a period of improvement.
Whereas, before a period in which the blood becomes worse and before
the final stage, the blood becomes poor in leucocytes and nucleated red
blood-cells. 3
Secondary sclerotic changes in the spinal cord cause late symptoms
of locomotor ataxia.
The etiology of the disease has not been determined satisfactorily.
It is more common in Germany and Switzerland than in other parts
of Europe or in America. It occurs most frequently after the twen-
tieth year, and between that and the age of fifty. Excluding the
influence of pregnancy and parturition, sex makes no difference. Pre-
vious exhausting disease, chronic gastric and intestinal catarrh, great
physical over-exertion, exposure, great shock or fright, precede in
certain cases the development of the disease. It is probably due to
faulty hsematogenesis and haemolysis.
Petrone and Halst regard the disease as infectious and its genu
identical with that found by Frankenhauser. Von Jaksch supposes
that it is brought about by a living contagium. Hunter traces the
cause to a poison produced by bacteria in the gastro-intestinal canal.
Diagnosis. The most important diagnostic features of the disease
are extreme oligocytha?mia, relatively high percentage of haemoglobin
(color-index high), great poikilocytosis, which may, however, occur in
1 Deut. Arch, fur klin. Med., Bd. xx.
2 W. S. Thayer: Boston Med. and Surg. Journ., February 16 and 23, 1893.
3 Quoted by Weiss, Diagnostisches Lexikon.
396 GENERAL DIAGNOSIS.
any severe anaemia, a noticeable number of large nucleated red blood-
cells (gigantoblasts), an average increase in the size of the cells, and
all this without emaciation or discoverable local disease which can bear
a causative relation to the anaemia. In addition, retinal, subcutaneous,
and submucous hemorrhages, a urine with high specific gravity, high
color, with urobilin in excess, alternating with urine of low specific
gravity, in the absence of organic disease, point to pernicious or idio-
pathic anaemia.
Leucocythsemia.
Leucocythaemia, or leukaemia, is a disease of the blood-making organs,
characterized by great and persistent increase in the white blood-cor-
puscles ; by a diminished number of red blood-cells, which are altered
in shape and size, and display nucleated and degenerate forms ; by a
lessened amount of haemoglobin, and by changes in the spleen, lym-
phatic glands, or medulla of bone. It is a persistent and progressive
cellular proliferation. It resembles a tumor of solid tissue in its cel-
lular overgrowth. The disease occurs twice as frequently in men as in
women, and two-thirds of the cases appear between the twentieth and
fiftieth years. In women, pregnancy, parturition, and the cessation of
menstruation are causative factors, while in both sexes depressing influ-
ences upon body or mind and antecedent disease, particularly malarial
fever, have a distinct influence.
The first symptom noted is generally enlargement of the abdomen ;
subsequently the patient complains of pains in the splenic region, weak-
ness, dyspnoea, hemorrhage, oedema, and digestive derangements. Occa-
sionally profuse hemorrhage from trifling cause, as the drawing of a
tooth, has been the earliest symptom noted. The increase of white
cells and diminution of red cells is progressive, and soon makes itself
evident in the pallor of the skin and mucous membranes, and in
increasing weakness and dyspnoea. Pallor is not a constant symptom
of leukaemia. A high grade of color is consistent with advanced
leukaemia.
In the so-called spleno-medullary form of the disease the spleen
steadily enlarges, but may attain considerable size before the patient
becomes aware of it. The enlargement is not usually painful, but gives
rise to a feeling of distention, weight, and dragging. There may be
tenderness on palpation and pressure, and sometimes the patient com-
plains of sharp, stabbing pains, due either to attacks of local peritonitis
or to sudden enlargement of the spleen and consequent stretching of
the capsule. The splenic enlargement is uniform, so that its shape and
characteristic notch are unchanged. Moreover, the spleen remains in
contact with the abdominal walls, lying in front of the splenic flexure
of the colon, pushing aside the descending colon and small intestine,
moving with respiration, and presenting the usual physical signs of a
solid organ. Not infrequently the enlargement is so great as to fill
the left hypochondriac and iliac regions, and reach beyond the middle
line toward the right groin. Sometimes a venous hum can be heard
over it. Pallor, however, is not a constant symptom ; more frequently
the cheeks are flushed and the lips red.
PLATE XII.
o.,-
\
\
y
«-*
\
100,000
\
f
1
\
90,000
V
i
i
\
80,000
\
i
\
\
70,000
\
i
/
\
60,000
V
\
/
V
50,000
\
/
/
40,000
V-
„^»
30,000
Leuktemia. Straight line, red cells ; small dots, hEemoglobin ; large dots, white cells.
The essential points in the diagnosis of leucocythsemia are : 1. Such
an excess of leucocytes in the blood that the ratio of white to red falls
below 1 : 50 or 1 : 20 ; if the ratio is higher, the white cells should
show a progressive increase. The individual leucocytes vary in size
and characteristics, as already described. 2. Enlargement of the spleen
or lymphatic glands. 3. The occurrence of hemorrhages and dropsies
unexplainable by disease of the heart, kidneys, or other organs. 4.
The symptoms of anaemia of a high grade, as dyspnoea. 5. Leukemic
retinitis. 6. Anaemic fever. 7. The presence of the myelocyte of
Ehrlich, " mast-cells," and nucleated red blood-cells. 8. Specific
gravity below 1040. 9. Excess of uric acid in the urine.
1 W. S. Thayer, loc. cit.
THE BLOOD. 399
The lymphatic form of the disease is rare. It is characterized by
enlargement of the lymphatic glands and by the great increase in the
proportion of the lymphocytes. The total increase in the colorless
elements is not so excessive. Eosinophils and nucleated red cells
are rare. The myelocyte of Ehrlich is not present. A case of a purely
myelogenous form has never been authenticated. Combination-forms
may also occur. It must be remembered that the number of myelo-
cytes is no indication of the involvement of the bone-marrow.
In secondary or so-called splenic ancemia we find the same enlarge-
ment and the general symptoms, though hemorrhage is not so common.
Leucocythsemia is distinguished from it by the great excess of leuco-
cytes and by their special characteristics.
In lymphadenoma, or Hodgkin's disease, there is extreme anaemia,
though the excess of leucocytes found in leucocythsemia is seldom
reached, and the cells are smaller. The glandular enlargement of
lymphadenoma is an early and constant symptom, the spleen not being
much enlarged. The cervical glands are the ones usually first in-
volved.
The duration of leucocythamiia is usually two or three years ; but
some cases terminate in six months or less, and some last six or seven
years. The size of the spleen and the degree of oligocythsemia appear
to have no influence. Gowers states that the cases in which enlarge-
ment of the lymphatic glands is an early symptom run a course appar-
ently much more acute than others, but he admits that the number of
such cases is comparatively small.
Death results most frequently from gradual loss of strength. Hem-
orrhage from various organs and surfaces is the immediate cause in
many cases. It occurs in about three-fourths of the cases, and, when
not directly fatal, increases the pre-existing asthenia. Diarrhoea and
pulmonary complications are not infrequent causes of death.
Acute Leukcemia. Cases have been described, especially in children,
in which there is a diminution of red cells of haemoglobin. Nucleated
red cells are present as well as an excess of white blood-corpuscles,
which consist almost entirely of large mononuclear elements, without
granulation. There is usually fever, and the disease runs a course
much resembling an infectious one. The lesions are leucocytic infil-
tration of the various organs. 1
1 See "Acute Leukaemia." Fussell, Jopson, and Taylor, Assoc. Am. Phys., vol. x.
1898 ; and Musser, Trans. Phil. Co. Med. Soc, 1887.
CHAPTER XXIII.
THE MORBID PROCESSES AND THEIR SYMPTOMATOLOGY.
Knowledge of symptoms of morbid processes essential ; they control conclusions drawn
from data. — Morbid processes are few. I. Alterations in blood and circulation:
Ansemia and plethora — Hyperemia, active and passive— (Edema and dropsy
— Thrombosis and embolism — Hemorrhage — Blood-pressure. II. Disturbances
of nutrition: Inflammation — Gangrene and necrosis — Fever — Atrophy and
hypertrophy. Degenerations : Albuminous — Fatty — Colloid — Mucous — Pig-
mentary — Calcareous — Amyloid — Fibroid. III. Anomalies of growth: Tumors
— Cysts — Cancer.
Although we may have secured all the data obtainable by inquiry
and by observation, and, if possible, made a diagnosis based upon them,
it frequently happens that the conclusion arrived at is not final and per-
haps cannot be, from the nature of the case. We are prompted, there-
fore, to view the case from a different stand-point, to utilize our
knowledge of the phenomena of morbid processes, and, for the purpose
of comparison, to review the features of such as apparently resemble
the process under consideration. Thus, for instance, in an obscure
case of fever, the objective and subjective phenomena have been fully
inquired into —we are unable to decide whether the disease under con-
sideration is a septic process with obscure lesion, a form of miliary
tuberculosis, or of malignant endocarditis. The known symptoms of
each are considered (our knowledge of such symptoms depending upon
our knowledge of the phenomena of the respective morbid process) and
compared with the symptoms presented by the case in question. In
this manner a diagnosis by exclusion is made. Moreover, after a diag-
nosis is made, a review of the symptomatology of morbid processes
serves as a check upon the conclusions that have been reached. We
should also, after making a diagnosis, compare the symptoms of the
process as exhibited in the patient with the symptoms which we know
to be common in the suspected disease.
It is necessary, therefore, that the student should fully know the
symptoms of morbid processes. Each process is characterized by
special phenomena by which it can be recognized. The symptoms
are modified by the function and anatomical structure of the organ in
which the process takes place. Thus the pathological products of in-
flammation of the mucous membranes of the bronchial tubes and of
the stomach are the same, but. the symptoms differ, because of the
difference in their functions, and hence we have cough in the former
case, in the latter, vomiting. Very frequently the symptoms differ
because of the physical alterations. Thus inflammation of the pericar-
dium is similar to inflammation of the pleura, but the pressure-symp-
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 401
toms of pericarditis are entirely different, because of the anatomical
relations, from the pressure-symptoms of pleuritis.
The morbid processes are not many. They include : I. Alterations
in the blood and circulation ; II. Disturbances of nutrition ; III.
Anomalies of growth.
I. Alterations in the Blood and Circulation. The composition
and distribution of the blood affect all the tissues for weal or woe.
The quantity of the blood alone will be referred to ; changes in quality
will be considered under diseases of the blood. Practically the symp-
toms, when the quality is affected, are those of anaemia plus the symp-
toms (physical and functional) of the primarily diseased organ — as the
spleen in leucocythsemia. The quantity may be increased or dimin-
ished.
1. Increased Quantity of Blood, or Plethora. Formerly
this was considered an entity, and the symptoms of flushed face, hot
and full head, throbbing pain, throbbing temporals, a full, strong
pulse, sluggish intellect, were thought to indicate an excess of the
general bulk of the blood. True plethora is rarely permanent. If
transitory, the veins and not the arteries are overfilled. The symp-
toms are not due to general plethora but to excess of blood-pressure
or to special fluxions of blood to superficial vessels, determined by a
nervous mechanism. Increase in one of the cellular elements of the
blood, the leucocytes, is not a plethoric condition.
2. Diminished Quantity of Blood, or An-emia. Anaemia em-
braces the diminution of the bulk of the blood as well as of the red
blood-cells and their haemoglobin.
The term might be used for loss of the water of the blood, as in
cholera Asiatica (see Infectious Diseases), or in serous purging. The
symptoms are those of collapse.
Oligaeinia or spanaeruia are terms that may be used to define the
general thinness or poverty — atrophy of the blood. Clinically, anaemia
is divided into simple anaemia, general poverty of the blood ; per-
nicious or idiopathic anaemia, reduction in the number of red cells ;
chlorosis, reduction in the quantity of haemoglobin ; leucocythaemia,
relative loss of red and increase of white corpuscles. (See Diseases of
the Blood.)
3. Local Disturbance of the Circulation. A. Hyper jemia
or Congestion. The process may be acute or chronic. It is usually
local, although it may be general. When the latter, many organs may
be simultaneously involved from a common cause.
Acute Hyperemia . The acute or active form of hyperaemia is
always local and arterial. There is an excess of blood in the part.
If the skin is the seat, there are redness and increased heat, and throb-
bing or pulsation may be seen. The parts are swollen. The excita-
bility of the nerves is increased, with local symptoms of warmth, fulness,
or itching.
The morbid blushing, or flushing, that occurs at the menopause or
reflexly from internal disorder is a hyperaemia, and in erythema of the
skin hyperaemia is also very marked.
26
402 GENERAL DIAGNOSIS.
Causes. Arterial hyperemia is caused by (1) neuroparalysis of the
inhibitory or vasoconstrictor fibres, of the cervical sympathetic,
splanchnic, and other sympathetic and some mixed nerves, as the
sciatic ; (2) neurotonic stimulation of the actively dilating or vaso-
motor dilator nerves, as the chorda tympani. There is relaxation of
the arterial walls. This may also occur directly through the vasomotor
system, being induced by heat, electricity, or chemical irritants, or
from paralysis of muscular fibres, after spasmodic contraction due to
cold, as in frost-bite.
(1) Neuroparalytic Hypercemia. Destruction of the cervical sympa-
thetic nerve by abscess, wounds, or a tumor pressing upon it, produces
hypersemia of the side of the face, rise of temperature, and contraction
of the pupil. Later on the vascular conditions are reversed. Lesion
of the fifth nerve, or one of its branches, causes hypersemia of the iris,
the conjunctiva, the cheek, the gums, and other structures supplied by
it, with associate loss of sensation followed, by atrophy. The sensory
symptoms have nothing to do with the vascular paralysis.
(2) Neurotonic Hypercemia. ' After wounds of the brachial plexus
hyperemia of the fingers is seen. (See Fingers.) The local temper-
ature rises and there is neuralgic pain. Local hypersemia with hyper-
sesthesia, known as erythromelalgia, belongs to the same class, being
due to affections of the nerve-trunks, or the peripheral nerve-endings.
It must be remembered that a reflex hypersemia is possible.
Cheonic ob "Venous Hypee^emia (passive congestion). The blood
accumulates in the veins, and, by backward pressure, in the capillaries.
The venous capillaries are over-distended and, as compared with the
arterial, much enlarged. They contain venous blood.
Any congested part, as the exterior, is bluish or purple in tint,
often swollen (clubbed fingers), cooler than normal, with lessened sen-
sation, and without pulsation. (See Cyanosis.) The dependent parts
are first affected, as the legs, or the lungs. In fevers a weak heart and
recumbent posture predisposes to congestion of the lungs.
Causes. Obstructive heart and lung diseases cause general venous
congestion. Local venous congestion is caused by tumors, the preg-
nant uterus, or collections of fseces pressing upon the veins. It is also
caused by inflammation of the veins, and thrombosis.
B. Local Anaemia. This may be due to arterial thrombosis or
embolism, arterial obstruction through endarteritis, or to arterial spasm.
Raynaud's disease is a form of arterial spasm. The grave effects of
arterial obstruction are seen in cerebral anaemia from endarteritis, or
myocarditis from obstruction of the coronary arteries.
C. (Edema and Dbopsy. The changes of the circulation which
produce these conditions have been referred to in previous chapters of
this book. The symptoms and signs of the condition are also noted
in the same section.
D. Theombosis and Embolism. The student should be familiar
with the symptoms of these conditions, and, what is fully as important,
with the causes that give rise to them. Thrombi may form in the
heart, the arteries, or the veins. Emboli may be formed in either
heart or vessels, but lodge in the vessels only.
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 403
Thrombosis. The symptoms of thrombosis are : 1. Mechanical.
The channel is obstructed ; hyperaeinia, engorgement, oedema, and
cyanosis arise. Its most typical form is seen in femoral thrombosis,
with cyanosis, and oedema of the leg. When an artery is obstructed
the symptoms are like those of occlusion under other circumstances (see
Embolism) ; when a vein, the mechanical symptoms vary according
to the particular vein affected. Thus, in thrombosis of the coronary
vein, the heart's action is interfered with. In thrombosis of the portal
vein, jaundice (not because of the obstruction), oedema (ascites), and
congestion of mucous membranes (gastric and intestinal) occur, as from
obstruction in any vein. In thrombosis of the cerebral veins, disturb-
ance of the function of the brain is seen ; of the pulmonary veins,
dyspnoea. 2. Inflammatory or septic. If it should happen that the
thrombosis developed secondarily to an inflammation of septic origin,
as in the extension of an inflammation into the radicles of the portal
vein from an abscess about the rectum or vermiform appendix, the
liver would be infected with micro-organisms. An infectious inflam-
mation with chills, fever, sweats, and other phenomena of a septic
character would result (pyelophlebitis). 3. Embolic. From the throm-
bus emboli are sometimes swept off ; hence, embolic symptoms arise in
the course of thrombosis.
While thrombosis is, as a rule, easily recognized, it is necessary to
call attention to the very great importance of going a step farther to
look for the cause. A thorough knowledge of the causes of thrombosis
often leads to the diagnosis of a thrombus when without such knowl-
edge its presence would never have been suspected. The causes are
not many. 1. Stagnation or stoppage of blood. It is seen chiefly in
the veins and the heart. External pressure upon the veins : as upon
the pelvic veins in pregnancy or abdominal tumor, upon the hemor-
rhoidal veins, upon the portal veins by tumor, upon the pulmonary
veins by mediastinal tumor. It must be remembered that some change
takes place in the internal coat of the vein also, but that the pressure
is primary. Then we have weakness of the heart as a cause of stagna-
tion. Feeble contractions lead to the formation of cardiac thrombi.
2. Thrombosis from changes in the vessel's walls. The change is
usually inflammatory and often proceeds from wounds. If the wound
was septic, the inflammation will be septic. In the heart, endocarditis ;
in the aorta, atheroma leads to the development of thrombi. 3. Throm-
bosis from the entrance of a foreign substance into the vessels. A
carcinoma or other new growth inav extend into the veins. Micro-
organisms penetrate the vein and cause inflammation and thrombosis,
or infect a previously existing thrombus. The clot is then broken and
distributed throughout the system, causing pyaemia. 4. Thrombi are
produced by extension. A clot enlarges by coagulating the blood next
to it. A large venous distribution may become blocked, as, first the
uterine veins, then the internal iliac, then the external iliac, and after
that the femoral — causing the affection which frequently occurs in the
puerperal form, phlegmasia alba dolens.
Embolism. An embolus is a substance which is swept into and
plugs a vessel. It may be a fragment of a blood-clot (thrombus), vege-
404 GENERAL DIAGNOSIS.
tations from valves of the heart, parasites, new growths -which had
entered the veins, fat, or air. If obstruction of the vessel alone is pro-
duced, the embolism is said to be simple ; if a new process, as inflam-
mation, accompanies the obstruction, it is specific. Fragments from a
thrombus in the systemic veins may become an embolus and block
the pulmonary artery ; a clot or portion of valve-leaflet from the left
heart may block a systemic artery, as a cerebral artery or the femoral
artery or its branches ; a clot in the portal vein may obstruct branches
in the liver.
The symptoms occur suddenly and depend upon the artery obstructed.
The cutting off of the blood-supply causes cessation of function beyond
the point of obstruction. In pulmonary venous embolism dyspnoea is
pronounced, the heart's action rapid and irregular, and many cases are
said to be " heart-failure." In the middle cerebral artery the embolus
causes aphasia and monoplegia or hemiplegia. In embolism of the
pulmonary artery cough and hemorrhage with dyspnoea occur suddenly.
The patient in whom this occurs usually has had antecedent mitral
regurgitation and dilated right heart.
The blocking of an artery may lead to various symptoms. If, for
instance, the main artery of the leg is blocked, anastomosis may be set
up ; if it does not, gangrene ensues. If an artery supplying any inter-
nal organ is blocked, anastomosis may occur, if the artery is not termi-
nal. If the artery is terminal, there results rapid necrosis or softening,
as in the brain ; gradual wasting, as of the kidney, or engorgement of
the arterial area and diffuse hemorrhage. The latter is known as a
hemorrhagic infarct. This may occur in the lungs (pulmonary artery),
spleen, kidneys, retina, and, rarely, the intestinal canal. The symp-
toms of hemorrhagic infarct are swelling and hemorrhage. In the
lungs, there are physical signs of consolidation, with haemoptysis,
cough, and dyspnoea ; in the kidneys, pain and hematuria ; in the
spleen, pain and at times enlargement ; in the retina, blindness with
ophthalmoscopic changes ; in the intestine, pain and hemorrhage with
sloughing of mucous membrane. Infective emboli cause abscesses.
Capillary embolism is seen in the skin and mucous membranes in many
infective diseases, notably ulcerative endocarditis. Fat-embolism occurs
in the pulmonary capillaries, and is due to fat-globules which some-
times enter the circulation in pregnant women, or in patients with bone
disease, as osteomyelitis, or fractures. The symptoms are those of
intense dyspnoea. It may cause sudden death. Air-embolism. Air
may enter wounds of the veins of the neck. It accumulates in the
heart, and as the ventricle cannot contract on it the blood is not pro-
pelled. Death takes place with the symptoms of heart-clot, the heart
being in asystole.
Hemorrhage. Hemorrhage may be arterial, venous, or capillary.
It may occur because the blood soaks through the walls, by diapede-
sis ; or it may occur from rupture, or rhexis. Hemorrhage by dia-
pedesis takes place in venous engorgement, stasis, or inflammation. It
is the small passive hemorrhage of congestion, as in pulmonary conges-
tion from heart disease ; it is venous or capillary ; the blood is dark.
Hemorrhage by rupture is arterial, venous, or capillary. If the artery
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 405
ruptures, it has been torn by violence, destroyed by ulceration or sup-
puration, or it is the seat of endarterial change. Veins are also diseased,
or their walls destroyed, before rupture takes place. Rupture of capil-
laries occurs from violence or great internal pressure. In death from
suffocation the capillaries are the seat of hemorrhage because of the
increased venous pressure. Such capillary hemorrhage occurs in
typhus, hemorrhagic smallpox, and scarlatina. The state of the blood
is sometimes the cause of hemorrhage, as in scurvy, purpura, and other
conditions. Haemophilia is a peculiar hereditary affection possibly
due to the state of the blood, more likely, however, due to the condi-
tion of the bloodvessels.
The special forms of hemorrhage and their symptoms, etiology, and
diagnosis will be considered in the sections to which the names in the
following list point :
Bleeding from the nose — epistaxis.
Vomiting of blood — hcematemesis.
Bleeding from the lungs — hcemoptysis.
Blood passed with the urine — hcematuria.
Blood passed from the uterus — menorrhagia or metrorrhagia.
There is also intestinal hemorrhage — melcena.
Hemorrhages underneath the skin are known as peteehice if small,
and ecchymoses or suffusions if large.
Hemorrhage into internal organs receives its name from the organ
affected, and is known as a parenchymatous hemorrhage. Apoplexy is
applied to hemorrhage into the substances of organs, particularly if it
occurs suddenly and is localized — as pulmonary apoplexy, cerebral
apoplexy, spinal apoplexy. Long usage has associated the term with
hemorrhage into the brain, so that it is applied to that form alone by
most writers. Hcematoma, or blood-tumor, is a collection of blood that
has coagulated in a cavity, organ, or tissue. (See Ear.)
The symptoms of hemorrhage vary in degree, depending upon the
amount of blood which escapes from the vessel, and whether the hem-
orrhage is external or internal. By external hemorrhage we mean one
which is accompanied by a discharge of blood visible to the bystander.
An internal or concealed hemorrhage is not apparent by any outward
sign of blood.
The symptoms by which external hemorrhage is recognized need not
be detailed. The show of blood in situations or at times other than
normal is sufficient. It must be remembered that arterial blood is
bright red, venous blood dark. It. must also be remembered that the
character of the blood coming from internal organs is modified by the
secretion of the affected organ. Thus the blood from the stomach is
coagulated and black, like coffee-grounds ; blood from the intestine,
tarry. The general symptoms of the various degrees of external hem-
orrhage are similar to the symptoms of internal hemorrhage, which
will be described later. Both vary with the rapidity of the flow of
blood. If the bleeding is slow, large quantities may be lost and more
or less profound anaemia result. It is often more difficult to determine
the source of hemorrhage. The mode of recognition of the anatomical
varieties of hemorrhage will be discussed under the respective systems
406 GENERAL DIAGNOSIS.
which are the seat of the bleeding. Hemorrhage may take place in a
cavity, as the stomach, bowels, or bladder, and after the blood has
undergone changes it may cause symptoms of, and be discharged as,
a foreign body.
Although internal hemorrhage presents vivid phenomena, they may
not be characteristic, and its recognition is often impossible without
some knowledge of the history of the case. The symptoms are com-
plex. First, we have pain, a symptom due to rupture of a vessel or
to the filling of a tissue with blood. In the beginning the pain is
sharp, severe, and of itself may cause shock. In the second place, the
symptoms due to loss of blood arise. After pain, sudden prostration
ensues ; pallor spreads rapidly ; the extremities become pallid and
cold ; a cold sweat breaks out on the forehead ; the features become
pinched and shrunken ; the pulse becomes weak and rapid, and later
thready, or disappears altogether at the wrist ; the carotids pulsate ;
the heart throbs violently and a diffuse impulse is seen, at first vigor-
ous, soon like a slap against the chest-wall, and then it fades away
completely. On examination of the heart and vessels so-called anaemic
murmurs are heard. The patient is restless, and sighs and yawns
frequently. The respiration becomes slow and shallow. Nausea and
sometimes vomiting may occur. He may faint but once or repeatedly,
to be restored again and again, or the syncope may terminate in death.
In the intervals between the syncopal attacks the mind is clear. If,
however, profound shock is associated with the hemorrhage, there is
dulness or stupor ; the intellect is dazed ; otherwise delirium and agi-
tation may be present. When the hemorrhage is profuse convulsions
may take place. The temperature of the body falls. If the patient
has fever at the time, the temperature suddenly falls to or below nor-
mal. We have, therefore, the following conditions in hemorrhage :
syncope, shock, and collapse. They may all be present in the same
subject, or one or two may be absent. The same symptoms may, how-
ever, occur from other causes, which must be excluded. Sometimes the
shock may be due to the same cause as the hemorrhage. The causes of
shock are so evident that they serve to distinguish it from the collapse
of hemorrhage. They are injury, anaesthesia, railway accidents, surgi-
cal operations, perforative peritonitis, strangulated hernia, intestinal
obstruction, profound mental impression, and pain.
Shock from hemorrhage must be distinguished from concussion.
In the latter the intellectual disturbance occurs at once, and is more
marked than the circulatory symptoms. The absence of the usual
phenomena of hemorrhage serves to distinguish syncope due to concus-
sion from that due to the many well-known causes of fainting.
There are many forms of internal hemorrhage sufficiently grave to
have a probably fatal result, or at least to create alarming symptoms.
In the chest, diseases of the lungs or the aorta cause hemorrhage. In
concealed pulmonary hemorrhage the blood accumulates in a large
phthisical cavity. When the aorta or an aneurism ruptures the blood
may enter the mediastinum or the pleura. Under these circumstances
a knowledge of the previous history is essential. Careful examination
of the lungs or of the heart or bloodvessels must be made in a case
MORBID PR CESSES AND THEIR S Y MP TO MA TO LOGY. 407
which presents the above-mentioned symptoms of internal hemorrhage.
Internal concealed hemorrhage into organs or cavities of the abdomen
occurs in gastric, duodenal, or intestinal ulceration ; in aneurism or in
ulceration of large vessels, from septic inflammation around them. It
must not be forgotten that alarming or fatal internal concealed hemor-
rhage may be due to haemophilia or purpura.
II. Disturbances of Nutrition.
Hypeeteophy and Ateophy. (See the Size, Chapter VI., and
Muscles.)
Inflammation. Inflammation, a process largely attended with vas-
cular alteration, but also with disturbance of nutrition. It may be
acute or chronic. It is due to injury, mechanical, physical, chemical,
or vital. The invasion of micro-organisms or the irritation of their
products is the most frequent cause in cases that come within the
province of the physician. The symptoms are modified by the struc-
ture affected and by the cause of the inflammation. The intensity and
the character also modify them. The classical symptoms —pain, heat,
redness, and swelling — are indicative of the tissue-process. In addition
we have exudation and alteration of function. Pain varies in degree
with the sensibility of the part. It is increased by pressure or move-
ment, and by the functional activity of the affected organ. Heat is
detected by the hand or surface-thermometer. It may be described by
the patient, in abscess within the peritoneum, or pyosalpinx, as a ball
of fire. The surface-temperature over an inflamed lung or pleura is
higher than over the healthy side. Redness can only be observed in
parts open to inspection, as the nasal, oral, faucial, and other cavities.
Swelling is observed with the redness ; it is shown by enlargement of
the affected organ, if the latter can be measured by palpation or per-
cussion. Exudation takes place from mucous surfaces, into serous
cavities, into the connective or any affected tissue, or into tubes or
channels (heart and bloodvessels, lymphatics, etc.). The symptoms
are : characteristic discharges from mucous surfaces ; pressure and
physical signs from accumulation in cavities ; symptoms of the obstruc-
tion of channels. Grave pressure-symptoms arise when the exudation
presses upon the nerves, nerve-centres, or nerve-tracts (brain cord,
peripheral nerves). The pressure-symptoms are often more pronounced
than the inflammatory in simple or tuberculous meningitis. Alteration
of function : The symptoms cannot be detailed here ; each organ and
structure must be referred to. The function may be stimulated at
first, but is soon perverted, or suppressed.
General Symptoms. Fever is the general expression of the local
process. It may be primary from reflex irritation of afferent nerves
which influence the heat-centre and disturb the thermotaxic mechan-
ism. It may be secondary, the products of inflammation (pus, toxins,
etc.) irritating the centres. The degree depends upon the cause. Active
inflammation may not be attended by fever. 1
Suppuration. The character of the fever indicates the variety of
1 Musser : "Abscess of Liver," Univ. Med. Magazine, 1892.
408 GENERAL DIAGNOSIS.
the inflammatory process. In most inflammations the fever is con-
tinuous. When there is suppuration, however, it becomes intermittent
or remittent. The presence of suppuration is also made known by
hectic, in which the fever is attended by chills and sweats. The appe-
tite is lost or impaired. There is also leucocytosis. The urine con-
tains a large amount of indican. In obscure inflammations about the
peritoneum the indicanuria points to a suppuration. While fever-
symptoms in inflammation are similar, save in degree and in the pecu-
liar type of the temperature-range — intermittent, remittent, or contin-
uous — septic inflammations are attended early by cerebral symptoms,
prostration, and the typhoid state. (See Fever, pages 218 and 224.)
As a corollary, when fever is present, local inflammation must be
sought for. Chronic inflammations may only give rise to altered func-
tion and cause exudation (swelling, effusion, etc.).
Inflammation of Various Structures. The symptoms vary according
to the anatomical and physiological peculiarities of the structure.
Inflammation of mucous membranes. Pain is not excessive ; heat is
complained of (rectum) ; redness is marked and varies with the in-
tensity from bright to dark red ; swelling is always present. In narrow
channels, as the nose, or the gall-ducts, it causes occlusion. The
exudation is at first mucous, then mucopurulent, and then purulent.
Before exudation there is a stage of dryness. The microscopical
appearance of the exudate varies with the anatomical character of the
membrane affected. Its peculiar epithelium is always present, also
micrococci, pus, red cells ; from the lungs or liver, special crystals.
The functions are impaired. Fever is usually not very high and is
continuous. The causes are direct local irritants or congestions from
external impressions (cold ?).
Inflammation of serous membranes. Pain is extreme and may cause
collapse. Heat, swelling, and redness cannot be estimated. The surface-
temperature rises. Exudation occurs after a brief dry _ stage. The
cavities — pleura, pericardium, peritoneum, joints, cerebro-spinal canal
— are filled, causing mechanical symptoms and physical signs. Fever
is excessive in some forms. Function is impaired or abolished. Gen-
eral symptoms are more pronounced. Shock or collapse is common in
peritonitis. The affections are always secondary to a general process
(rheumatism), to infection, to disease of neighboring structures, or to
Bright' s disease, diabetes, cancer, scurvy, or other diathetic condition.
Inflammation of muscles (rare), of connective tissue, and of glands is
characterized by symptoms common to the morbid process, with alter-
ation of function.
Inflammation of bone and 'periosteum presents the same group of
symptoms. The pain may be intense or of a dull, aching, or boring
character.
Inflammation of the heart and vessels is also attended by the cardinal
symptoms. When the central organ is the seat of the disease pain is
not common, but in the arteries or veins it is of frequent occurrence.
The striking symptom, however, is the obstruction to the channels.
It is characteristically seen in phlebitis, as of the femoral vein.
(Edema of the leg, and cyanosis, reveal the obstruction. In the heart
M ORB ID PROCESSES AND THEIR SYMPTOMATOLOGY. 409
the acute process or the results of the process give rise to all the symp-
toms of obstructive heart disease.
Inflammations of the nerves, the .spinal cord, and the brain are fol-
lowed more strikingly by pressure-symptoms and by the symptoms < >f
degenerations secondary to the inflammatory process. Hence, while
pain and tenderness are present in the exposed nerves, increased irrita-
bility, then abeyance, perversion, or abolition of function are the princi-
pal signs of inflammation of these regions.
Inflammation of internal organs, lung, liver, kidneys, and pancreas, is
made known by pain (minimum amount) and swelling (enlargement of
liver), and by change in the function, indicated by modifications of the
respective secretions as well as by functional and physiological symp-
toms.
Local Death, Necrosis, and Gangrene. If nutrition is not
complete, the life of the cell is endangered. This process is known as
necrosis or gangrene. The nutrition is annulled : 1. By stoppage of
the circulation. 2. By the direct action of an irritant which destroys
the cells. 3. By abnormal temperature. A combination of the three
causes quickly produces gangrene. Stoppage of the circulation may
be due to an embolus or thrombus, or to stagnation by pressure, or to
capillary stasis alone. Sloughing and " bed-sores " ensue in the latter
instance ; gangrenous eschars in the former. The cells are destroyed
by corrosives and caustics, by heat and cold, by bacteria. Where
decomposition takes place, as in retained and infiltrating urine, cell-
destruction and sloughing ensue. All pathogenic bacteria cause necro-
sis to a greater or less degree. Frost-bite and burn illustrate the destruc-
tive power of abnormal temperature.
Xerve-lesions, trophic disorders, produce necrosis. We have, allied
to bed-sores and known as decubitus, a form of necrosis in spinal-cord
diseases. The sloughing is extensive and rapid. Trophic disorders
cause paralytic hyperemia, and hence necrosis.
It must not be forgotten that debility, cachexia, and feeble circula-
tion play a great part in assisting the local changes.
Gangrene of internal structures concerns us. This form is nearly
always due to stoppage of the circulation. It is seen in constriction
of the intestine, from hernia, or obstruction. It occurs in phthisis
from thrombi. Clinically, we see it frequently in diabetes. The lung,
the brain, the intestines, are most frequently affected.
The symptoms of necrosis or gangrene are modified by the tissue
involved, the function interfered with. If external, the decomposing
structures emit a foul odor, there is rapid prostration and development
of the typhoid state. Fever ensues from intoxication by decomposing
substances — sapraemia. Often the symptoms are latent. A man aged
sixty, in my ward, was about all the time. He died suddenly of pul-
monary hemorrhage, the result of gangrenous ulceration of a large
vessel'; at the autopsy gangrene of the lung was found. The only
symptom was the characteristic odor. In the course of inflammatory
processes the onset of gangrene is frequently attended by the cessation
of pain, the peculiar odor when it communicates with the exterior, and
the development of exhaustion and the typhoid state. The character
410 GENERAL DIAGNOSIS.
of the discharge points to gangrene. When the lungs are affected
the expectoration is like prune-juice ; when the bowels, the discharge
is dark and putrid.
Fever is a morbid process, with the cause and symptomatology of
which the student must be familiar. It has been fully treated in
previous chapters. (See Fever.)
The Degenerations. The symptomatology varies with the form
of degeneration and the organs affected. The prostration of the gen-
eral economy is due to the same cause as the degenerations themselves.
Albuminous degeneration occurs in fever, and causes the weak heart
and defective gland action. The weak heart of the convalescent period
in diphtheria and other infective diseases is well known.
Fatty Degeneration and Infiltration. In fatty degenera-
tion there is cell-destruction. The brain, the heart, the kidneys in
Bright' s disease, the liver, all undergo degeneration. It may be due
to phosphorus-poisoning or to snake-bite. It is seen in acute yellow
atrophy of the liver. It is caused by other toxic agents. Fatty infil-
tration or lipomatosis is seen in the ' • fat " heart of brewers, the en-
larged liver, the excess of fat in the abdomen, etc. The affected
organs are enlarged, but they are iunctionally weak. Fatty infiltra-
tion of organs is recognized by its etiological associations. In alco-
holic subjects of sedentary habits, in subjects who eat an excess of
fatty foods, in overfed and pampered children, and in tuberculosis it
is commonly seen. In fatty infiltration the cells are not destroyed. If
with the above conditions the liver is enlarged or the heart weak, or
both, we may expect to find fatty infiltration. There is enlargement
of the affected organ, which is painless, smooth, not usually soft on
palpation. The condition occurs at any age, but usually in later life.
Emaciation may not be present. Lithsemia is common in fatty infil-
tration.
Amyloid Degeneration. This is rarely confined to one organ
of the body. The causes are syphilis, malaria, tuberculosis, and pro-
longed suppuration. The liver and spleen are enlarged, hard, smooth,
and painless. There are great pallor, and oedema of the feet and face.
There is ancemia, but no fever. The kidneys are affected, hence "poly-
uria and low specific gravity of the urine ; a few casts are found. The
bowels are likely to be loose because the process has involved the intes-
tine. It occurs at any age. The diagnosis rests on the presence of a
cause, the painless enlargement of organs, the pallor, and the polyuria.
Fibroid Degeneration. This is not so much a degeneration as
an overgrowth of connective tissue with coincident primary or second-
ary atrophy of the parenchyma. The function of the organ is impaired
or abolished. Increase of connective tissue in the nerve-structures
is known as sclerosis, in the liver or kidney as cirrhosis. In the
artery it leads to the changes known as endarteritis. Whatever the
pathology may be, whether atrophy of cell-elements of the affected
structure be primary or secondary, the condition is productive of seri-
ous, even grave consequences. It is part of the senile process. It
leads to the manifold symptoms of endarteritis ; it is the cause of
many nervous affections which will be discussed in their proper sections.
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 41 1
The varied phases of so-called interstitial nephritis are due to the
fibroid changes primarily in the kidneys, and secondarily in the arte-
rial system. In the lungs it attends emphysema, or may even be pro-
ductive of that condition. The fibriod heart is another manifestation
of the same process. The tubes and channels are closed by the same
process as in fibrous stricture of the duodenum. Wherever situated
its development means gradual abolition of function.
Mucous Degeneration. This form of degeneration is seen in
myxoedema. The albuminous intercellular substance is replaced in
the connective tissue by mucin.
Pigmentary, calcareous, and colloid degenerations are local morbid
processes without other symptoms than those of the primary affection.
III. Anomalies of Growth.
Tumors. Tumors, other than cancer or sarcoma, produce only
mechanical symptoms, and must be considered in their special section.
The mechanical symptoms are due : 1. To the tumor (foreign body).
2. To obstruction of any channel in near relation.
New Growths. They cause local symptoms. This is most striking
in structures which must necessarily be destroyed as the growth in-
creases in size, as in the brain or spinal cord, or where tubes or chan-
nels are closed, as in cancer of the stomach or oesophagus. Local symp-
toms may precede the general symptoms ; on the other hand, general
symptoms may arise for which no local cause can be assigned. The
local symptoms of cancer are variable and depend upon the anatomical
nature and physiological offices of the organ affected, and upon its
anatomical relation to surrounding organs. This class of symptoms
will be referred to in the section on special diagnosis. Suffice it to
say they cause gradual abolition of the function of the organ, or closure
of the channels in connection with it, as the intestinal canal, the pharynx,
or the hepatic ducts. Cancer and sarcoma are accountable for a group
of symptoms to which the term cachexia has been applied. In addi-
dition, a few symptoms belong to the cancerous process wherever situ-
ated. They may or may not all be present ; in the large majority of
cases one or more are wanting ; they should always be sought for in
order to confirm a diagnosis of cancer. These symptoms are :
1 . Pain, recognized by peculiar characteristics in most cases : (a) It
is sharp and lancinating ; (6) it is paroxysmal ; (c) it is increased by
irritation, as food when the stomach is affected ; (d) it is increased by
functional activity, as speaking or swallowing in carcinoma of the
larynx or pharynx ; (e) at the outlet of canals, as the bladder or
rectum, it gives rise to tenesmus.
2. Hemorrhage. If the malignant mass is in communication witli
the exterior, the blood maybe discharged per cias until rale*. In malig-
nant disease of the upper air-passages or the lungs hemorrhage is
likely to occur. It is common in gastric carcinoma as well as in
uterine cancer. If the organs do not communicate with the exterior,
and the lesion gives rise to exudations or transudations, the latter are
frequently bloody, as in carcinoma of the pleura or peritoneum.
3. Abnormal Discharge. This occurs especially in cancer of the
412 GENERAL DIAGNOSIS.
hollow viscera and of the canal-structures. The discharge is the result
of inflammation, suppuration, and necrosis, and particularly microbic
inflammation. It is recognized by its more or less bloody character
and by its odor, which is peculiar. It is most offensive and pene-
trating, and, particularly in uterine cancer, is almost pathognomonic.
Even the utmost cleanliness will not obviate it.
4. Tumor. It may be readily detected or elude all search. Some
swelling is certainly present. It is discovered by external examina-
tion, by the objective physical signs of enlargement or change of con-
tour of the affected organ.
5. Foreign Body. The growth gives rise to symptoms similar to
those present when a foreign body is fixed in any portion of the
hollow viscera, as the respiratory tract, the gastro-intestinal, including
the hepatic and the genito-urinary tract, a. Through reflex influence
an attempt is made to remove it, hence cough, vomiting, diarrhoea
with tenesmus, repeated and painful micturition with tenesmus, etc.,
the particular symptoms varying with the organ affected, b. Obstruc-
tion of the channels, with all the accompanying symptoms, depending
upon the location of the growth.
6. Temperature. A morbid process is often recognized by its nega-
tive symptoms, if the term may be used. Thus, fever is absent or the
temperature is even subnormal in carcinoma.
7. The Cancerous Cachexia. Wherever situated the disease is
sooner or later attended by extreme general symptoms which are, in
a measure, striking. It is to be admitted that cases of carcinoma often
occur without marked cachexia, a. One symptom may always be
looked for ; it is emaciation. It may be rapid or gradual and extend
over one or two years ; toward the end it is always rapid. Ultimately,
if the patient does not succumb to other conditions, it presents an ex-
treme picture. The eyes are sunken, all normal accumulations of fat
disappear. The fat in the rectal fossae disappears, causing deep de-
pression of the rectum. The abdomen is retracted. The appearances
are most striking in cancer of the oesophagus. b. Pallor (see Color) ;
this may be present, c. Ancemia, with breathlessness, palpitation,
vertigo, d. Exhaustion. This with accompanying emaciation is pro-
gressive, and may be the first symptom. Progressive weakness is
often seen without fever or local disorder to account for it. Toward
the end it becomes so extreme as to forbid exertion, e. Malnutrition.
Evidences of malnutrition appear ; the skin is hard and dry ; its elas-
ticity is unpaired and it becomes the field for parasitic invasion.
Tinea and other parasites may flourish. Bacteria invade the suscepti-
ble areas, and boils make their appearance. The secretions are per-
verted. In the mouth ulcers develop ; the fungi of this situation (the
throat, etc.) become more active ; the gums are inflamed. In the later
stages the ' ' typhoid state " (see Fever) may ensue. If the gastro-
intestinal tract is invaded, symptoms of acute intoxication may arise.
8. Metastasis. We are often aided by the occurrence of this event,
particularly by involvement of the glands. In gastric carcinoma
secondary hepatic disease or enlarged glands above the left clavicle
are found ; in rectal carcinoma, secondary hepatic cancer. In many
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 41 3
instances the presence of cancer is revealed by the metastasis, even
when the primary growth cannot be recognized.
The diagnosis rests upon the above conditions. In obscure cases
the age, the sex, the associate pathological conditions, the duration of
the disease become important factors in the diagnosis. Cancer usually
occurs after forty, or, some authorities say, after fifty years of age.
The female sex is most frequently affected. It may be associated
with a history of previous lesion or irritation, as ulcer in vaginal,
gastric, or rectal cancer ; the irritation of teeth or a pipe in labial and
lingual cancer ; of gallstone in cancer of the bile-ducts ; of renal or
visceral calculus in disease in that situation. A disease of grave and
malignant character, the duration of which is over eighteen months or
two years, is not, in all probability, cancer.
Morbid Processes in Tubes or Channels. The effects produced by
obstructions.
When tubes or channels are the seat of disease symptoms arise apart
from the special morbid process, which are due to obstruction and are
common to all tubes or channels. The symptoms of obstruction of the
bloodvessels and lymph-channels — cyanosis, oedema, gangrene (throm-
bosis and embolism) — have been described. But in addition we have
hypertrophy, a secondary condition, not referred to above, which,
nevertheless, follows obstruction of any channel. In the cases of vas-
cular obstruction the hypertrophy is seen in the heart and the arteries.
(See Diseases of the Heart.)
In obstruction, therefore, of tubes or channels we have to a greater
or less extent (1) hypertrophy behind obstruction ; (2) diminution of
the normal flow of fluid and consequent accumulation of material
which normally passes through the channels ; (3) atrophy and cessa-
tion of functional activity beyond the point of obstruction ; (4) dilata-
tion of the primary hypertrophy ; (5) degeneration, ulceration, low-
grade inflammation (bacterial), secondary rupture of the affected
viscera. The morbid anatomist can readily point out the examples of
the morbid changes sequential to obstruction. Thus in cancer of the
oesophagus there are hypertrophy of the muscular coats, regurgitation
of food, atrophy of the stomach, dilatation with accumulation of food,
secretions from the glands of the oesophageal mucous membrane,
secondary ulceration, rupture into the lungs, with gangrene or pneu-
monia. In obstruction at the pylorus there are (1) hypertrophy ; (2)
accumulation; (3) intestinal atrophy; (4) dilatation of the stomach,
with its train of symptoms. In obstruction of the biliary channels,
or the bladder, or ureters, the same secondary conditions arise plus
obstruction to the flow of bile or urine. Secondary symptoms arise
from accumulation of the non-escaping fluids. Subjective symptoms,
it may be said, are not marked; there are pain and difficulty in the
performance of the usual functions. It need scarcely be said that the
obstruction sometimes gives rise to symptoms which are due to the
abnormal obstructing material which acts as a foreign body. The
symptoms are reflex and depend entirely upon the seat of the foreign
body.
414 GENERAL DIAGNOSIS.
The causes of obstruction in whatsoever channel situated are, first,
pressure from disease outside (growths, hernia) ; second, disease of the
walls, with contraction ; third, occlusion by a foreign body, as gall-
stone, renal calculus, worms, or other material according to the channel
obstructed. The symptoms are most marked when the obstruction is
due to disease outside the walls or to obstruction by occlusion within
the walls.
In all cases of obstruction, nasal, faucial, laryngeal, bronchial, oesoph-
ageal, gastro-intestinal, biliary, renal, or pancreatic, look for the symp-
toms of the secondary morbid change. Each form of obstruction will
be specially considered elsewhere. (See Special Diagnosis.)
The Bloodvessels. Blood-pressure. It must not be forgotten
that the bloodvessels are in a measure distinct from other tubes,
although subject to the same laws, physiological and pathological.
They contain fluids, and have a continuous function by which the
fluids are propelled. They are subject to the laws that govern the flow
of fluids under all circumstances in nature. Any derangement or
disease will effect changes which are explainable by hydrostatic or
hydrodynamic laws. Fluids within vessels exert pressure. Pressure
produced by weight of the fluid is known as the hydrostatic pressure ;
that produced by the flow is known as the hydrodynamic pressure.
Pressure can be gauged by proper instruments. In the case of fluid
in the bloodvessels it is called the blood-pressure. The blood-
pressure is estimated at the pulse by the educated finger and by the
sphygmograph. A certain definite pressure is always present in
health. It is subject to slight fluctuations, but tracings with a sphyg-
mograph follow a definite course. In the description of the pulse,
modifications of blood-pressure will be given in detail ; it is sufficient
here to say a few words regarding hydrostatic and hydrodynamic
pressure.
Hydrostatic pressure is modified by the weight of the fluid. It is
of pathological importance in the veins only, and especially in those of
the lower limbs. When the pressure is increased the increased weight
of the blood-column causes increased bulk and over-distention, as in
varicose veins, unless the support to the blood-column is increased.
Inflammations of the lower limbs are attended by venous accumulation
and followed by ulceration. For this reason dropsies arise more
readily in these portions. The common occurrence of gout in the feet
may be due to slow circulation.
Hydrodynamic pressure is variable. Its changes indicate increase
or diminution of blood-pressure. The bloodvessels are resisting elastic
tubes ; the resistance is always equal to the pressure within, hence
blood-pressure and arterial tension are equivalent terms. We speak
of increased or diminished pressure, or correspondingly of high or low
tension. Now, the hydrodynamic or blood-pressure depends upon : (1)
Variations in the volume of blood ; (2) variations in the capacity of the
vascular system ; (3) facility of the capillary circulation ; (4) the force
of the heart. The tension of the artery depends upon the same
conditions.
MORBID PROCESSES AND THEIR SYMPTOMATOLOGY. 415
1. Variations in the volume of the blood, a. Volume increased.
Causes : absorption of fluid after meals or drinking to excess. Result :
increased blood-pressure and increased tension. Controlled in health
by action of the vasomotors relaxing the vessels, and by enlargement
of the veins. b. Volume diminished. Cause : hemorrhage, serous
purging. Result : diminished blood-pressure, lowered tension. Con-
trolled in health by contraction of arteries through vasomotor nerves.
In hemorrhage the loss of blood produces anaemia. The latter is a
stimulant to the vasomotor centre in the medulla, and produces con-
traction of peripheral arteries and high tension.
2. Variations in the capacity of the vessels, a. Diminution of the
capacity of the blood-channels (volume of blood not lessened). Cause :
cutting off of a vascular area by ligation or obstruction, by narrowing
the calibre of the wall, as in arterial spasm or endarteritis, by disease
of the kidneys, contracting the lessening channels in the aortic circuit,
or disease of the aorta, causing obstruction to the outflow of blood.
Result : increased pressure, high tension. Controlled by normal regu-
lating vasomotor apparatus, or by diminution of the volume of blood.
b. Increase of capacity of blood-channels. Cause : relaxation of mus-
cular coats • of vessels. Result : diminished blood-pressure, lowered
arterial tension. Controlled by contraction of vessels or increase in
amount of blood. In shock, the vasomotor sympathetic system of the
splanchnic arteries is so disturbed that the arteries are dilated and all
the blood is sent into the abdominal vessels (fall of pressure).
Mode of action of the vasomotor apparatus. Centres in the medulla,
in the spinal cord, and locally in the sympathetic ganglia of different
parts, control the vasomotor nerves, which influence hydrodynamic
pressure. 1. If the centres are stimulated, tonic contraction of the
vessels is produced. This may be general or local. Increased press-
ure or heightened tension is the result. It may be reflex from the
periphery, or due to some state of the blood. 2. If the centres are
paralyzed, or inhibited, or cut off from the arteries, the latter become
relaxed (dilated). The pressure is lowered, the tension is less. Shock,
pain, certain drugs, reflexes (probably) produce inhibition.
3. Facility of capillary circulation. Obstruction to outflow of blood
from capillaries into the veins increases blood-pressure. Cause : the
same as when arteries contract. Result : increased blood-pressure, high
tension. Regulated in the same manner as arteries. Relaxed capilla-
ries produce opposite conditions.
4. The force of the heart, a. Heart's action (left ventricle) increased.
Cause : hypertrophy, palpitation. Hence the greater force of blood-
impact, greater resistance by arteries. The tonic resistance narrows
the calibre of the vessels. Result : increased pressure, higher tension.
6. Heart's action weakened. Hence, less force of blood, less resistance.
Result : lessened pressure, low tension.
The recognition of variations in tension. (See Pulse.)
1. High arterial pressure or tension. By (a) incompressibility and
tension of the arteries ; (6) accentuation of the aortic second sound ;
(c) prolongation of the left ventricle first sound ; (d) increased flow of
urine, pale and watery ; (e) characteristic pulse-tracing by sphygmo-
416 GENERAL DIAGNOSIS.
graph. If the high tension is permanent, (/) hypertrophy of the
heart ; (g) atheroma, more or less.
2. Low arterial pressure or tension. By (a) soft, compressible, often
dicrotic pulse ; (6) enfeebled sounds, aortic second and left ventricle ;
(o) scanty, high-colored urine ; (d) special pulse-tracing. If perma-
nent, stases, congestions, cyanosis, with general weakness and impaired
nutrition.
PART II.
SPECIAL DIAGNOSIS.
CHAPTER I.
THE NOSE AND LAEYNX.
The Nose.
The symptoms of disease of the nose result from disturbance of the
function or alteration of the structure of the organ and the morbid
process. Physiological symptoms : Impairment of the sense of smell,
ansemia, and symptoms of obstruction may occur. Obstruction causes
retention of secretions. These secretions are exposed to infection.
Putrefaction and fermentation set in and give rise to offensive odoi*s.
More serious is the effect of the obstruction on the rest of the respira-
tory tract. The patient becomes a mouth-breather. The appearance
of the face is altered ; the voice changes, snoring is common, mastica-
tion is interfered with, and there is a diminution in the amount of air
passing to the lungs. As a result a vacuum is created which is com-
pensated for by external pressure. In children the result is marked
deformity of the chest, leading to the development of the " pigeon " or
" chicken breast." (See the Lungs, Chapter II., Part II.) The general
symptoms attending mouth-breathing will be referred to again.
Symptoms due to the Anatomical Structure. The nose is an open space
or a series of air-spaces lined with mucous membrane. The mucous
membrane is the frequent seat of infectious inflammation, as in hay
fever, influenza, and measles. Most of the nasal symptoms are due to
disease of the mucous membrane. The membrane is subject to affec-
tions that are common to all mucous membranes, and the subjective
and objective symptoms are similar to those that arise in other organs,
modified by the function and anatomical arrangement.
The abundance of bloodvessels and glands is the cause of one of the
symptoms — namely, the discharge. Moreover, the difficulty of removing
the discharge from the various cavities in the nose in which they are
pent up leads to putrefaction and odor. Because the air is constantly
passing over the parts, discharges are very liable to become dry, and
hence crusts and scabs form. Again, the vascularity of the structures
of the nose is the cause of development of symptoms. The blood-
vessels are richly supplied with nerves, which cause them to contract
or dilate, on comparatively slight provocation, by reflex action. Chilli-
ness of the body, or of local areas of the body, chilling of the extremi-
27
418 SPECIAL DIAGNOSIS.
ties, and other peripheral impressions, are followed by congestion of
the nasal mucous membrane, which may go on to inflammation. The
vascularity predisposes to hemorrhage.
The nose is richly supplied with nerves (in addition to the olfactory
nerve), which are susceptible to various irritations or impressions —
impressions made by the air laden with unusual material, as fumes of
a chemical nature, emanations from animals, or plants, and certain
substances not yet isolated, which are decidedly irritating. There
is often local irritation from polyps and adenoid growths, and foreign
bodies, or enlarged bone. The nerves are connected by a mechanism
directly with the centres in the medulla, with particularly the pneumo-
gastric centre. The effect of peripheral nasal irritation may be felt
reflexly in the area of distribution of that nerve ; hence an unpleasant
odor may bring on sudden nausea or vomiting. But of more striking
and frequent pathological significance is the occurrence of asthma, or
sudden dyspnoea, from reflex excitation of the pulmonary division of the
pneumogastric nerve.
Morbid processes in the nose are symptomatic of some general affec-
tions. The occurrence of asthma, or of deformity of the chest and
general ill-development, has been spoken of. Acute inflammations are
significant of the exanthematous diseases, particularly measles. An
acute inflammation (as pointed out by Meigs), with great obstruction
of the nares and an abundant, puriform discharge, is a complication or
symptom of Bright' s disease that may portend the onset of uraemia.
Chronic inflammations may be due to syphilis or other chronic infection.
The Data Obtained by Inquiry.
Of the data obtained by inquiry, that belonging to the social history,
the family history, and the history of previous diseases yield but
little information of diagnostic value. It is true the acute inflamma-
tions secondary to measles and other exanthemata occur at an early
age, while the chronic attacks occur late in life, as do also tumors,
except adenoid. Foreign bodies are more likely to be found in chil-
dren and the feeble-minded. Those occupations which are in-doors, in
overheated apartments, and among noxious vapors predispose to
catarrhs. In the family history we must look for gout, rheumatism,
syphilis, and affections which lead to osseous changes. More marked
than all is the influence of syphilis. A chief predisposing factor in
the production of nasal disease is the morphological arrangement of
the parts, which may be congenital, or the result of early infantile dis-
ease. Thus, when congenital, the high palatal arch, etc., is looked
upon as the stigmata of degeneration.
On inquiry of the history of previous diseases, we look for syphilis,
the exanthemata of early life, the occurrence of gout or rheumatism,
and of those gastrohepatic and nutritional disorders which lead to
catarrhs.
The Subjective Symptoms. General. They are often accom-
panied by extreme distress, but do not lead to a fatal termination.
The general subjective symptoms are like those of inflammation of
other mucous membranes.
THE NOSE AND LARYNX. 419
1. Lassitude occurs when there is fever. It is a frequent precursor
of rhinitis, and is pronounced in croupous and diphtheritic rhinitis ;
extreme prostration may attend the latter.
2. Chilliness following the lassitude, or rigor, may occur in the
same class of cases. If distinct rigors occur, an abscess in one of the
cavities may be suspected, if the subjective and objective symptoms
point to it ; or glanders may be present.
3. Fever. This occurs in the inflammations ; it is never marked,
and is not of diagnostic significance. It is most severe in glanders.
It is then attended by general symptoms of rigor, with pain in the
trunk and limbs. In the first twenty-four hours there may be nausea
and vomiting. Locally, a small pimple is seen which is quite painful.
A yellowish sanious discharge oozes from the nostrils. Hard pustules
appear about the nose and other parts of the body. (See Infectious
Diseases.) It is of low type in diphtheria, and of hectic character when
there is abscess. High fever associated with inflammations of the nose
points to influenza or one of the exanthemata as the primary cause of
the rhinitis. Foreign bodies in the nose may cause fever. Emacia-
tion occurs with malignant growths.
Local. Pain, varying in degree, occurs in all acute affections of
the nose. Its seat and character are of some diagnostic significance.
Smarting or burning pain at the root of the nose accompanies acute
rhinitis and attends post-nasal catarrh. The pain is diffuse and indefi-
nite in dry catarrh and in diphtheria. The most severe pain occurs
when foreign bodies are present in the nose and in cases of glanders
and primary syphilis. Foreign bodies of a vegetable nature by swell-
ing and germinating induce pain, which increases gradually in in-
tensity.
In tropical regions parasites may be found in the nostrils. They
are the larva? of the lucilia hominivora. It is said that the pain is so
severe at the root of the nose, extending backward, as to cause mani-
acal delirium. Sleeplessness is marked, and there may be extensive
destruction of the bones and skin. There is a fetid, sanious discharge.
Pain Over the Frontal Sinus. The pain of an inflamed frontal
sinus is more severe than the pain of inflamed nostrils. It is some-
times intense and agonizing. Pain may be located in the cheek from
inflammation or tumors of the antrum. In disease of the nose, if the
pain radiates to the ear, the Eustachian tubes are probably involved.
Headache is frequently caused by nasal disease of all forms. (See
Chapter IV., Part I.)
Disturbance of the Sense of Smell. (See the Nerves.) Anosmia and
Parosmia. Loss of smell, or anosmia, occurs to a moderate degree in
all the inflammatory and obstructive diseases of the nose. The in-
tensity depends upon the degree of change in the mucous membrane.
It may also be due to disease of the nerves or the olfactory centre in
the brain. Parosrfria is the perception of abnormal odors, and may
be a neurosis or psychical difficulty entirely, and hence purely subjec-
tive, or there may be inability to distinguish an odor when presented
to the nostril. All odors may appear the same, or agreeable odors
may seem to the patient very disagreeable. In addition, the patient
420 SPECIAL DIAGNOSIS. ■
may complain of the perception of an odor in connection with the
nasal disease with which he is affected. Parosmia is due to an involve-
ment of the olfactory nerves.
A sense of dryness is a symptom of which the patient frequently
complains, particularly in the early stages of acute rhinitis and through-
out the entire course of dry catarrh, or atrophic rhinitis.
Obstruction or Stenosis. This sometimes causes the greatest
discomfort to the patient. There may be simply a seuse of stuffiness
and fulness in the nasal and frontal region, or complete obstruction,
causing difficulty in breathing. In infants it prevents nursing, and
should always suggest inherited syphilis. It occurs in all the obstruc-
tive diseases of the nose and nasopharynx, as acute rhinitis, chronic
inflammation (except the atrophic form), hyperemia, the hypertro-
phies, polyps, tumors, deviations of the septum, foreign bodies, and
adenoid vegetations.
Deafness is present when the Eustachian tubes are invaded or ob-
structed from inflammation or stenosis. When associated with anosmia
it may be of central origin. Tinnitus annum frequently accompanies
the deafness.
Cough. The discharge may pass into the pharynx and the larynx
and cause cough. (See Chapter on Cough.) It occurs, therefore, in
the catarrhs and obstructive diseases, and is not diagnostic of any nasal
condition. When the nostrils are too wide, as in atrophic rhinitis,
cough may occur because irritating particles are admitted through the
widened aperture. A so-called reflex cough occurs in hypertrophic
and post-nasal disease.
Reflex Neuroses.
Hay Fever. Hay fever is an acute affection ushered in by paroxysmal
sneezing, itching, and smarting of the inner canthus of each eye, or of
the throat or nose. After hours or days of sneezing coryza develops.
The disease continues for a varying length of time, is more pronounced
at certain seasons of the year, particularly the late fall. Coughing may
be an additional symptom, and paroxysms of asthma may develop
which are hard to distinguish from true bronchial asthma. The attack
may be excited by vegetable emanations, particularly the pollen of
plants, but other emanations may also induce it. Certain conditions
of the nasal mucous membrane predispose to the attack. Local inflamma-
tion of the nose or obstructive diseases from hypertrophies are primarily
present. To the exciting cause and the local predisposing cause may
also be added a neurotic factor. The disease affects families of ner-
vous constitution, and may occur through several generations. It is
more common in this country than in other countries, and dwellers in
cities are more subject to it than residents in the country. Asthma may
be due to disease of the nose, but the only proof that it is of nasal origin
is that it disappears after the nose has been treated for the various ail-
ments that are supposed to cause it.
Idiopathic Rhinorrhcea. Characterized by a sudden profuse
discharge of yellowish water. It ceases as suddenly as it develops, and
is thought to be due to some functional derangement of the fifth nerve.
THE NOSE AND LARYNX. 421
The Data Obtained by Observation.
The Objective Symptoms. Of the general objective symptoms,
fever has been noted. In certain affections of the nose defective de-
velopment of the general system is observed. This is particularly the
case in adenoid vegetations of the nasopharynx in children. (See
Diseases of the Pharynx.)
Local Examination. The Exterior. The external appearance
of the nose is of diagnostic significance when marked deformity takes
place. Its true shape is changed in niyxoedenia (q. v.). It is changed
in disease of the bone due to syphilis. The bridge of the nose is sunken
or depressed. It must not be confounded with the depression that
occurs in fracture. The nose may be broadened in cases of tumors of
an expanding nature in the nasal cavities. The local change soon
extends to the cheek. The nose is also the seat of eruptions, as acne
and hyperemia, but they are usually of local origin. They may be
suggestive of a gouty diathesis.
Internal Examination. The examination of the cavities of the
nose consists of two procedures, both of which are necessary to deter-
mine with accuracy the condition of the organ. These are :
1. Anterior Rhinoscopy. For this are needed a good light, a nose
speculum of some form, probes, a 10 per cent, solution of cocaine, and
a head-mirror with central opening.
The examiner proceeds as follows : The patient is seated facing the
surgeon, with the light behind and at one side of the head, as nearly
as possible on a level with the eye of the operator. He must sit with
shoulders and head a little forward. The operator adjusts his head-
mirror so that the central aperture is in front of his own eye, and the
reflected light falls on the nose of the patient. It is very important
for nose-examination that the operator look through the aperture and
not under the mirror. The speculum is then taken in one hand and
the nostril dilated, so that the view of the interior is unobstructed.
Do not try to dilate the bony part of the nose, but only the nostril.
Proceed from before backward with the examination, carefully focus-
ing the light on each part in succession, and gradually tilting the
head of the patient backward. Thus the floor of the nose, the septum,
inferior turbinated bones, middle turbinated bones, and sometimes the
superior turbinated bones, are brought into view successively. In a
broad nose one may at times see the posterior wall of the pharynx,
which is distinguished by its peculiar wave-like movement when the
patient swallows. The use of the probe is important, and without it
no positive diagnosis can be made. With the probe the operator tries
the condition of the mucous membrane, tests the consistency of tumors
or hypertrophies, and so judges of the character of the condition. After
this the enlarged parts should be touched with cocaine and the result
observed. Contraction of a swelling under its influence proves its
vascular origin.
2. Posterior Rhinoscopy . This is the most difficult part of the ex-
amination and requires much practice on the part of the operator.
The instruments needed are a tongue depressor, head-reflector, two
422
SPECIAL DIAGNOSIS.
sizes of throat-mirrors, a palate-hook or flat strings for holding for-
ward the soft palate, and a curved applicator for cocaine, or a spray
bottle with tip turned upward.
The patient is seated as before, the tongue held down by the tongue-
depressor, and the patient is told to breathe freely through both mouth
and nose. The light is directed into the pharynx and a mirror of the
largest possible size inserted carefully behind the soft palate. The
proper angle and the movement necessary to bring all parts into view
can only be learned by practice. As a rule, it is best to hold the
Fig. 110.
Rhinoscopic mirror in position. (Bosworth.)
handle well up at first, and note the condition of the vault of the phar-
ynx, then gradually depress it, examining the choanse from above
downward. Do not keep the mirror too long in the throat. It is
better to insert it several times than to weary the patient by attempting
to see everything the first time. After the choanse have been exam-
ined a turn of the mirror to either side will bring into view the orifices
of the Eustachian tubes, and the examination is complete. If, after
repeated attempts, it is found to be impossible to see the posterior
nares, one must first seek to accustom the patient to the presence of
THE NOSE AND LARYNX. 423
the instruments ; if this fails, it may be necessary to resort to the
palate hook or the cords to hold the uvula forward. The best hook is
White's. It is necessary to apply cocaine to the soft palate before in-
serting the hook. Another plan, which is preferred by some, is to
take the flat cords used for corset-laces, soak them in mucilage and dry
them. These are then stiff enough to pass through the nostril, yet
flexible enough to pull down and out through the mouth with forceps.
Then by drawing forward both ends the soft palate is pulled out of
the way. This is almost always necessary when applications are to be
made to any spot in the pharynx.
Sometimes a view of the posterior nares may be obtained by making
the patient breathe in short, quick gasps, by which the uvula is re-
leased. In ordinary breathing it is often tightly pressed against the
posterior wall of the pharynx.
Fig. 111.
2 3 I ''~'' m *m&
12
Rhinoscopic image.
1. Vomer or nasal septum. 2. Floor of nose. 3. Superior meatus. 4. Middle meatus. 5. Superior
turbinated bone. 6. Middle turbinated bone. 7. Inferior turbinated bone. 8. Pharyngeal orifice
of Eustachian tube. 9. Upper portion of Rosenmtiller's groove. 11. Granular tissue at anterior
portion of vault of pharynx. 12. Posterior surface of velum. (Seiler.)
By the above methods we are to determine the appearance and nutri-
tion of the mucous membrane, relative size of the cavities, the nature
of the discharge, and the presence of ulceration or perforation of the
nares. Deviations of septum, enlargement or contraction of turbinated
bones, the size of the cavities, and the presence of foreign bodies or
abnormal growths are also detected.
Inspection. Appearance of the Mucous Membrane. The
observer may find it unusually pale. This is seen in tuberculosis
and in atrophic rhinitis. If a protuberant mass is observed to be
transparent and shining, as well as pale, it is due to a polypus. If the
mucous membrane is bright red, it may be due to acute inflammation,
to glanders, or to syphilis. It is dull red in chronic catarrhs and caseous
rhinitis. The coatings of the mucous membrane are of significance.
If a dry mucus covers the part, it is due to dry catarrh ; on the other
hand, a dirty-gray membrane is indicative of diphtheritic rhinitis.
It is swollen and bathed with a serous, seropurulent, or purulent
discharge, the character depending on the stage of inflammation. The
424 SPECIAL DIAGNOSIS.
contractile tissue over the turbinated bones is congested and swollen.
When probed it is elastic, and when cocaine is applied it shrinks.
In chronic hypertrophic rhinitis the uvula is thickened and elon-
gated, on 'account of the hawking. The outer surface or the edges of
the turbinated bones are enlarged throughout or hi localities. The
mucous membrane covering these spots is thickened, hard, and rough.
If cocaine is applied, the mucous membrane does not contract, as in
the swelling due to hyperemia. The posterior ends of the inferior or
middle turbinated bones are enormously enlarged, forming round
tumors which obstruct more or less the posterior nares and project into
the pharynx ; polyps and deviation of the septum complicate these
cases.
The same appearances are seen in chronic post-nasal catarrh, and
in addition a mammillated and thickened appearance of the pharyngeal
mucous membrane and that of the posterior third of the septum. In
dry catarrh the mucous membrane is coated with mucus or covered
with crusts. The membrane is thin, pale, hard to the touch, and cov-
ered with a layer of dried secretions and -crusts in atrophic rhinitis.
The nasal passages are abnormally wide and one or both turbinated
bones are atrophied.
Abnormal Growths. A grayish yellow or greenish shiny mass, with
a broad base, soft and yielding on probing, is a nasal polypus. It
cannot usually be circumscribed. The passages are enlarged in atrophic
rhinitis. One may be occluded by an enlarged turbinated bone or by
deviation of the septum.
Ulceration. Ulceration of the mucous membrane is usually a
manifestation of lupus, tuberculosis, or tertiary syphilis. In lupus the
ulceration has extended from the exterior. If ozaena is present in a
patient with lupus it is probable that there is also lupus of the nasal
passages. The ulcers may be followed by necrosis and caries of the
bones. If the ozama is not removable by antiseptic sprays the bones
are probably affected. A discharge of sequestra makes the diag-
nosis positive. Rhinoscopy and careful palpation may reveal the ulcer
and a carious bone. Tuberculous ulcers are usually found in the septum.
They are rarely primary. They present a whitish-gray surface, with
elevations of infiltrated tissue. They bleed on the slightest provoca-
tion. The mucous membrane surrounding them is torn. Tubercle
bacilli can be found in the scrapings from the ulcer. In syphilis the
ulcers are situated anywhere in the nares. A history of infection, or
of secondary and tertiary manifestations, can be obtained. The stench
of the breath is sickening, and the patient complains of stenosis and
loss of smell. There is some localized tenderness, and sleeplessness,
debility, and emaciation may ensue. They may be mere superficial
excoriations, or deep serpiginous ulcers surrounded by an inflammatory
zone. Caries can be detected with a probe. The ulcerated surfaces
are covered with a dry, greenish crust. Foreign bodies usually cause
ulceration if impacted.
Xeuro-paralytic ulcers are painless and spread rapidly over consider-
able surface ; they follow paralysis of the fifth nerve. They are dry
and sluggish and do not extend to the skin. Post-febrile ulcers follow
THE NOSE AND LARYNX. 425
measles, scarlatina, typhoid, and variola, and are due to rupture of
small abscesses, with the subsequent formation of ulcer. They are
usually anterior on the septum or inside the alse, and scabs form over
the surface. They are very irritable. Ulcers may perforate the
septum or the floor of the nose. They are usually due to syphilis.
Simple perforating ulcer of neuro-paralytic origin may also occur.
Nasal Secretion. The odor of the discharge is suggestive of
diphtheria and also of the presence of foreign bodies. The discharge
in the latter instance is sanious or purulent. Animal parasites, as
well as pease and beans, cause pain, symptoms of obstruction, and ulcer-
ation. In syphilis with caries the odor is marked, usually gangrenous.
Atrophic Rhinitis, or Ozaena. The odor is characteristic, and is
diagnostic if syphilis is excluded. A sense of dryness is complained
of. Occasional obstruction arises from accumulation of crusts, other-
wise the passage is unduly open. There are constant hawking and
spitting of brownish-green crusts, which are often blood-tinged. Frontal
headaches may occur in paroxysms. The patient is often depressed in
spirits. The bridge of the nose may fall in slightly.
Physical Character. The character of the secretions is of diag-
nostic significance. They may be liquid, semi-solid, or solid. The
liquid secretions may be serous, mucous, or purulent. Serous secretions
occur in acute rhinitis, hay fever, and idiopathic rhinorrhcea, and follow
bursting of cysts. The secretion of mucus occurs in the later stages
of inflammation of the mucous membrane and in chronic forms. A
mucopurulent secretion is seen in chronic rhinitis, and pure pus in
abscesses of the septum or cavity. In hereditary syphilis it is at first
mucopurulent, then purulent, and then sanious. A sanious acrid dis-
charge, with false membrane discharged or evident on inspection, is
due to diphtheria. A fetid, sanious, or ichorous discharge, with fre-
quent attacks of epistaxis, attends malignant nasal growths. A dis-
charge of blood is known as epistaxis. (See page 426.) The semi-
solid secretions may be due to mucus alone, or to blood-clots mingled
with serum or with pus. The latter occur in atrophic and hyper-
trophic catarrhs.
Caseous Rhinitis. A semi-solid secretion is diagnostic. On exami-
nation the cavities in this affection are found to be filled with cheesy
matters, easily broken up with the probe. The mucous membrane is
dull red. The material is discharged in masses at intervals through the
mouth or nostrils, relieving the previous extreme stenosis. If neglected
for a long time, deformity of the face and disease of the bones and car-
tilages ensue from pressure.
The solid secretions may be mucous crusts, as in acute and chronic
catarrhs, blood-crusts after epistaxis and traumatism, membrane in
diphtheritic rhinitis, slough from ulcers, and rhinoliths. The latter
are gray or greenish-brown in color, hard and rough, either fixed or
movable.
Microscopical Character. The normal secretion from the nose con-
tains squamous and ciliated epithelium, isolated leucocytes, and vari-
ous fungi. The fluid is thick, alkaline in reaction, and lias a slight
odor. It contains mucin. In disease of the nasal cavities the fluid
426 SPECIAL DIAGNOSIS.
changes. In acute nasal catarrh it is niore copious and thinner. It
remains alkaline, and contains epithelium and fungi. When the stage
of suppuration is reached, the secretion may consist entirely of pus.
Cerebro-spinal fluid may also be discharged through the nose in certain
brain-tumors. In such fluid albumin is absent. Detection of this
fluid is of diagnostic value, as it points to the central lesion.
The Charcot-Leyden crystals are found in the nasal secretion in
asthmatic patients, and sometimes in acute coryza.
Bacteriological Character. In diphtheria the characteristic micro-
organism is seen. Recognition of glanders may be based upon finding
the bacillus in the nasal secretion. (See page 336.) Cultivations
may be made. The nature of ulcers may be determined by microsco-
pical examination. The tubercle bacillus can sometimes be detected.
A pneumococcus or bodies that resemble it have been found in the
secretion in ozsena. Thrush-fungi have also been found, as well as
some mould fungi.
Mouth-breathing. Much valuable information is obtained by
noting the breathing and the condition of the voice. Mouth-breathing
may be present if the face is drawn and vacant and there are cracks
and fissures in the mouth. The voice is usually nasal. The resonating
quality is lost entirely. Snoring accompanies these conditions. (See
Obstructive Symptoms.)
Palpation. The probe is used to determine the character of en-
largements or tumors, and the patulency of foramina ; also to examine
the mucous membrane as to induration and the presence of caries or
necrosis. By the finger the nasal pharynx is palpated to confirm the
results of rhinoscopy. In this manner adenoid vegetations and hyper-
trophy of the inferior turbinated bones are detected. The finger should
be protected by the use of a mouth-gag or by a jointed thimble.
Epistaxis. The blood may flow in drops, or a continuous stream
may pour out from the anterior nares. Sometimes it falls into the
pharynx and is hawked up, or is swallowed and then vomited.
It may be due to local causes, or to constitutional conditions. Trau-
matisms (scratching the nose), new growths, and foreign bodies are
causative agents ; it may be due to fractured skull. Local causes :
On inspection, the cause may be found in enlarged veins at the anterior
inferior portion of the septum, a bleeding ulcer, a new growth, or
the ulceration of a foreign body. The general conditions w T hich are
causal are : (1) Plethora ; (2) engorgement due to the ascent of an
elevation ; (3) all forms of ansemia ; (4) hseinophilia ; (5) cerebral con-
gestion and severe headache ; (6) the commencement of fevers, particu-
larly typhoid fever ; (7) early stages of leprosy. In children exposed
to the sun, and after exertion, it is of frequent occurrence, and is seen
often at puberty in delicate children.
Diseases of the Nose.
The subjective and objective symptoms previously described are due
in general to inflammations, malformations, morbid growths, and foreign
bodies. They are recognized by their subjective and objective signs,
by rhinoscopic examinations, and by bacteriological and microscopical
THE NOSE AND LARYNX.
427
research. The inflammations may be acute or chronic, primary or
secondary. When secondary, both acute and chronic inflammations
may be due to infections. To the acute varieties belong the acute
catarrh of measles, glanders, hay fever or influenza ; to the chronic
belong syphilis and tuberculosis.
Simple Acute Rhinitis. Acute Coryza, " Cold in the Head."
Ushered in with a feeling of lassitude, aching in the back and limbs,
and feverishness, a sense of fulness is felt in the nostrils, with sneezing.
After twenty-four hours an irritating discharge begins. During this
time the malaise has increased. The pain in the forehead and cheeks
has become more pronounced, and a nasal twang is given to the voice.
The feverishness continues, reaching 101° in the more pronounced
Fig. 112.
Vertical section through nasal cavities. (Diagrammatic.) (Seiler.)
1. Superior turbinated bone. 2. Middle turbinated bone, with posterior hypertrophy. 3. Section
of hypertrophied pharyngeal tonsil. 4. Inferior turbinated bone. 5. Orifice of Eustachian tube.
cases, with thirst and loss of appetite. At the height of the fever, in
twenty-four or forty-eight hours, a crop of herpes very often develops
on the lips. The general symptoms then subside and the local symp-
toms change. The discharge becomes thick and purulent, the fulness
continues, but the pain is diminished. The inflammation often extends
up to the tear-ducts and to the eyelids. The latter are congested and
smart very much. Very frequently, also, the inflammation extends
to the pharynx, causing soreness of the throat and stiffness of the neck,
and the larynx even may be involved. A slight deafness may result
from the inflammation extending into the Eustachian tube.
Chronic Rhinitis. Four varieties are distinguished, to all of which
the term nasal catarrh is applied. In one there is hypertrophy of the
428
SPECIAL DIAGNOSIS.
turbinated bones ; in the second there is extension of the disease to the
post-pharynx — chronic post-nasal catarrh ; in the third there is abso-
lute dryness of the mucous membrane — rhinitis sicca, or dry catarrh ;
hi the fourth there is atrophy of the mucous membrane — atrophic
rhinitis, or ozsena.
Chronic Hypertrophic Rhinitis. The affection comes on gradually
after repeated acute attacks of coryza. The only symptoms may be
Fig. 113.
Dilated nostril, showing anterior hypertrophy. (Seiler.)
slight fulness in the nose and a little hoarseness of the voice. In more
advanced stages the symptoms of stenosis are marked with oral breath-
ing, snoring, and nasal sound. There is a constant discharge of muco-
pus backward into the pharynx, causing hawking. The hearing is
frequently impaired, as well as the taste and smell. The discharge
Rhinoscopic image from a case of posterior hypertrophy on the middle turbinated bone. (Seilek.)
often affects the larynx, causing an irritating cough. The hypertro-
phied tissue on the turbinated bones, and the pressure of the bone on
the septum, may lead to reflex attacks of asthma.
Chronic Post-nasal Catarrh is an extension of the rhinitis into the
pharynx. It is distinguished by discomfort or pain in the soft palate
and posterior nares. There are tingling and a sense of fulness at the
root of the nose, with frontal headache ; the patient complains of a
THE NOSE AND LARYNX. 429
bad taste in the back of the mouth and of constant flow of thick secre-
tion into the pharynx, causing snoring and hawking. The same per-
version of the senses of taste, smell, hearing, and of the voice occurs
as in acute rhinitis. Headache seems to be due to the condition of
the pharynx. (See Atrophic Rhinitis, page 425.)
Dry Catarrh, or Rhinitis Sicca, is also chronic in its course, accom-
panied by tingling and dryness of the nostrils. A faint, musty odor
is detected, but there is no discharge or sense of obstruction. In severe
cases there may be sharp pain in the nose extending to the forehead.
Syphilitic Coryza is seen in infants and young children affected
with hereditary syphilis. The nostrils are swollen and red at the
edges, sometimes completely occluded, causing oral respiration and
inability to take the breast or bottle.
Pustules, fissures, and ulcers are found in the nose and at the margin
of the orifices. They are also seen in the pharynx and larynx. Hem-
orrhages may occur. Other evidences of hereditary syphilis are present.
The Auxiliary Cavities of the Nose.
The Antrum is subject to abscess, cysts and polypi, parasites, and
tumors.
Abscess. An odor somewhat like that of ozsena, a putrid taste,
nausea, anorexia, pain in the cheek and root of the nose, often neural-
gia in the frontal region, and malaise are present. A very character-
istic symptom is the discharge of pus from one nostril on leaning the
head forward. There is often a bad tooth on the same side in the
upper jaw.
The Sinuses. The frontal, ethmoidal, and sphenoidal sinuses are
subject to inflammation, abscess, traumatism, and the irritation of
foreign bodies, usually parasites.
The frontal sinuses are the only ones which exhibit external symp-
toms. When these cavities are inflamed the patient complains of pain
and tenderness over the frontal protuberances ; if the process goes on
to the formation of abscess, there may be redness and swelling and
finally fluctuation. If the communication is not closed, there is a
fetid discharge from the middle meatus.
When the sphenoidal and ethmoidal sinuses are affected there are no
external symptoms unless the enlargement is so great as to affect the
orbit. There is deep-seated pain. Pus is seen exuding into the supe-
rior meatus and flowing backward into the pharynx. Parasites cause
intense pain and lead to abscess, caries, and necrosis. Rhinoscopic
examination in disease of the antrum shows rough hypertrophic en-
largement on the under surface of the middle turbinated bone and a
flow of pus into the middle meatus. Sometimes a probe can be passed
into the antrum from the nose. Often an exploratory puncture is
necessary. When the foramen is obstructed there is a dull aching pain
in the upper jaw, with deformity of the orbit, face, hard palate, and
nostril. Fluctuation can usually be found at some point after a time.
The lacrymal duet and sac are often the seat of inflammation by ex-
tension, causing pain, obstruction in the nose, and epiphora. On
430 SPECIAL DIAGNOSIS.
examination pus will be seen flowing forward over the inferior meatus.
When the lacrymal probe is introduced the ducts are found to be
painful and obstructed, and pus exudes.
The Larynx.
The structural composition of the larynx does not differ from that
of other parts of the respiratory passage. Mucous membrane, connec-
tive tissue, cartilages, and muscle are similar to the same tissues situ-
ated elsewhere.
The result of their anatomical association in the larynx is the estab-
lishment of the functions of that organ, the formation of the voice and
the admission of air. Now, the morbid processes that affect the larynx
do not differ from morbid processes elsewhere in which similar tissues
are involved. Each tissue is liable to congestion, to inflammation, to
degeneration, to new-growth formation ; the joints may become anky-
losed, the muscles either paralyzed or the seat of spasm, and we have,
therefore, all the symptoms common to morbid processes in each class
of tissue. We meet with other symptoms beside, which result from
the anatomical position of the larynx and of its functions. The cords
cannot vibrate, or the muscles and articulations cannot move, and dys-
phonia or aphonia occurs. The narrow chink of the glottis soon be-
comes occluded, giving rise to dyspnoea. Obstruction to the pathway
or pain from inflammation or ulceration causes dysphagia. The sensi-
tiveness of the mucous membrane provokes cough on the slightest
provocation.
The larynx is a highly specialized organ, and is well innervated.
Large central nuclei, connected by a large nerve which passes over a
circuitous route and which anastomoses with other nerve-cords, preside
over the function of phonation. Affections of the central nuclei, affec-
tions of the nerve-trunk or of adjacent structures exerting pressure
upon the trunk, have their expression in disorder of the larynx, par-
ticularly if phonation is disturbed. In other words, the phenomena
of laryngeal disease may be symptomatic of affections of the brain or
of the nerve-trunk, as well as of the larynx. (See Nervous Diseases.)
Owing to the anatomical position and special function of the organ
the symptoms of disease of the larynx are very striking, pointing at
once to the seat of trouble. Laryngeal affections are not likely to be
mistaken for disease of contiguous parts, although retropharyngeal
abscess, abscess at the side of the pharynx, disease of the thyroid gland,
and inflammation of the lymphatics or cellular tissue in the neck may
cause symptoms suggestive of laryngeal disease.
Finally, morbid processes in the larynx determined by the symp-
toms and physical appearances may be symptomatic of general processes :
acute inflammation, of erysipelas, typhoid fever, smallpox, or measles ;
chronic inflammation or ulceration, of the rheumatic or gouty diathesis,
syphilis or tuberculosis ; scars, of syphilis ; ankylosis, of rheumatic
gout. The laryngeal symptoms of brain disease or of affections of the
nerve-trunk have been referred to.
The practical point of all this is that affections of the larynx are not.
THE NOSE AND LARYNX. 431
due to primary disease of that organ alone, but are often secondary
either to general processes or to local morbid processes elsewhere.
Therefore, when laryngeal symptoms or lesions are observed, seek
beyond the larynx, as well as in it, for their cause.
The Data Obtained by Inquiry.
The Social History. Acute laryngeal diseases are more common
in childhood, chronic diseases in late life. Those occupations which
compel the inhalation of noxious vapors or excessive use of the voice
predispose to laryngeal diseases. Alcoholic subjects and those who
use tobacco to excess are liable to laryngeal affections. As with the
nose so with the larynx, no special disease is inherited and need be
looked for in the family history. But we may inquire for a diathetic
condition, as gout or rheumatism, which predisposes to a mucous mem-
brane inflammation, or a family type which leads a parent to say his
child ' ' has a tendency to croup," a popular expression which has in it
an element of truth. That condition or state which predisposes to
" colds " belongs also to a family type.
On inquiry as to previous disease various acute infections and syph-
ilis and tuberculosis are to be looked for. In a study of the present
disease it must be borne in mind that laryngeal affections notably may
be secondary, and, therefore, the presence of other diseases must be
inquired into. Particularly do we inquire for nervous diseases, and in
children for rhachitis. One thing is to be borne in mind — one attack
of acute laryngitis predisposes to subsequent attacks.
Subjective Symptoms. Paix. Pain in the larynx maybe sharp,
stabbing in character, or simply a tickling or burning with a feeling
of pressure. It is increased by pressure and by speaking or swallow-
ing. Pain is sometimes so intense as to render speaking and swallow-
ing impossible. In acute laryngitis the pain is cutting and burning.
In the milder inflammations, in dry catarrh, and in lupus it amounts
to soreness only. The pain is severe and sharp in cases of cancer and
tuberculosis, rarely in syphilis, and when foreign bodies are present .in
the structures. The pain may be very severe and intense when there
is destructive ulceration. It is a diagnostic symptom of perichondritis.
Perichondritis. Inflammation about the cartilages or perichondritis
is usually phlegmonous in character, and leads to the formation of
abscess. The collateral oedema is so great as to cause some obstruction,
with cough and hoarseness. On palpation the larynx is extremely
tender. The pain is increased by movement of the larynx, as in speak-
ing or swallowing. If the inflammation involves the arytenoid carti-
lages, pain extends toward the ear, the vestibule is swollen, the car-
tilage fixed. On the other hand, when the cricoid is diseased there
are pain on swallowing of solid food, on account of interference with
the muscular attachments, dyspnoea, and paralysis of the posterior
crico-arytenoid muscles.
Inflammation of the thyroid cartilage may open externally or inter-
nally. In the latter case the abscess can be seen in the larynx. Dis-
charge of pus and necrosed cartilage confirms the diagnosis. By means
432 SPECIAL DIAGNOSIS.
of a sound the bare cartilage can be detected, giving further proof of
the presence of the disease. The pain niay extend to the ears in carci-
noma. The pain is propagated by the auricular branches of the vagus.
Paresthesia. Peculiar sensations are frequently complained of.
They may be burning, tickling, or itching in character, or it may seem
as if a foreign body were present in the part, as a hair, or it may seem
like a draught of cold air striking the parts. Sometimes after a foreign
body has actually been present, the sensation of its presence will con-
tinue a long while after its removal. A sense of pressure or fulness,
the feeling of a lump in the throat, is frequently complained of, pro-
voking a desire to swallow. The patient will seek advice on account
of it. It is known as the globus hystericus, and is recognized by the
absence of local changes in the larynx, by its association with other
phenomena of hysteria, and by its disappearance or aggravation under
the influence of excitement. This abnormal sensation is seen in hys-
teria and hypochondriasis. It is one of the nerve-perturbations in
chlorosis and anaemia.
A feeling of dryness is frequently complained of, and attends the
first stage of acute, and any stage of chronic laryngitis. The sense of
fulness, or pressure, or feeling of the presence of a foreign body is com-
plained of in all forms of laryngitis, in croup, in oedema of the glottis,
or epiglottis, and in syphilitic infiltration.
Hyperesthesia and Anesthesia. When there is hyperesthesia
there is constant desire to cough (see page 435), and the act is induced
by the slightest irritation. The desire to cough, independently of the
act, however, is of itself an extreme annoyance. It is a disagreeable
sensation present in acute inflammations and in early phthisis. At
times of menstruation and during pregnancy both symptoms are fre-
quently complained of. Hypersesthesia is easily recognized with the
probe. In ancesthesia particles of food fall into the larynx. The
mucous membrane is insensitive to the contact of the probe. Anaesthe-
sia occurs in hysteria, diphtheritic paralysis, paralysis of the superior
laryngeal nerve, bulbar paralysis and cerebral softening or hemor-
rhage, or coma from any cause.
Dysphoria. The most common symptom of affections of the
larynx is disturbance of the function of speech. The voice is changed
in character, or may be lost in any affection which causes swelling of
the mucous membrane, or occlusion of the orifice, or which interferes
with the action of the vocal cords. The voice may be hoarse in acute
and chronic inflammations, in tumors and in specific ulcerations about
the larynx, and in paralysis of the cords. From simple hoarseness it
may vary in intensity to complete aphonia. Laryngoscopic examina-
tion is necessary in order to detect the presence or absence of paralyses.
(See Paralyses.)
Chronic Laryngitis. Chronic hoarseness may be due to chronic
laryngitis. This affection either originates in an acute attack or comes
on slowly. Prolonged use of the voice in a higher key than natural,
or in the open air, the use of alcohol, constant exposure, are exciting
causes. It is symptomatic of syphilis and tuberculosis. It frequently
results from inflammation of the upper air-passages, particularly chronic
THE NOSE AND LARYNX. 433
pharyngitis. It occurs after middle life more frequently, and usually
in the male sex. There is discomfort on long speaking, with dryness
and tickling. At first the secretion of mucus is very slight, but after
hawking and coughing it increases in amount. Hoarseness occurs, and
if the patient is careless or persists in the baneful occupation, complete
aphonia may result. The voice is clearest in the morning, after expec-
toration of the mucus that accumulated in the night, but becomes husky
toward night. The aphonia may occur in paroxysms, and is relieved
by coughing up a dry secretion. The cough is never severe. The
sputum is small in amount, glairy, and is often in little balls or crusts.
Lupus. Slight hoarseness, deepening to dysphonia or even aphonia,
attended by soreness, and later some dysphagia, is seen in lujius. In-
filtration and scar-contractions cause dyspnoea later in some instances.
Dysphonia from inflammation or oedema is also a symptom of leprosy,
which, however, is present in other situations as well. The duration
may be significant. Hoarseness of long duration (years) is said to be
prodromal of cancer (Ziemssen).
Functional Dysphonia or aphonia may occur after excessive use
of the voice and in hysteria. Hysterical aphonia occurs in women
and young girls ; the laryngoscope reveals nothing ; the acts of cough-
ing, laughing, and sneezing are normal, and a sound may be created
in either act ; it appears and disappears suddenly.
Tone of the Voice. The character of the voice may change.
When one-sided paralysis of a cord is present the voice is flat and
toneless. In cases of paresis of the tensors of the cords a falsetto voice
results. Diplophonia occurs in one-sided paralysis, and in some cases
in which small tumors lying between the cords come up during the
act of phonation and form nodes. Two tones are formed at the same
time. Frequently only certain tones are doubled.
Dyspncea. This is one of the frequent symptoms — and the most
serious — of laryngeal disease. It may be due (1) to obstruction by
inflammatory or oedematous swelling ; (2) to spasin ; (3) to tumors or
foreign bodies in the larynx ; (4) to the cicatrization of ulcers after
syphilis or lupus ; (5) to paralysis of the abductors or adductors of the
larynx. It may be, therefore, organic or spasmodic.
Duration. Dyspnoea from disease of the larynx may develop grad-
ually and continue over a long period of time, or it may be acute in
onset, depending upon the character of the morbid process which has
brought about the obstruction. Acute paroxysms of dyspnoea, one of
which may end in death, sometimes occur in the course of affections in
which chronic dyspnoea is present ; thus sudden oedema may occur in
cases of syphilitic or tuberculous ulceration.
Laeyngeal Dyspncea must be distinguished from other forms of
dyspnoea : 1. Dyspnoea from diseases of the heart and lungs. 2.
Dyspnoea from pressure upon the trachea. The larynx is not markedly
moved during the respiratory acts, and the patient bends the head for-
ward instead of backward. 3. Dyspnoea from pressure on the larynx.
Cellulitis of the neck, tumors of the lymph-glands, goitre, and retro-
pharyngeal abscess are provocative of this form of laryngeal dyspnn'ji.
Examination of the respective localities by inspection and by touch
28
434 SPECIAL DIAGNOSIS.
reveals the cause. It may be worthy of remark that dyspnoea in
diphtheria, frequently thought to be due to internal occlusion, may be
due to pressure of enlarged glands on the bronchus and larynx.
Inspiratory Dyspnoea. Dyspnoea may vary in degree from slight
inconvenience in breathing, noticeable to the patient, to the violent
struggling for breath which is seen in cases of extreme stenosis of the
larynx. If carefully observed in either case the larynx is seen to rise
and fall. In extreme forms of obstruction the head is bent back, the
neck stretched, the muscles of the neck contracted. The spaces above
the sternum and at the sides of the trachea are drawn in with inspira-
tion, and the alee of the nose work vigorously. Further evidence that
sufficient air does not enter the lungs is found in recession of the epi-
gastrium and drawing in of the ribs at the base of the chest during
the act of inspiration. The countenance is dusky or ashy-gray, the lips
become cyanosecl, and the nails bluish as the dyspnoea persists and
increases. A cold perspiration breaks out on the forehead, and finally,
from exhaustion, the respiration becomes slower and slower until mere
gasps are seen. The heart's action increases in frequency as the ste-
nosis increases. Death usually takes place from asphyxia, the child
first falling into a stupor, on account of carbonic-acid-poisoning.
Sounds attend the act of inspiration, the character depending on the
nature of the obstruction. In obstruction from simple spasm, or from
intense inflammation of the larynx, without secretion, the sound of
inspiration is harsh and stridulous. In obstruction from oedema or
from exudation, as in laryngeal diphtheria, the sound of the inspiration
is loud and stridulous, but not shrill. The expiration is usually noise-
less and prolonged. The short, stridulous,. or gasping inspiration is
followed by prolonged gentle expiration. In spasmodic croup the
expiration is like snoring. The interval between expiration and inspi-
ration is lessened, the respirations are hurried.
Laryngismus Stridulus. In this form of dyspnoea the act of
breathing ceases in the midst of inspiration, and is attended by a
characteristic sound. It is seen usually in poorly nourished children.
It is of frequent occurrence in rickets, its presence suggesting that
disease when other manifestations of it are obscure.
The symptoms occur suddenly and are very alarming. The child
awakes in the night, and suddenly stops breathing after a few short
whistling inspirations. The child is seized with terror, which is de-
picted on the countenance ; the eyes stare ; the face is pallid at first,
tut rapidly becomes livid. The alse nasi are extended, the head is
thrown back, and the spine arched. A cold perspiration breaks out
over the forehead. Carpo-peclal spasms may occur and the urine and
feces be discharged involuntarily. In a few seconds, or, at most, two
minutes, the child draws two or more deep, noisy inspirations, each
one lessening in depth and sound, when color returns to the face, the
cyanosis gradually disappears, and the child becomes tranquil.
In mild forms the child " catches its breath." It holds its breath,
and then makes a noisy inspiration.
Attacks of laryngismus stridulus are more rare in adults. They
may occur in hysterical subjects. In the attack there occurs a series
THE NOSE AND LARYNX. 435
of long, harsh, whistling or stridulous inspirations, followed by short,
noisy expirations. Rarely is there complete closure of the glottis.
In both children and adults general convulsions may occur during
the attack, or carpo-pedal spasms alone may be seen. Among adults
the convulsions occur only in hysterical subjects.
The diagnosis of laryngismus stridulus is based upon the absence of
laryngeal symptoms prior to the attack, the absence of cough or hoarse-
ness, and complete disappearance of all laryngeal symptoms when the
attack subsides. The absence of pain and fever and of laryngoscopic
signs is noteworthy. This applies, of course, to spasm that occurs in-
dependently of laryngeal disease.
Expiratory Dyspnoea. In some forms of laryngeal obstruction
the exit of air is interfered with, as in a movable tumor below the vocal
cords. We have expiratory dyspnoea. The act of inspiration is com-
plete, the act of expiration is suddenly checked by the obstruction, on
account of which the lungs become overfilled with air and an emphy-
sema develops.
Dysphagia. Difficulty in swallowing is most marked when destruc-
tion of tissue in the larynx takes place, or when there is acute inflam-
mation about the muscles or their attachments ; hence, when ulcers,
tuberculous or malignant, are present, or perichondritis arises, the
difficulty is so great as to prevent the taking of food.
Dysphagia is recognized by pain and by the falling of particles of
food into the larynx, exciting cough. It must be distinguished from
the dysphagia of pharyngeal affections by ocular examination, the loca-
tion of the pain, and the non-association of rheumatism.
Inflammation of the Epiglottis. When the epiglottis is the seat
of acute inflammation there is great dysphagia on account of pain, or on
account of the obstruction. The sensation of a lump in the throat at
the base of the tongue or the top of the larynx is complained of, and
there is pain on swallowing. The pain becomes very intense at times.
Fluids cannot be taken, for the fluid enters the larynx when the patient
attempts to swallow, because the epiglottis does not protect the glottis.
The voice is usually clear throughout the attack, and the general symp-
toms are not marked.
When the epiglottis is fixed or ulcerated, and in some forms of ulcer-
ation of the larynx, the food enters the larynx, and hence produces
dysphagia.
Mis-S wallowing, or " swallowing the wrong way," occurs in all
conditions in which food is allowed to enter the larynx. Although
conditions favorable for its occurrence are present, it may not take
place unless the patient is off his guard during the act of swallowing,
as when he is laughing. It may then occur even in normal cases.
It is associated with anaesthesia of the larynx, and occurs in central
nerve affections which cause that condition.
Cough. (See Diseases of the Lungs.) Sometimes valuable infor-
mation is derived from the character and severity of the cough. Sev-
eral forms are noted :
First, the dry cough, as seen in acute laryngitis. It is almost con-
stant, and is aggravated when the patient speaks, takes fluid, or inspires
436 SPECIAL DIAGNOSIS.
deeply. In children it is abrupt, brassy, or metallic, stridnlous or
whistling, so-called ( c croup-cough," as seen in cases of ' ' false croup "
and laryngitis with cedenia.
Second, a dry hoarse cough occurs in the course of chronic laryngitis.
Third, cough with whoop. With the act of coughing a whooping
sound may be heard in inspiration. After rapid violent expiratory
acts the whoop takes place with inspiration. It is spasmodic and con-
vulsive, and is followed by retching, and often by vomiting. (See
Pertussis.)
Fourth, the cough is of such a character as to give one the idea that
it is suppressed in membranous and oedematous laryngitis.
Fifth, a cough frequently occurs without any local anatomical changes
in the larynx, which seems to be purely of nervous origin. Two forms
are seen : a. Paroxysmal. Severe coughing occurs suddenly, and can-
not be controlled by the patient. It ceases without cause, returning
in a few hours. There is no expectoration, b. Continued and rhythmi-
cal. It is not so severe as in the paroxysmal form, but consists in a
regularly recurring cough more or less loud. It does not occur while
eating or speaking and ceases entirely during sleep. It is usually
tvorse when the patient is under observation. Examination with the
laryngoscope reveals absence of disease. This form of cough is seen
after diphtheria, when sexual disturbances are present, at puberty, in
cases of anaemia and chlorosis, or of neurasthenia or hysteria. The
tone is usually high.
Hemobehage. Hard coughing or an unusual straining of the
voice may lead to the occurrence of slight hemorrhage. Only after
injuries are hemorrhages from the larynx at all copious. Moderate
hemorrhages occur in scurvy, haemophilia, hemorrhagic smallpox,
typhus fever, and leukaemia.
Disttjbbaxce of Co-oedixation. Several forms of such disturb-
ance are seen. Spasm of the glottis may occur with each effort to
speak, causing either serious interference or complete inability to utter
a word, as in stuttering. Sometimes, instead of the glottis opening to
complete the act of inspiration, it may close. Sudden inspiratory
dyspnoea, therefore, occurs, and is attended with stridor.
Spasm of the glottis is a frequent complication of disease of the
larynx. It is seen in " crises," as in locomotor ataxia.
The Data Obtained by Observation.
Objective Symptoms. The objective symptoms are determined by
inspection and palpation. Inspection of the exterior of the larynx re-
veals the presence of swelling, and the movements of the organ as a
whole. Local swelling of the tissues over the larynx may occur in
inflammations of the cartilages ; they are usually of syphilitic origin,
but may attend carcinoma or tumor. There is more or less marked
swelling in inflammation of the cartilages, which after a time fluctu-
ates, and, when opened, discharges pus and necrosed cartilage. The
objective signs of inflammation are noted.
The movement of the larynx is increased in cases of dyspnoea. It
THE NOSE AND LARYNX.
437
is accompanied by recession of the spaces above the sternum and the
clavicles, with clonic contraction of the sterno-cleido-mastoid muscle.
The interior of the larynx is studied by inspection (laryngoscopy),
and by palpation (probe or fingers).
Laryngoscopy. The first requisite is a good light, sunlight, a good
student's-lamp, or an Argand "or Welsbach gas-burner ; the electric
light is not satisfactory. Second, a good reflector is required. It may
be attached to a head-band or a spectacle-frame. It should be concave
for artificial light, plain for sunlight, and should be pierced in the
centre. Third, laryngeal mirrors of different sizes and a curved probe
complete the instruments necessary for examination of the larynx.
Fig. 115.
Laryngeal mirror in position, displaying the laryngeal image. (Cohen.)
Ex.vmixatiox. The patient is seated with the source of the light
at one side and behind him ; the head and shoulders are brought well
forward and the head slightly raised. The operator takes a seat in
front at a proper distance for the focal length of the reflector, and
focuses the licjht on the patient's mouth, warms the laryngeal mirror
438 SPECIAL DIAGNOSIS.
over the flame and tests its temperature on the back of the hand. It
should be moderately heated, so that when it is placed in the mouth
the vapor of the breath will not precipitate on its surface. The patient
must open the mouth and protrude the tongue, which is grasped be-
tween the folds of a napkin by the thumb and fingers of the operator.
The tongue should be gently but firmly grasped. The mirror is then
inserted carefully and quickly, face downward, into the pharynx.
Care must be taken not to touch the tongue or palate, otherwise the
patient may be made to retch and become alarmed. The mirror is
passed to the posterior wall of the pharynx, and so directed that the
image of the larynx is reflected to the eye of the operator. The patient
is made to phonate "a" or " ee," not " ah," and then to respire.
The various structures and the action of the cords are observed. The
appearances of the mucous membrane are studied during quiet respira-
tion.
The epiglottis is very dependent, so that often the larynx can only
be seen by having the patient stand while the operator remains seated.
The patient's head is bowed on his chest and the examination proceeds.
The first examination may not result satisfactorily, but little being
observed on account of the spasm of the pharyngeal muscles. Re-
peated sittings may remove apprehension and accustom the mucous
membrane to the presence of the instrument. This object may be
attained by administering bromides, or by applying cocaine to the
pharynx.
The probe is needed only to ascertain the consistency of tumors and
growths. Cocaine must be applied before it is used.
Appearance of the Larynx in Health. Fig. 115 shows the larynx
as it is seen in the laryngoscopic mirror. Above (upper part) is the
arched epiglottis, below it the cavity of the larynx. In the centre are
the vocal cords, white and glistening ; on each side of these the pink
folds of the false cords. At the bottom of the mirror are the aryte-
noid bodies, and between them the folds of the inter-arytenoid space.
Below and outside the arytenoid bodies are the fossse. The mucous
membrane is pink throughout except on the cords. In respiration
Fig. 116. Fig. 117.
Laryngeal image during respiration. Laryngeal image during phonation.
the arytenoids separate, carrying the ends of the cords which are
attached to them with them, and leaving a triangular opening — the
glottis — through which the rings of the trachea can be seen. (See Fig.
116.) In phonation the arytenoids approach each other, obliterating
the inter-arytenoid space ; the inner edges of the cords come in con-
tact and close the glottis. (See Fig. 117.)
THE NOSE AND LARYNX. 439
Appearance in Disease. A note must be made of the color of the
various parts, of the presence or absence of swelling, of ulceration, of
new growths, and of alterations of the movements of the parts concerned
in phonation, particularly of the cartilages and the cords.
Color. The color is an indication of the degree of congestion.
Anaemia of the larynx may be merely a part of a general anaemia from
any cause. In chlorosis it is seen before the external appearance is
marked. An intense anaemia of the larynx is an early and valuable
symptom of pulmonary tuberculosis. The mucous membrane is pale.
Hypoxemia may be active or passive. It is readily recognized by
the intense redness.
Active hyperemia occurs in acute laryngitis, either of the primary
or secondary forms.
Passive hyperaemia occurs in general obstruction to the circulation,
as emphysema or valvular lesions ; pressure on veins by tumors ;
forced expiration and holding the breath ; in paroxysmal cough, espe-
cially whooping-cough. Active hyperaemias lead to catarrhs, passive
to oedema.
Swelling and Infiltration. Swelling of the epiglottis and of the
aryteno-epiglottidian folds is seen in ©edematous laryngitis, in acute,
submucous, and chronic laryngitis. In oedema of the glottis the swell-
ing is below the vocal cords. The swelling may be circumscribed
and undergo suppuration. Swelling and oedema is also seen in peri-
chondritis.
Tuberculosis. Swelling and infiltration succeeds the primary
anaemia or catarrh of the first stage of laryngeal tuberculosis. At first
there is slight intumescences of tubercular infiltration, not well out-
lined, and gray in color. They are most frequently found in the inter-
arytenoid space, less often on the false cords and arytenoid cartilages,
rarely on the epiglottis.
1. A hill-like prominence between the arytenoid cartilages either in
the middle or on one side. In phonation it presses between the cords.
2. When a false cord is affected the whole of it is usually infiltrated,
forming a tumor-like swelling which often hides the vocal cords.
3. Vocal cords. Usually only one cord is at first affected. It is
thickened and the free border is red. Sometimes the free edge seems
split. The infiltration may extend to the subcordal region and cause
a hypoglottic laryngitis.
4. Epiglottis. Infiltration of the epiglottis is rarer than oedema
after ulceration, and care must be taken not to confound these condi-
tions. The whole epiglottis, or only portions of it, may be affected.
It is thickened and curled upon itself, and not freely movable.
5. Arytenoid cartilages. They appear enlarged and puffy, and often
fixed from perichondritis.
Syphilis. In syphilis we have three forms of swelling :
1. Mucous Patches. These are flat elevations of 3 to 7 mm. diam-
eter, oval or circular, and of a whitish-gray color. When the epithe-
lium is lost they appear yellow and purulent. There is no tendency
to ulceration, and the patches soon disappear, even without treatment.
They occur usually from three to nine months after the infection.
440 SPECIAL DIAGNOSIS.
2. Infiltrations. Usually these are overlooked, as they produce no
symptoms. They are diffuse thickenings in various parts of the larynx,
most often on the epiglottis. This may be uniformly thickened or
only in part around the edge. The cords may be so swollen as to cause
dyspnoea. Usually an ulcerated spot is seen in the centre of the infil-
tration. The mucous membrane is either normal or reddened. Infil-
trations appear three to four or more years after infection.
3. Gummata. They appear as round prominences of the same color
as the surrounding tissue. They occur on either side of the epiglottis,
on the aryteno-epiglottic folds, often in the inter-arytenoid space, on
the false cords, and on the under surface of the vocal cords. If they
break down, deep ulcers form, leading to extensive destruction of the
parts.
Lupus. In lupus isolated or grouped nodes are seen flowing to-
gether into patches, situated on the epiglottis. The disease is usually
present on the face or in the pharynx and mouth. In leprosy the
epiglottis is swollen, and nodes from the size of a pin-head to that of
a pea are seen on the epiglottis, arytenoid bodies/ and false cords.
Fissures. Fissures and erosions are present in chronic laryngitis.
Ulcers. Ulceration is seen in tuberculosis, syphilis, carcinoma, lep-
rosy, and lupus.
Tuberculosis. Ulceration occurs in tuberculosis in the —
1. Inter-arytenoid space. The mucous membranes are notched with
irregular projections. When the ulcer is visible it is irregular and of
a dirty-gray color.
2. False cords. The ulcers are flat and aphthous, with a pale-white
base and a membranous deposit. The mucous membrane sometimes
appears sieve-like.
3. Aryteno-epiglottic ligaments. The ulcers are superficial and run
lengthwise of the ligament.
4. Vocal cords. " The ulcers are either on the upper surface or on
the edge of the cords. The former are superficial and seldom destruc-
tive. Those on the edge are either small separate ulcers or long ones,
affecting the whole border. The circumscribed ulcers occur usually
at the posterior portion of the cord and on the processus vocalis. The
ulcers of the whole border are often very destructive.
5. Epiglottis. Tubercular ulcers of the epiglottis occur only on its
laryngeal side. They are either aphthous and superficial, or deep, and
arise from the breaking down of previous infiltration. Sometimes
tubercles can be seen at the edge of the ulcers, but they are of no diag-
nostic value, as similar nodes are seen with non-tubercular ulcers. The
epiglottis is usually thickened and oedematous.
Syphilis. Syphilitic ulcers are circular, deep, with a sharp border
and inflammatory areola, and overlaid with a whitish-yellow deposit.
They develop from an infiltration or a gumma, and not on an unchanged
surface. Ulcers on the upper surface of the epiglottis are always
syphilitic.
Tumors Papilloma. The most common form of the benign
growths is the papilloma. The growth may spring from the true or
false cords, the aryteno-epiglottic ligaments, rarely the posterior surface
THE NOSE AND LARYNX. 441
of the epiglottis. The tumor has a broad base. There may only be
one, or it may be multiple, and may vary in size from a split pea to a
walnut. Three varieties are met with : 1. Small warty growths,
usually on the cords, dark red in color, and seldom larger than a bean.
2. Groups of raised white papilla? on a broad base, also growing on the
cords. 3. Large, red, mulberry-shaped or cauliflower-shaped growths,
partly villous, partly warty, which All up the whole larynx.
Fibroma. It appears as a hemispherical, pedunculated tumor of
dirty-white, reddish, or dark-red color, more or less dense in consist-
ency. It is usually single, and grows most frequently from the cords.
When seen in its smallest size it is known as the "singer's node." It
may be as large as a hazel-nut.
Malignant Tumors. In addition to the symptoms indicated in
benign tumor, pain and hemorrhage occur. Both carcinoma and sar-
coma are found ; the latter is very rare.
Carcinoma. The most common form is the epithelioma, although
the medullary and scirrhus have been described. The epithelioma is
seen as a circumscribed, hemispherical, warty, or cauliflower-like forma-
tion, varying in size, or as a knotty infiltration projecting into the
larynx. The medullary form is larger, soft and bloody, and rapidly
ulcerates. Scirrhus is firm and hard. The structure of the larynx is
gradually invaded, with necroses of the tissues. Perichondritis and
abscess frequently ensue.
In carcinoma of the cords two kinds of growth are seen.
In the polypoid form the tumor develops on the cord like a warty
growth, sometimes papillary and of a reddish-gray color. In diffused
cancer of the cord the structures are red and knotty, and invade the
surrounding tissue without distinct demarcation.
Sarcoma. The tumor has a broad base, is shining in appearance,
and sometimes lobulated. Sometimes the structure is dark red or
yellow.
The Epiglottis. The epiglottis is swollen and red in inflammation
of that structure, and may then be palpated with the finger.
Sputum. The sputum from the larynx is generally scanty ; it is
not frothy, and is colorless and transparent ; it is often discharged in
small globules ; it may be streaked with blood. Sometimes pseudo-
membranes are coughed up. It is doubtful if purulent sputum ever
comes from the larynx, excepting in cases of perichondritis in which
the abscess bursts into the larynx. Laryngeal sputum is found in
catarrh and malignant tumors. It is blood-streaked when the catarrh
is very intense, or after injuries.
Fever. Fever is present in acute laryngitis and tuberculous ulcer-
ation. It is high in acute laryngitis with stenosis ; in tuberculosis it
is of a hectic type.
Acute Laryngitis.'
Acute laryngitis is an inflammation of the larynx, characterized by
a sensation of fulness and dryness, with cough, hoarseness, and at times
dyspnoea. Several varieties are observed : Simple acute laryngitis,
442 SPECIAL DIAGNOSIS.
laryngitis with great stenosis, laryngitis with membrane, laryngitis with
spasm.
It is caused by exposure to cold or by the inhalation of acrid vapors.
Overstrain, as in singers, excessive use of the voice, particularly in the
cold air, may excite an attack. It may be symptomatic of the erup-
tive fevers, as measles or smallpox, or erysipelas. Its occurrence in
the course of chronic diseases must be looked upon with alarm, partic-
ularly in cases of Bright' s disease, if dropsy is present in other situations.
The attack begins with a feeling of chilliness, followed by fever of
varying degree, but usually mild. The patient complains of a feeling
of pressure and dryness in the larynx, or as if a foreign body were
present. Some pain gradually develops in the height of the attack,
never so severe as to require an anodyne. From the first there is
cough. It is dry and hacking, and slightly painful. In the more
intense forms the cough is continuous, disturbing the patient night and
day. Paroxysms occur when the patient speaks or takes food. First
the cough is dry ■ within a short time it becomes moist, and expecto-
ration of clear, transparent mucus takes place. The mucus may be
tinged with blood. At the end of forty-eight hours expectoration be-
comes more yellowish and opacpie. The voice may be merely hoarse,
or may be lost entirely. Sometimes aphonia without general symp-
toms occurs in acute laryngitis. In laryngitis sicca cough and dyspnoea
occur in paroxysms and are not relieved until a dry secretion is coughed
up. The paroxysms take place at night or in the early morning, and
may cause retching and vomiting. It is seen in adults.
Acute Laryngitis with Stenosis Xo doubt some of the cases of
so-called membranous croup in children are cases of acute laryngitis,
with swelling and occlusion of the glottis by congestion and by tough
secretion. CEdema may or may not be present. The attack begins
with catarrhal symptoms. The child is languid, refuses to eat, is
thirsty and has some chilliness and rise of temperature. With the
slight cough, which may be shrill, there are hoarseness and some
difficulty in breathing, but no pain on swallowing. On the second
day, or after the lapse of four or five days, during which time mild
fever continues, the catarrhal symptoms become more marked. The
voice is more hoarse or may be suppressed. The harsh, clanging
cough becomes toneless, and soon the sound is sivppressed. Dyspnoea
is most severe, and the aspirations are hurried and noisy, attended by
loud whistling inspiration, and snoring expiration. The stenosis is
inspiratory, and during the day or in the succeeding twenty-four hours
may become very intense. It is attended with violent efforts at breath-
ing and the occurrence of cyanosis in its most aggravated form. The
larynx moves up and down, the head is thrown back. There is reces-
sion at the root of the neck and along the margins of the ribs and the
epigastrium. The lower portion of the sternum may be drawn in.
Duskiness of the extremities and of the lips is observed as the stenosis
becomes more marked, finally deepening into cyanosis. It may be
relieved from time to time by removal of the obstruction, which occurs
after cough, vomiting, or change of position. A paroxysm soon recurs.
With each paroxysm lividity becomes more and more marked, the res-
THE NOSE AND LARYNX. 443
pirations continued hurried. The face becomes pale, the extremities
cold, and a cold sweat bathes the brow. Restlessness is characteristic.
The child tosses about in the bed or from the bed u) the arms of the
nurse. The heart's action is increased each hour in frequency as the
stenosis advances, and becomes weaker. As exhaustion ensues and
the symptoms of obstruction become more marked, stupor deepening
into unconsciousness develops. Convulsions may occur at the end.
The attacks rarely recur if the patient once recovers. They follow
exposure to cold.
If recovery takes place, the child usually becomes more free from
dyspnoea, the cyanosis fades, and the restlessness disappears. A pro-
longed sleep follows relief, although the voice may remain hoarse or
suppressed, and the cough continue many days.
Laryngeal Diphtheria. The same symptoms are seen in mem-
branous croup and laryngeal diphtheria. In the latter affection there
may be a history of exposure or of infection. At the commencement
of the attack the diphtheritic patches may be seen in the fauces or
nares. If a membrane can be secured and a bacteriological examina-
tion made, the diagnosis of diphtheria with stenosis is positive. En-
larged glands in the neck, with marked physical depression, a mod-
erate degree or entire absence of fever, and the occurrence of early
albuminuria, also point to diphtheria. The distinction between the
two affections is nevertheless quite difficult, and as long as there is a
shadow of doubt, for prophylactic reasons the case should be consid-
ered one of diphtheria.
Acute Laryngitis, with Spasm. False Croup or Spasmodic
Laryngitis. In children, in addition, another form of laryngitis asso-
ciated with spasm of the larynx is seen. The catarrhal symptoms
are mild, so that the child seems to be well during the day. Fever
is absent, and a slight cough or huskiness alone calls attention to the
larynx. After the first three or four hours of quiet sleep the child
suddenly awakes with a barking cough, sits up and struggles for breath.
The dyspnoea continues from a few minutes to an hour or so, gradually
lessening, to disappear entirely as the child lapses into sleep. Through-
out the next day the child seems as well as on the previous day, and
the succeeding night is again seized with another attack of " croup."
This may occur once or twice during the night. It seems to be influ-
enced by the weather. Damp days and an east wind are provocative
of an attack. It recurs frequently during the same season.
(Edema of the Larynx.
This condition arises in the course of acute laryngitis; frequently
occurs in chronic diseases of the larynx, particularly if ulceration is
present; and as a complication of erysipelas and diphtheria. In some
cases of Bright's disease it may develop suddenly.
In the course of the above-mentioned disease symptoms of laryngeal
stenosis may occur suddenly. The voice becomes husky and sup-
pressed, the dyspnoea is very extreme, so that in a few hours grave
symptoms of obstruction arise. There is no cough. The patient com-
plains of the sensation of a foreign body, and tries to grasp it.
444
SPECIAL DIAGNOSIS.
The Diagnosis of Acute Diseases of the Larynx.
Acute affections of the larynx are distinguished from other diseases
without much difficulty. To recognize the various forms of acute
laryngitis, however, is not easy. In all there is laryngeal stenosis to
a certain degree, and practically the question to answer is, Which form
of stenosis is present ? The accompanying table shows the differential
points for diagnosis. It is seen that the age, occurrence of previous
attacks, the character of the general symptoms, the existence of pre-
vious laryngeal disease, the association of faucial disease, the presence
or absence of membrane, and the results of laryngoscopic examination
must be considered before making a positive diagnosis.
Simple Acute Laryngitis. -
Larvnx. ' '
-" Catarrh of
Gradual onset of laryngitis, with dyspnoea
very slight or absent.
All ages.
Fever of varying degree.
Dry irritating cough.
May be hoarseness.
Pharynx reddened.
Gradual increase and decline.
Larynx red and slightly swollen, as seen
by laryngoscope.
Acute Laryngitis with Spasm. — Spasmodic
Croup.
May be slight hoarseness or cough, or
none. Suddenly, in night, child wakes
with intense dyspncea and crowing in-
spiration.
Children.
Temporary high fever.
Slight brassy cough during day.
May be slight hoarseness in day. Very
hoarse in attack.
Lasts a few minutes to one hour. May
recur, or no attack until next night.
Slight redness, or nothing seen by laryngo-
scope.
(Edema of Larynx.
Some inflammatory disease of larynx exists.
Rapid development of dyspnoea, increasing
to great severity.
All ages.
Depends on cause.
No cough.
No hoarseness.
Increases steadily to climax, then death,
or decline of dyspnoea.
Epiglottis and aryteno- epiglottic folds
swollen, pale, and waxy.
Acute Laryngitis with Stenosis.
Gradual onset of laryngitis, but dyspnoea
develops to great severity.
Children.
Fever of varying degree.
Dry cough, often paroxysmal.
Hoarseness.
Pharynx reddened.
Gradual increase, and either death of
patient or decline of dyspnoea.
Same, but swelling much greater.
Laryngismus Stridulus. — "Child-crowing."
No laryngitis. .Sudden attacks of dyspnoea
with crowing inspiration, either day or
night. Very severe. May be general
convulsions.
Children or hysterical adults.
No fever.
No cough.
No hoarseness.
Occurs often in rhachitic and hysterical
cases.
Ends suddenly, in at most two minutes,
and occurs often.
Nothing seen in larynx.
Membranous Laryngitis. — Croup ;
Diphtheria.
Epidemic.
Gradually developing hoarseness and
croupy cough, with low fever and lassi-
tude, then development of dyspnoea,
gradually and without intermission, as
a rule.
Children
Low fever and depression.
Croupy cough, later suppressed.
Very hoarse.
Fauces red and often with membrane ;
albuminuria ; paralysis.
Increases steadily, broken by intense par-
oxysms- Either death or gradual im-
provement.
Red, swollen, with membrane.
THE NOSE AND LARYNX. 445
Foreign Bodies. Pertussis. — Whooping-cough.
During eating or while holding object in Epidemic.
mouth sudden dyspnoea, varying in in- Bronchitis, with cough developing in from
one to three weeks. Then dyspucea
caused by severe paroxysm of coughing
— absent between them.
Children.
Only the fever due to bronchitis.
Intense paroxysm of coughing.
No hoarseness.
Hemorrhages in various places from strain
or emphysema.
May be death from exhaustion, or gradual
improvement.
tensity according to object.
All ages.
No fever.
Irritative, expulsive cough.
May be hoarseness or not.
Cough persists till removal of body, or
occasionally the larynx becomes accus-
tomed to its presence, and cough ceases.
See the foreign body.
Nothing seen, unless slight laryngitis.
Acute Submucous Laryngitis. The inflammation extends to the
submucous cellular tissue. It arises in the course of acute laryngitis,
and is the form seen in traumatism, or from burns and scalds. The
symptoms are those of intense laryngitis, with stridor. They increase
in severity until stenosis arises. If the under surface of the cords is
affected, death will occur from asphyxia. Sometimes the inflamma-
tion is circumscribed and is followed by development of an abscess.
The chronic form of submucous inflammation of the larynx is usually
seen in drunkards, and is recognized usually by the laryngoscopic
examination. The symptoms are those of slight stenosis.
Paralyses of the Laryngeal Muscles.
They are divided for convenience into groups. The symptom is
dysphonia, which, with laryngoscopic appearances, leads to the recog-
nition of the paralysis.
1. Paralysis of the Tensors of the Cord. The crico-thyroid
muscle is paralyzed ; the superior laryngeal nerve which supplies the
muscle is concerned. The voice is deep and rough, and incapable of
producing high tones. Usually, the whole nerve is involved, and the
result is ancesthesia of the larynx and paralysis of the epiglottis.
Laryngeal Examination. The epiglottis is fixed, and falls back
against the tongue. The glottis opening is a wavy line.
Causal disease. The condition described occurs almost exclusively
after diphtheria.
2. Paralysis of the Closers of the Glottis, or Adductors of the
Cords. The muscles involved are the crico-arytenoideus lateralis,
arytenoideus transversus, and the thyro-arytenoideus interims and
exteruus. The nerve is the recurrent laryngeal.
The symptoms are complete aphonia, coming on suddenly, and often
disappearing as suddenly.
Laryngeal Examination. During pho nation the cords remain in the
inspiratory position. The paralysis may affect one or both sides.
Sometimes the arytenoideus transversus alone may be affected. Then
there is hoarseness or aphonia. The anterior portions of the cords
come together in phonation, but the posterior portions do not, leaving
a triangular opening posteriorly. (See Fig. 118.)
446
SPECIAL DIAGNOSIS.
Or, the thyro-arytenoideus interims alone may be affected. There
is then dysphonia or aphonia, as before, but the cords come together
at both extremities and remain apart in the middle, forming an oval
opening. (See Fig. 119.)
Fig. 118.
Fig. 119.
Paralysis of the arytenoideus transversus in
phonation. (Gottstein.)
Paralysis of the thyro-arytenoideus internus
in phonation. (Gottstein.)
Causal Disease. These paralyses occur in hysteria, catarrh, or severe
overstrain of the voice.
3. Paralysis of the Openers of the Glottis, or Abductors of the
Cords. The muscle affected is the crico-arytenoideus posticus, and
the nerve is the recurrent laryngeal.
Symptoms. When one side is affected the respiration is free, but there
is stridor or forced inspiration. The voice is harsh.
Laryngeal Examination. One cord remains in the middle line. (See
Fig. 120.)
When both sides are affected there is gradually developing inspira-
tory dyspnoea with stridor. The voice is nearly normal.
Fig. 120.
Paralysis of the left recurrent nerve ; inspiration. (Gottstein.)
Laryngeal Examination. The glottis is a narrow cleft which be-
comes still narrower on inspection.
Complete Paralysis of the Recurrent Laryngeal Nerve. Symp-
toms. Unilateral Paralysis. A weak, toneless voice which breaks
into a falsetto when the patient endeavors to speak loud.
Laryngeal Examination. The cord and arytenoid body are in the
cadaveric position — viz., half-way between the phonating and the inspi-
ratory positions. In phonation the other cord passes beyond the middle
line, and the glottis is slanting. The edge of the paralyzed cord is
excavated.
Bilateral Paralysis. Aphonia and inability to cough and ex-
pectorate.
THE NOSE AND LARYNX. 447
Laryngeal Examination. Both cords are in the cadaveric position
and their edges excavated.
The adductors are usually paralyzed before the abductors, and one
can see all the intermediate stages by close watching.
Causal Disease. The conditions which give rise to the paralysis
are numerous. It may arise from simple catarrh or from hysteria.
More often it is due to pressure on the vagus or recurrent laryngeal, or
some disease affecting these nerves or their roots.
The causes of pressure are : Aneurism of the subclavian or aorta,
mediastinal tumor, tubercular bronchial glands, the apex of a tuber-
cular lung, cancer of the oesophagus, goitre, or carcinoma of the pleura.
The diseases are : Diphtheria, tumor, softening or hemorrhage into
the brain, bulbar paralysis, neuritis, typhus, cholera, variola, articular
rheumatism, toxaemia (?), sclerosis of the cord, progressive muscular
atrophy, and paralytic dementia.
Tumors of the Larynx.
Both benign and malignant growths are seen. At first dysphonia
or aphonia takes place. The impairment of voice may continue for a
long period of time before dyspnosa arises. This develops very gradu-
ally, and in some few cases is attended by an irritative cough. The
general symptoms are not marked in benign cases. In the malignant
forms they are pronounced, but characterized by the development of
cachexia later than in carcinoma elsewhere.
The diagnosis of malignant disease of the larynx is based upon the
association of symptoms of laryngeal disease with pain, and with the
characteristic appearances found on inspection, on its occurring after
the middle period of life, and lasting from six to nine months only,
with the development of cachexia and emaciation without fever. En-
largement of the cervical glands points to cancer. Simple and syph-
ilitic perichondritis must be excluded.
Tuberculosis of the Larynx.
The existence of primary laryngeal tuberculosis is doubtful. It
cannot be proved clinically, and the majority of cases, at least, are
secondary to tuberculosis of the lungs. The manifestations of tuber-
culosis of the larynx may be either a simple persistent catarrh, an in-
filtration, or an ulceration. (See pages 439 and 440.) The symptoms
vary according to the lesion.
a. Catarrh. There is a slight hoarseness and the voice tires easily.
Often paresthesia or peculiar sensations in the larynx are present.
Cough, when due to this alone and not to the process in the lungs, is
short and dry.
b. Infiltration. At first the symptoms are those of simple
catarrh, then the alteration of the voice increases even to aphonia ;
there is a feeling of dryness or soreness in the larynx, and dysphagia.
The cough is very slight and is usually wholly disguised by the cough
due to the disease in the lungs. There is some difficulty in expecto-
ration.
448 SPECIAL DIAGNOSIS.
c. Ulceration. The symptoms are the same as those of infiltra-
tion, but the dysphagia and pain are greater.
Diagnosis. Tuberculous ulcer occurs most frequently in the male
sex, and during the period ranging from eighteen to thirty years of
age. If the symptoms develop in the course of phthisis, or in case
that affection cannot be recognized, if there is a history of infection, or
exposure, and if bacilli are found in the sputum, the diagnosis is not
difficult. A portion of the diseased mass may be removed for micro-
scopic examination or inoculation. In examining the secretion for
tubercle bacilli, it is to be remembered that the exudation may have
been brought up from the lungs. The examination in cases of phthisis
is of little practical value, except to determine whether the ulceration
present may be syphilitic and grafted upon a tuberculous disease of the
lungs. Enlargement of the glands of the neck is often present, but is
not diagnostic.
Fever is present, and, indeed, may be an important diagnostic
feature in doubtful cases. The temperature should be taken every two
hours, for the morning or evening exacerbations may not be present.
Emaciation ensues, and sooner or later the hectic phenomena and signs
of tuberculosis in other structures arise. When tuberculous ulceration
of the larynx occurs in the course of local pulmonary tuberculosis the
disease runs a much more rapid course.
The laryngeal symptoms are not diagnostic. Pain may be the most
distinct. The appearances observed by the laryngoscope are more
characteristic. Local anaemia with paresthesia, paresis of the cords,
and short cough, or an obstinate diffuse catarrh, are suspicious symp-
toms. The peculiar ridged infiltration between the arytenoids is
almost invariably tubercular.
Isolated thickenings anywhere in the larynx that taper off gradu-
ally into the normal tissue can only be tuberculous or syphilitic. The
regularity and number, with anaemia and lack of inflammatory signs,
will usually distinguish the tuberculous from the syphilitic. The
ulcers are non-erosive. Syphilitic ulcers do not often occur, except on
the edge and lingual side of the epiglottis and on the cords. They
extend more rapidly than the tuberculous, and may be continuous with
ulceration in the pharynx. The area of ulceration may extend to the
base of the tongue, which is very infrequent in tuberculous disease.
In syphilitic ulceration scars or cicatrices are seen, but they are absent
in the tuberculous form. Laryngoscopic examination in tuberculous
ulceration is difficult, as it causes great pain ; in syphilis comparatively
little pain attends examination. (See the Infections.)
Syphilitic Affections of the Larynx.
Mucous patches, papules, infiltrations, or gummata may be present
in the larynx for some time without exhibiting any symptoms. Usu-
ally a change in the voice is the first symptom noticed, due either to
the catarrh or to ulcers, scars, infiltrations, or gummata affecting the
cords. There is often a feeling of pressure or a tickling sensation.
Pain is not usual, and, when present, is very slight. Dysphagia
THE NOSE AND LARYNX. 449
occurs only when the epiglottis is extensively ulcerated. There is
little or no cough.
The diagnosis rests upon the history of infection, the objective signs
of syphilis indicated by pigmentation or recent eruption, scars, perios-
titis or nodes on the bone, and enlarged glands. The laryngeal symp-
toms are not diagnostic, save that pain is absent in spite of extensive
ulceration, while difficulty of deglutition, on account of food entering
the larynx, is of frequent occurrence. The laryngoscopic appearances,
as indicated above, are characteristic of this affection. In obscure
cases the distinctions spoken of in tuberculosis are of diagnostic value.
Although the patient may be broken down and cachectic the febrile
range is not high, unless perichondritis occurs, or pneumonia sets in,
on account of food in the air-passages.
The Larynx in Other Diseases.
Laryngeal symptoms due to lesions of the nervous system are found
under the following circumstances. (See Cerebral Localization.)
Cerebral Hemorrhage. 1. Aphasia. The movement of the
muscles is normal, but they cannot be controlled by the will. Caused
by hemorrhage in the cortex or along the course of connective fibres.
2. Recurrent paralysis. Due to hemorrhage in the medulla.
3. Symptoms of bulbar paralysis. Same cause.
Encephalomalacia. (Softening.) When in the brain, aphasias
result ; when hi the medulla, bulbar symptoms.
Tumors of Cerebrum. The symptoms are, according to location,
aphonia, aphasia, or paralysis of the cords.
Bulbar Paralysis. We have, of course, the other symptoms of
the disease. The voice becomes weak and monotonous without modu-
lation. High tones are impossible. It progresses to hoarseness and
finally aphonia. Particles of food and drink enter the larynx. Paresis
or paralysis of the cords.
Multiple Sclerosis. The speech is low, uncertain, and scanning,
later hoarse. Laughing and crying are accompanied by peculiar yawn-
ing inspirations. Laryngoscopical examination : Slight paresis of the
cords is seen.
Posterior Sclerosis (Tabes). The muscles act very slowly.
Sometimes symptoms of irritation, as tickling or burning in the larynx,
with a dry cough, occasionally severe paroxysms of coughing, even to
spasm of the larynx, occur. " Laryngeal crises." In rare cases a
phonetic spasm has been observed. Less often paresis or paralyses of
the various muscles occur, most frequently the posticus, next the
recurrent. Sensibility may or may not be disturbed.
Amyotrophic Lateral Sclerosis. There is a mixture of bulbar
with spinal symptoms. (See Sclerosis.)
Progressive Muscular Atrophy. The same mixture of symp-
toms occurs very late.
Paralytic Dementia. There may be disturbances in articula-
tion, with paresis and paralysis of the cords.
Chorea. There may be a tremor of the cords from under-tension,
but probably no true choreic movements.
29
CHAPTER II.
DISEASES OF THE LUNGS AND PLEURAE.
The lungs are composed of a relatively small amount of tissue.
They are made up of tubes and canals. The tissue which composes
the structure of the lungs independently of the canals, the connective
tissue, is liable to the same morbid processes that affect it in other situ-
ations. But, curiously, it is not often subjected to irritants which cause
acute inflammation, while chronic inflammations occur secondarily, in
the large majority of cases, to processes in the channels. Diseases of
the lungs are really the disease of its channels, and the symptoms that
arise are due to morbid alterations of them (1) by processes common
to the structure of such channels and (2) by obstruction of them.
There are three sets of channels : First, for the passage of air ; second,
for the flow of blood ; and, third, for the flow of lymph. The symp-
toms, therefore, are due to the morbid process or to obstruction of the
channels just mentioned.
Physical Classification. The various affections of the lungs occur
without any change in the volume of air in the lungs, or are attended
by an increase or diminution in the amount of air.
I. Diseases with Normal Amount of Air.
Affections of the Bronchial Tubes, except Asthma.
II. Diseases with Increased Amount of Air.
Enlargement of the Chest. The enlargement with in-
creased amount of air may be unilateral or bilateral. It
seems paradoxical that the more air there is in the thorax,
the greater is the need for air, and hence the occurrence of
dyspnoea.
1. Asthma.
2. Emphysema.
III. Diseases with Diminished Amount of Air.
A. The Consolidations. The consolidations may be local,
unilateral, or bilateral.
1. The congestions.
2. Pulmonary embolism and thrombosis.
3. Pneumonia.
4. Bronchopneumonia.
5. Chronic interstitial pneumonia.
6. Pulmonary tuberculosis.
7. Abscess of the lung.
DISEASES OF THE LUNGS AND PLEUBJE. 451
8. Gangrene of the lung.
9. Collapse of the lung.
10. Cancer and other new growths of the lung.
11. Hydatid disease of the lung.
B. Diseases of the Pleura.
1 . Diminished amount of air from inhibition of movement,
on account of pain.
2. Diminished amount of air from the physical condition
within the thorax.
The Morbid Processes.
Affections of the lungs may be divided into the neuroses, the con-
gestions, the inflammations, the degenerations, the morbid growths and
gross parasites. Influences operating through the pneumogastric and
phrenic nerve may be responsible for respiratory neuroses. The con-
gestions are so intimately associated with vascular phenomena that the
latter may be included in the process. The inflammations are limited
to the bronchi, to the alveoli, and to the connective tissues surround-
ing both. The intimate relation of the small bronchi, the alveoli, and
their surrounding connective tissues implies their conjoint involvement
in many processes.
A. The Neuroses.
B. The Congestions.
1. Active, including hemorrhagic infarct.
2. Passive.
Subsidiary : hemorrhage.
C. The inflammations, chiefly infectious.
1. The Bronchi.
Acute.
Chronic.
2. Bronchi and alveoli.
Bronchopneumonia (an infection).
3. Bronchi, alveoli, and connective tissue.
Pneumonia.
Tuberculosis.
Abscess of the lung.
Gangrene.
Chronic interstitial pneu monia — pneumonokoniosis.
Syphilis of the lung.
D. The Degenerations.
Emphysema.
Bronchial dilatation.
E. Morbid growths.
F. Gross Parasites.
Hydatid disease.
Symptoms Due to the Morbid Process. The air-tubes arc lined
with mucous membrane, which is subject to morbid processes that
.attend any such lining — congestion, or acute and chronic inflammation
452 SPECIAL DIAGNOSIS.
— with a fliis as the characteristic symptom. The muscle and elastic
tissue of the canal become involved in the process. The former un-
dergoes spasm, with or without mucous membrane inflammation
(asthma). Grave consequences do not arise until degeneration takes
place, then the power of confining the air or driving it out is lost,
and emphysema results.
In the blood-canals, hyperemia (congestion), embolism and throm-
bosis, and secondary cedema take place ; in the lymph-canals, inflam-
mation (acute and chronic pleurisy), and transudation (hydrothorax or
hsemothorax). Xow, the symptoms that arise in each or all of the above
processes — pain, local discomfort, mucous or purulent discharge, serous
or purulent exudation, and fever — are not different from those which
are found in diseases of similar tissues in other localities. (Compare with
affections of mucous membranes in other organs or of serous membranes).
Symptoms Due to Obstruction of Channels. In addition to these,
however, there is a group of symptoms due to obstruction of the various
channels, and hence, interference with the function of the lungs. The
symptoms are purely mechanical.
1. Dyspxcea occurs from obstruction of either the bronchial tubes
or bloodvessels in addition to causes mentioned below. It is as pro-
nounced in asthma or capillary bronchitis as in embolic obstruction
(fat-embolism) or congestion and stasis in the bloodvessels. It occurs
when the canals are occluded by extrinsic causes — foreign bodies in
the bronchi or pleural effusions.
2. Cyaxosis. As a sequence of the above symptoms we have
another vivid picture — the development of cyanosis from interference
with aeration.
Symptoms Due to Altered Muscle or Nerve Mechanism.
Other structures (the bony thorax and its muscles) are required for
the performance of the function of the lung, the aeration of blood.
Of these we have more particularly : first, muscles, to hasten the
movement of the air ; and, second, a nervous mechanism to control
the movement of the muscles. 1. Inactivity of the former, from pain,
from debility, or from paralysis through disease of the nerves, practi-
cally occludes the canals, for the normal contents slacken or cease
their movement, and therefore the amount of air is lessened — hence
dyspnoea. 2. The nervous mechanism not only controls the large
muscles of the exterior, through a centre stimulated or depressed
by various influences, chiefly the blood, but also receives and sends
impressions to the muscles of the tubes, giving rise to (a) cough
or (6) bronchial spasm with dyspnoea. This nervous mechanism by its
centre of control is in relationship with higher and lower centres, and
the nerve that connects it with the bronchial tubes supplies other organs
or anastomoses with other nerves. Hence, Ave may have : J.. A central
affection, causing pulmonic symptoms from the following causes : 1.
Because higher centres influence the lower pulmonary centre, as we see
in hysterical cough, or emotional cough, and in asthma — respiratory
neuroses. 2. Disease affecting the region of the centre, as in tumor or
in bulbar or glosso-labio-laryngeal paralysis. 3. Irritants acting upon
the centre, as urea, exciting ura?mic asthma. B. An affection of the
DISEASES OF THE LUNGS AND PLEURA. 453
nerve-trunk, as from the pressure of an aneurism or morbid growth.
C. Reflex influences through the pneumogastric and correlated nerves.
The asthma of nasal disease, or of peripheral irritation, and reflex
cough (neuroses) are of this nature. Corollary : Lung symptoms, chiefly
dyspnoea and cough, may be due to local 'causes (affections of the mus-
cles), or to causes at a distance, operating directly through the pneu-
mogastric centre, or the nerve-trunk, or by anastomoses in a reflex
manner. The practical deduction is to look further than the lungs in
the investigation of pulmonic symptoms. Lung symptoms are not
often expressive of disease in other parts, nor are diseases of the lungs
symptomatic of disease in other organs.
Affections of the Pleura. In diseases of the pleura, one side is
usually affected. Simple inflammation and inflammation with exuda-
tion into the pleural cavity occur. In both forms there is diminution
of movement, and hence less air entering the affected lung, although
the cause is different in each case. In acute inflammation, the dimin-
ished amount of air is for physiological reasons : the movement of the
affected side is inhibited by pain — hence diminution of expansion and
lessened ingress and egress of air. Enfeeblement of breath-sounds and
fremitus, with diminished expansion, alone indicate the diminution.
On the other hand, in acute inflammation with exudation, the amount
of air is diminished for physical reasons. The effusion encroaches
upon and causes diminution of the air-space, and hence lessens the
amount of air. It will be remembered that the physical signs of dimi-
nution in the amount of air from effusion are quite distinct from the
physical signs due to consolidation.
The Lustgs axd Heart. The relationship of the pulmonary vas-
cular channels to the remainder of the circulation is very close. Over-
filling of the pulmonic bloodvessels, and hence dyspnoea, may be due
to alterations or changes in the central pump, the heart ; or in the
vessels between— as from the pressure of an aneurism. The nature
and importance of lung symptoms cannot be appreciated without an
investigation of the heart and the blood-ways. Many pulmonic con-
gestions are due to dilatation of the heart, and are relieved by digitalis.
At the other end of the beam, it may be noted that lung diseases cause
heart disease ; from backward pressure of blood-columns in over-
distended vessels, a dilated right heart follows.
Space forbids tracing out the effects of the blocking of channels, but
it is suggestive that all the aeration of the body takes place through
the first set of tubes, that all the blood of the body passes through the
second, and that the third is an enormous drainage-area of lymph.
The student can readily appreciate how profoundly diseases of the
lungs must affect the general system. Apart from the nerves, the tie
that binds the other organs to them is the blood. In proportion as the
lungs enrich them with oxygen, the other organs act with vigor. . Im-
perfect oxygenation soon causes diminution of all function, with the
secondary effect on the blood of the production of anaemia, which, with
its long train of symptoms, is seen in all chronic lung affections.
Relative Value of Subjective and Objective Symptoms. The
subjective symptoms are few, and, as will be seen later, are common
454 SPECIAL DIAGNOSIS.
to so many pulmonary diseases that they are of little diagnostic value.
The objective symptoms are more decisive, and the laws of physics as
applied to the lungs aid in the distinction. The effect of the occlusion
of channels is mechanical or physical, and hence a physical change in
the lung follows. The objective symptoms occur (1) because of the
physiological movement of air. Sound attends the movement of air
in health ; if the air-movement is checked, no sounds occur, or abnor-
mal breath-sounds and new sounds (rales) are created. They also
occur (2) because of physical changes in the structure. Air is replaced
by solid structure ; the physical condition of the lung changes. The
objective signs of these conditions are determined by inspection, palpa-
tion, percussion, and auscultation.
Diagnosis. The diagnosis of disease of the lungs is attained by the
collection and consideration of data- obtained both by inquiry and by
observation. By observation the objective phenomena are secured,
first, by physical examination ; second, by an examination of the
sputum ; and, third, by an examination of the fluids secured by punc-
ture.
It is not usually difficult to distinguish diseases of the lungs from
affections of other structures. It is true, pleurisy and pleurodynia are
often distinguished with difficulty. AVe are called upon, also, to decide
between pleurisy and subdiaphragmatic inflammation, a pleural and
hepatic inflammation, a pleuritis and pericardial inflammation, and
between cardiac and pulmonary disease, especially when both are pres-
ent and it is desirable to determine which is the primary affection.
The contiguous relations of the organs make this necessary, and with
care in ascertaining the history and the subjective and objective symp-
toms the distinction may not be difficult.
In chronic disease, affections of the lungs, of the mediastinum, and
of the great vessels must be distinguished from one another. An
aneurism or mediastinal disease may simulate chronic phthisis.
Infections. It often happens in a pulmonary disease that some of its
pronounced symptoms may strongly point to an infection other than
that of the lungs ; thus the cerebral symptoms of pneumonia may be
held to be due to meningitis, or the fever thought to be due to typhoid
fever. On the other hand, the presence of a pulmonary affection, as
tuberculosis, may explain the nature of the morbid process in other
organs or structures. Hence, in all cases in which there is a possibility
of secondary tuberculosis the lungs should be examined to determine if
they are the seat of the primary disease. In this way the true nature
of a meningitis, a peritonitis, or other tubercular affection may be recog-
nized. So, too, in secondary ansemia and in protracted debility of un-
known source the lungs should be examined. It must be borne in
mind also that in chronic diseases, as chronic renal disease, chronic
arthritis, diabetes, etc., pulmonary tuberculosis may set in most insidi-
ously. In the same class of diseases pneumonia is frequently a ter-
minal infection, and likewise runs an insidious course. Finally, in
the extremes of life pulmonary infections, as pneumonia, present symp-
toms out of the usual run. In infancy and childhood the cerebral
symptoms may mask the pulmonary symptoms ; in senility the ab-
DISEASES OF THE LUNGS AND PLEUBM. 455
sence of cough or expectoration may lead to the dismissal of all thought
of pulmonary disease. In short, the lungs should be examined in all
affections.
This injunction is particularly to be observed, as lung diseases are
often secondary to other diseases ; phthisis, to tuberculosis elsewhere,
pneumonia or pleurisy to all infectious disorders, to Bright' s disease,
cancer, and diabetes. Above all, the possibility of a hydrothorax,
secondary to causes of transudations, must be borne in mind.
The Data Obtained by Inquiry.
The Social Histoey. A glance at the various processes which
take place in the lungs readily lead one to infer the social history.
Age. In the earlier and later periods of life bacterial invasion is
more likely to take place ; hence, at these extremes streptococcus and
pneumococcus infections are common ; tuberculosis, on the other hand,
is more common in early adult life, although it does not respect age.
The degenerations are more common later in life, as we may say of the
morbid growths, both obeying the usual rules concerning the course of
these processes. The sex. As the infections predominate and as one
at least is more liable to develop in those whose resistance is lessened,
it follows that tuberculosis is more frequently seen in the female sex.
That sex which follows occupations compelling the inhalation of irri-
tating particles — the male — is more liable to have fibroid and other
inflammations of the lungs.
The Occupation. From this we gather little of diagnostic value,
save that the chronic inflammations are more prone to occur in those
who inhale solid particles, as miners, stone-cutters, etc., while tubercu-
losis attends those whose occupations are debilitating and require in-door
duties. Nor does a knowledge of the habits lend much aid save as
they depress the system and render it more vulnerable to bacterial
action. It is needless to say clothing, exposure, residence, and the
diet may be hygienic factors in the life of the patient. The amount
of exercise, etc., must be inquired into in each case.
Infections. It is readily seen, however, that the facts in the social
history of diagnostic importance are just those facts which are predis-
posing factors in many infectious disorders. Most lung diseases are,
therefore, correlated in their antecedents with the infections. It must
be borne in mind it is always well to trace the source of the infection if
possible.
The Family History. Heredity plays a serious part, and hence
the family history should be sought for, particularly in the study of
those affections which are of tuberculous origin. The tendency of this
infection to follow in successive strains is well known. In like man-
ner we inquire in cases of asthma and other neuroses for evidence of
their occurrence in previous generations — a well-known clinical fact.
Then emphysematous changes seem to be a peculiarity of certain fam-
ilies.
The Occurrence op Previous Diseases is to be inquired for.
Pneumonia is likely to be followed by other attacks. Pleurisy is
456 SPECIAL DIAGNOSIS.
related to, and may be an expression of rheumatism ; it may be pre-
ceded by other rheumatic phenomena ; it may be the earliest expres-
sion of tuberculosis, and may precede the latter by two or more years,
an interval of health separating the two. Then it must be borne in
mind pulmonary tuberculosis may succeed a long antecedent joint or
glandular tuberculosis — a history of which should be inquired for.
The state of the circulation should be studied, and the occurrence of
previous heart disease sought for. In affections of the pleura we must
inquire for previous infections and note the presence or absence of
disease of contiguous structures, as the ribs and muscles of the chest
and the viscera below the diaphragm.
The Subjective Symptoms. Dyspncea. Dyspnoea, in its true
sense, means difficult breathing. The respirations are deeper than
natural, but of normal frequency, or they may only be more frequent
than they should be, or they may be both deeper and more frequent.
The patient is usually conscious of suffering or of some distress in
breathing. Lung disease without dyspnoea : While a common, indeed
almost constant symptom of lung disease, it does not -follow that be-
cause a patient has extensive disease of the lung he need suffer from
difficult or hurried breathing. This is because the system requires no
more air than the capacity of the lung is able to supply. The change
takes place very gradually, but many persons with chronic fibroid
phthisis, or with emphysema, in both of which the disease may be
extensive, may not have dyspnoea, unless an unusual demand is made
upon the system. The subjects are under- weight, move slowly, and
otherwise show that they are deprived of an essential to active being.
Varieties of Dyspncea Depending upon Cause.
I. Anything which cuts off or lessens the normal amount of air re-
quired for oxygenation of the blood. A. Obstruction of the air-pas-
sages. B. Diminution of air-space from causes within and outside of
the thorax. C Interference with the action of the muscles concerned
in breathing.
II. Affections which lessen the amount of blood, as obstructive
heart disease. Rarely, tumors pressing upon the bloodvessels.
III. Affections in which the red blood-corpuscles are diminished —
anaemia.
IV. Pulmonary embolism and thrombosis. In cases of weak heart
the vessels become occluded. After labor a clot of blood may escape
from a uterine sinus, be carried to the right heart, and thence to the
pulmonic veins. The clot may arise from inflammation of the veins
in any situation.
V. Fat-embolism. Foreign substances in the blood, as fat, occur-
ring in parturient women three or four days after labor, after frac-
tures, and in diabetes.
VI. Dyspnoea due to interference with the nervous mechanism of
respiration, a. Tumor, hemorrhage, or degeneration about the respi-
ratory centre in the medulla, b. Irritation of the centre by toxic
agents, as in uraemia, diabetes, auto-intoxication from gastro-intestinal
disorder. To this class belongs " heat dyspnoea," which occurs in all
febrile conditions. The warm blood acts as a direct irritant to the
DISEASES OF THE LUNGS AND PLEURA. 457
respiratory centre in the medulla oblongata (Landois). This explains
the dvspnoea of fever and the curious fact pointed out by Cohnheim,
that the respirations in pneumonia lessen as soon as the fever disap-
pears, notwithstanding the persistence of the physical condition, which
may have accounted for the dyspnoea. Reflex dyspnoea (asthma, q. v.)
belongs to this variety. The dyspnoea of hysteria is of the same class.
Anything which cuts off or lessens the normal amount of air required
for oxygenation of the blood causes more or less dyspnoea.
A. Obstruction of the Air-passages.
1. Occlusion of the nares, unless compensated by mouth-breathing.
2. Enlargement of the tonsils, retropharyngeal abscess, or any ob-
struction in the throat, from diphtheritic or oedematous swelling.
3. Disease of the larynx, causing stenosis, also causes a characteristic
form of dyspnoea known as inspiratory dysjmoea. (See Disease of the
Larynx.)
4. Obstruction of (a) the trachea or (6) the bronchus from external
pressure or from a foreign body. It must be distinguished from
dyspnoea, the origin of which is higher up in the air-passages, by
careful inspection.
a. Tracheal Obstruction. In this form of dyspnoea there is no
increased movement of the larynx. There is no change in the voice,
except that it may be weakened, and the sonorous quality diminished.
The voice will be modified, however, if there is at the same time
disease of the larynx from syphilis, or paralysis of the muscles
from pressure on the recurrent laryngeal nerves by the same cause as
the tracheal stenosis. If so, on laryngoscopic examination the tumor
pressing upon the larynx can be seen at times, especially if the larynx
is healthy.
Expert operators can secure quite an extensive view of the wind-
pipe, particularly if the head is bent slightly forward and the patient
is seated in the upright posture. A mirror must then be placed
against the soft palate, with the surface more horizontal than usual.
By this means an aneurism may be seen bulging into the trachea. It
must not be mistaken for pulsation of the lower end of the trachea,
due to transmission of the impulse of the aorta to the trachea, which
has been shown to occur in healthy persons.
The dyspnoea is expiratory, and is never so extreme as in laryngeal
stenosis. The lower ribs are therefore not sucked in during inspira-
tion until late in the disease. A stridor attends the dyspnoea, which is
heard with the stethoscope over the trachea, as well as over every part
of the chest. Sometimes a point over the trachea can be determined
at which the sound is heard loudest. The point may indicate the seat
of a stenosis. Sometimes the sound is more marked over the larynx
than over the sternum, when the lower part of the trachea is obstructed.
Demme has pointed out that in cases of prolonged obstruction in the
lower air-passages the upper portion of the thorax may diminish in
size. Not only is the dyspnoea constant, but paroxysms may take
place in which the distress is very severe. These paroxysms of dysp-
noea may be due to spasm of the vocal cords ; but it is very likely that
they are due, as Bristowe has shown, to swelling of the mucous mem-
458 SPECIAL DIAGNOSIS.
brane, or to mucus which has accumulated at the point of obstruction
and cannot be dislodged, or to spasm of the muscular tissue of the
trachea itself. In addition to the subjective symptom of want of breath
the patient may complain of pain or oppression behind the sternum,
or possibly only of a slight soreness. Cough usually attends the dysp-
noea, with expectoration of mucus. Sometimes the mucus is blood-
tinged, and even streaks of blood may be expectorated after a consid-
erable time, in cases of leaking aneurism.
If the obstruction is due to a foreign body, the dyspnoea is of the
same type, but occurs suddenly.
b. Bronchial Obstruction. Laryngeal movement is not in-
creased and the voice is not changed. If a bronchus is obstructed,
the lung of the unobstructed bronchus becomes the seat of emphysema.
When obstruction takes place gradually, compensatory emphysema
occurs, developing slowly, not rapidly as in the former instance, the
degree depending upon the amount of obstruction in the opposite
bronchus. The physical signs over the lung of the obstructed bron-
chus are pronounced. The vesicular murmur is absent,- the fremitus
is absent, the movement of the affected side is impaired. With these
changes the percussion-sound is normal at first, although its limits are
influenced less by forced inspiration and expiration ; later, it progresses
from impaired resonance and dulness. As the case advances, the affected
side may fall in and measure less than the opposite side. A snoring or
whistling sound may be heard over the root of the lung, between the
scapula and vertebrae, or moist rales may be present.
The causes of tracheal and bronchial obstruction are : («) External
pressure. First, tumor of the thyroid gland; second, thoracic aneu-
rism; third, mediastinal tumor from other causes than aneurism, as
disease of the glands, cancerous or tubercular, or mediastinal abscess ;
fifth, cancer of the oesophagus; and, finally, in rare cases, a dilated
auricle. (6) Diseases of the walls of the trachea. They cause obstruc-
tion by narrowing the calibre. Syphilis is the most frequent cause of
such obstruction, (c) Foreign body. The presence of a foreign body
within the lumen causes obstruction. The foreign body may remain
free for a time, moving up and down as the patient coughs, and, indeed,
it may be felt against the side of the trachea when the finger is placed
outside the neck. Later, the foreign body usually becomes fixed in the
right bronchus, or one of its main divisions, because the opening of
the right bronchus is more direct than that of the left. In some in-
stances the body may be dislodged and fall into the opposite bronchus.
Rarely it falls first into the left.
B. Diminution of the Air-space in the Lungs. All forms of
pulmonary disease attended by consolidation, by compression of the
lung, or occlusion of the small bronchi, are included under this sub-
division. The degree of dyspnoea, of course, depends upon the extent
of the diminution in the air-space. In pleural effusions from any cause
the air-space is lessened and dyspnoea occurs. In bilateral effusions it
is more marked than in unilateral. The severity of the dyspnoea de-
pends somewhat upon the rapidity with which the effusion takes place.
In cases of sudden effusion of air, as in pneumothorax, the dyspnoea is
DISEASES OF THE LUNGS AND PLEURA. 459
very alarming at first, but, as accommodation takes place, it is grad-
ually relieved. In rapid effusion of serum it is also serious.
The characteristic form of dyspnoea due to lessened air-space is seen
when obstruction of the air-tubes takes place on account of spasm.
Asthma.
Asthma is a chronic disease caused by spasmodic narrowing of the
bronchial tubes, and characterized by paroxysmal attacks of dyspnoea,
diminished respiratory movement of the chest, prolonged expiration,
attended by a wheezing sound and sibilant rales, and ending abruptly
with the expectoration of tenacious mucus. The attack may be limited
to a single night, or may be prolonged for days, with nocturnal exacer- -
bations.
Premonitory symptoms are said to occur in about one-half the cases.
These are for the most part nervous, such as headache, neuralgia, irri-
tability of temper, vertigo, drowsiness. Hyde Salter found that there
were premonitory symptoms in 111 out of 226 cases collected by him.
In 63 they were nervous, in 8 there was profuse diuresis, and in 14
they were connected with the digestive system.
The attack itself usually begins during sleep, and often at a regular
time. It may, however, begin during the day, and at a certain hour,
independently of sleep. The onset is manifested by tightness across
the chest and more or less difficulty in breathing. This dyspnoea in-
creases rapidly and often reaches an extreme degree. The face becomes
pale and anxious, and may be covered with a cold perspiration ; the
lips are dusky from insufficient oxygenation of the blood. The patient
feels smothered, and makes frantic efforts to get his breath, rushing to
an open window, no matter how cold the weather, or, if unable to
leave the bed, sitting up with the hands pressed upon the bed so as to
give purchase to the accessory muscles of respiration. Notwithstand-
ing that great respiratory efforts are made, the chest moves but little,
because the lungs are already distended to the extent of a full inspira-
tion. The patient is unable to expel the contained air, owing to the
spasm of the bronchial tubes.
The frequency of respiration is diminished, sometimes to one-half
the normal ; the rhythm is also altered, inspiration being short and
gasping, and followed without pause by expiration, which is much
prolonged and accompanied by a wheezing sound audible to bystanders.
There is an increased amount of air in the thorax, and inability to
remove it. The chest is enlarged — barrel-shaped — the movement of
the chest is lessened and strikingly out of proportion to the muscular
exertions. The diaphragm is lowered.
The physical signs are hyper-resonance on percussion ; on ausculta-
tion, faint, short inspiration, prolonged expiration, and sibilant and
sonorous rales, more marked on expiration.
The duration of an attack of asthma varies from half an hour to a
day or two. In patients with chronic bronchitis it may be prolonged
for a week or two, with remissions during the day. It may subside
abruptly or by degrees.
460 SPECIAL DIAGNOSIS.
Subsidence of an attack is marked by expectoration, the sputa having
special characteristics. (See under Sputum.) At first it is made up of
rounded gelatinous masses, which, when unfolded in water, are seen to
be made up of spirals. Later it becomes mucopurulent.
Curshmann's spirals and the Charcot-Leyden crystals are nearly
always found. The leucocytes are increased, and 25 per cent, of them
are eosinophils.
The causative factors in asthma are various. About twice as many
males as females are affected, and there is a marked hereditary ten-
dency in some families. There is probably some special peculiarity in
asthmatic patients, but just what it is has not been determined. It may
reside in the lungs, and may be part of a general constitutional irrita-
bility (Salter). Bronchitis, emphysema, and heart disease act as causes,
and so do syphilis, malarial poisoning, and chronic Bright' s disease.
The above description applies to that form of dyspnoea treated of
in the text-books as spasmodic asthma, a respiratory neurosis winch
for lack of knowledge is classified as a disease. Up to this time the
dyspnoea is paroxysmal. Sooner or later it becomes constant. AVhen
the dyspnoea associated with asthma becomes constant other changes
have taken place in the lungs. First, there is persistent bronchitis ;
second, the presence of emphysema. Indeed, in many cases it is diffi-
cult to ascertain the exact sequence of affections. In emphysema of
the lungs dyspnoea is constant, but, on exposure to cold or on account
of an attack of indigestion, more severe paroxysms may occur, as well
as asthmatic attacks, although the patient is not an asthmatic. On the
other hand, a patient may have had asthma for a number of years,
during which attacks of dyspnoea occurred only in paroxysms. As
time passes the paroxysms become more and more frequent, and
emphysema develops. With the advent of emphysema the dyspnoea
becomes more constant.
Asthma, as above described, is a type of dyspnoea of nervous origin.
It has just been said that it is due to spasm of the bronchial tubes.
This may occur from a number of causes : (a) It may be of central
origin, from irritation of the pneumogastric centre ; (b) it is just possi-
ble that some disturbance of the trunk of the pneumogastric nerve will
also cause asthmatic dyspnoea ; but what concerns us most is (c) the
paroxysmal dyspnoea which arises renexly from irritation of the ter-
minal endings of the pneumogastric nerve, or of nerves intimately
associated with the pneumogastric, in the medulla. (1) Disease in the
upper air-passages, as polyps, or a hypertrophy of the turbinated
bones, or adenoid growths, are the most frequent source of paroxysmal
dyspnoea. Xot only in permanent disease of this character do we have
such dyspnoea, but temporary irritants applied to the nares likewise
produce it. Various odors, the irritation of micro-organisms, or of
pollen, or emanations from vegetable life, provoke attacks of nasal
congestion and reflex dyspnoea. The irritation is propagated through
the ethmoidal and posterior nasal branches of the nerve, the Vidian
and nasopalatine nerves, to the septum, and the anterior palatine to
the middle and low turbinates. (2) Irritation in the fauces and larynx is
not so likely to cause dyspnoea, yet there is no doubt that the presence
DISEASES OF THE LUNGS AND PLEURA. 461
of a constant irritant in these situations tends to provoke, or keep in a
state of excitability, the respiratory tract, so that asthma is more likely
to persist. (3) To this class of cases belongs the irritation of the terminal
branches of the pneurnogastric nerve in the stomach. Peptic asthma,
or the asthma of indigestion, may owe its origin to these causes. Often
the irritation is central, due to the irritating influence of an abnormal
product of indigestion upon the respiratory centres in the medulla.
(4) For the same reason we have asthma due to other poisonous sub-
stances circulating in the blood, as the poison of uraemia. The dysp-
noea due to this condition usually occurs in paroxysms, but may become
constant. Sometimes it is the first intimation of the presence of renal
disease. The dyspnoea of diabetic coma may occur from the same
cause. The nature of both is recognized more particularly by their
associate symptoms. The condition of the urine, the odor of the
breath, and the exhalations, the presence of hypertrophy of the heart
and of an accentuated second sound, point to a ursemic origin. The
history and symptoms of diabetes, the odor of acetone on the breath,
the presence of sugar in the urine, the absence of organic pulmonary
disease, point to diabetes. The dyspnoea of uraemia cannot be distin-
guished from other forms of dyspnoea, except by the exclusion of
cardiac and lung disease. It is often difficult to do this, because
uraemia so frequently develops after the hypertrophied heart has failed,
so that the physical signs of dilatation may be sufficient to explain the
dyspnoea. The dyspnoea of diabetic coma, known as {i air-hunger," is
characterized by slow and deep respirations. Cheyne-Stokes respira-
tion is due to the same cause — namely, irritation in the medulla, as in
other forms of nervous dyspnoea. It must not be forgotten that the
dyspnoea of uraemia may present the Cheyne-Stokes phenomenon.
Diminution of Air-space from Extrapulmonary Causes.
Anything which crowds upon the thorax, interfering with pulmonary
expansion, causes dyspnoea. This is notably the case in affections
below the diaphragm. Hence, in enlargements of the various organs
of the abdomen, as the liver, spleen, kidneys, pancreas (cystic disease),
and uterus, dyspnoea always occurs. In accumulations of gas (flatu-
lency), or of fluid (ascites), the diaphragm is pressed upward and
encroaches on the thoracic capacity. In abdominal tumor, as of the
ovary, the omentum, and of the organs above mentioned, dyspnoea is
a distressing feature.
C. Interference with the Action of the Muscles. Practically
any derangement of the action of the respiratory muscles diminishes
the air-space, as expansion of the lungs is interfered with. Neverthe-
less, the cause of the dyspnoea is extrapulmonary. It is due to weak-
ness or paralysis of the muscles concerned in breathing, or to inhibi-
tion of their action on account of pain, or to interference with their
action on account of obesity, myxoedema, or oedema, or on account of
actual disease, as in trichinosis or myositis.
1. Phrenic dyspnoea is a peculiar form due to paresis of the phrenic
nerve and consequently to interference with the action of the diaphragm.
It may not be observed as long as the patient is at rest. Upon slight
exertion the effort distresses him and causes an increase in frequency
462 SPECIAL DIAGNOSIS.
of the respirations. After a few steps a sense of suffocation ensues,
or upon ascending an elevation the patient must stop frequently to
take breath.
Other physiological processes are affected in phrenic dyspnoea. In
the act of sighing the patient feels as though the abdominal organs
were drawn up into the chest. Any straining effort, as defecation, is
rendered difficult. The voice is weak, and there is difficulty in cough-
ing and sneezing, because a full inspiration cannot be taken. A slight
attack of bronchitis may be very serious on this account. On inspec-
tion during inspiration, instead of the natural expansion of the ribs and
chest, the epigastrium and the hypochondriac regions are drawn in.
During expiration they are pushed forward. The thoracic movements
are reversed. The abnormality may be detected on palpation with
both hands below the cartilages of the ribs, even better than by inspec-
tion. Unilateral paralysis of the diaphragm causes drawing in of the
corresponding hypochondriac region.
In progressive muscular atrophy, in general lead-poisoning, and in
multiple neuritis from other causes, paralysis of the diaphragm may
take place. It is said to occur in hysteria, and Walshe states that he
has seen it after diphtheria. In fatty degeneration of the diaphragm,
on account of inflammation extending from the peritoneum to the pleura,
the same phenomenon has been seen. It may occur in trichinosis.
Paralysis of the diaphragm must be distinguished from inaction.
If during the act of inspiration one or both hypochondriac regions are
drawn in, it is diagnostic of inaction rather than of paralysis ; whereas
paralysis of the diaphragm is always accompanied by paralysis of other
muscles.
Dyspnoea due to paralysis of other respiratory muscles can be recog-
nized on careful inspection and palpation. The atrophied groups of
muscles are readily observed. Electricity may aid in the diagnosis.
2. Pain inhibits muscular action. The source of the pain may be
in the pleura, the muscles, or the intercostal nerves. Frequently it is
below the diaphragm, as in peritonitis, hepatitis, etc., interfering with
the action of that muscle. The dyspnoea that occurs from pain, as
pleuritis, or inflammation of the chest-wall, is recognized by the posture
which is taken in order to relieve the affected side, by local tender-
ness, and by the physical signs of pleurisy or of pleurodynia.
Clinical Varieties. We observe whether dyspnoea is (a) influenced
by exertion ; (b) modified by the frequency of respiration ; or (c) by
the respiratory rhythm ; and (d) is constant or paroxysmal.
(a) Influenced by Exertion. 1. Shortness of breath may be
apparent on exertion only, as in cases of simple debility, or of inter-
ference with respiratory action on account of obesity. It is the form
of shortness of breath seen in ansemia and in moderate cardiac debility.
It may not be observed by the patient unless he walks hurriedly or
ascends a flight of stairs. 2. Shortness of breath independent of exer-
tion is of more serious import, and is due to a number of causes. It
is the shortness of breath that is seen in severe cardiac and pulmonary
disease. To the latter belong asthma and emphysema, bronchial ob-
struction, pulmonary consolidation and compressions (by effusions).
DISEASES OF THE LUNGS AND PLEUBJE. 4(J3
(b) The Frequency of Respiration. Dyspnoea varies clinically
in the frequency of the respiration. In its most extreme form it is
known as orthopnoea, when the upright posture of the trunk is assumed.
(See Posture.)
1. Respiration Slow or Normal, a. Dyspnoea may be characterized
by deep inspirations, the frequency of respiration being less than nor-
mal. This is one of the forms of dyspnoea seen in diabetic coma —
tl breathlessness without dyspnoea." It is most characteristic, and
associated with nausea, vomiting, and coma, while the breath and urine
smell of acetone, b. The breathing may be slow and stertorous. Such
breathing is likewise associated with coma, but the coma is of central
origin, due chiefly to apoplexy or tumor. It may be observed that
respirations with dyspnoea are usually central or toxic.
Toward the end of life the respirations, even though hurried before,
become slower from carbon clioxid intoxication.
2. Respirations Increased. The respirations may be hurried and
create distress in simple nervousness alone, and hurried respiration is
quite common in cases of hysteria. In the latter affection the frequent
breathing is often attended by distress. The respirations are quick-
ened, and are half the normal pulse-rate or even as frequent as the
pulse. The term u panting" is applied to such respiration. The same
character of breathing is seen in exophthalmic goitre. The rate of
respiration is increased in all forms of dyspnoea upon exertion (see
above), and in all forms due to heart or lung disease.
(c) The Rhythm. Alternately slower and shallower breathing, and
then quicker as well as deeper, is seen in the peculiar form of breath-
ing known as Cheyne-Stokes respiration. It includes a period of
apnoea, with simultaneous alterations in the size of the pupils. (See
Uraemia and Diseases of the Brain.)
(d) Dyspnoea may further be divided clinically into constant and
paroxysmal dyspnoea. Constant dyspnoea implies a persistence of the
cause. Paroxysmal dyspnoea does not include the form that is in-
creased by exertion — a form which in one sense may be paroxysmal.
It is seen in its most typical form in asthma. It is often of cardiac
origin, but may be due to central or reflex causes. It occurs usually
at night. Constant dyspnoea is frequently subject to aggravations
paroxysmal in occurrence. Asthma is the type of true paroxysmal
dyspnoea.
Diagnosis. While dyspnoea is usually easy of recognition, it must
not be forgotten that attacks of acute indigestion, with thoracic symp-
toms of oppression, may simulate the oppression of dyspnoea. This
form of dyspnoea is temporary, however, and not associated with in-
creased rapidity of respiration. Dyspnoea is recognized by increase in
rapidity of chest-movement, with increased action of all the muscles
of respiration, both the essential and the auxiliary muscles. At the
same time the expression is characteristic. The alse nasi move, the
eyes and countenance are indicative of more or less agony, the pupils
are dilated. As the dyspnoea continues cyanosis develops, and fre-
quently a cold sweat breaks out. This may be limited to the forehead
and face and to the extremities, or may become general. The hands
464 SPECIAL DIAGNOSIS.
and feet become cold. Stupor sets in, carpo-pedal spasni or general
convulsions follow, the respirations become slower, and death takes
place in coma or from heart-failure (asystole).
The dyspnoea of emphysema is characteristic ; it is due to inability
to empty the chest of air {expiratory dyspnoea). The inspiration is
short and quick ; the expiration is prolonged, and all the auxiliary
muscles are called upon to complete the act. The powerful abdominal
muscles are seen to contract vigorously, and thus aid in pressing up
the diaphragm. The quadratus lumborum and serratus posticus supe-
rior et inferior draw down the ribs. The scaleni are strongly con-
tracted, the serratus magnus, latissimus dorsi, and the pectorales all
aid in elevating the ribs. Knowledge of the processes involved in
forced expiration renders the diagnosis comparatively easy. The con-
traction of the broad abdominal muscles confirms the diagnosis.
Cough in Pulmonary Affections. (See Larynx.) Coughing is a
reflex act. A deep inspiration is taken, followed by closure of the
glottis, succeeded immediately by a sudden expiratory effort, during
which the glottis is opened, causing a loud sound with the forcible
passage of air outward, along with any substances in the air-vessels.
Causes. The pulmonic irritation, on account of which the act takes
place, usually begins in the respiratory mucous membrane. The cough
is then used to expel accumulations of mucus or pus, or foreign sub-
stance. It occurs in all forms of bronchitis and in the lung affections
generally in which bronchitis is associated. The cough of phthisis, if
not laryngeal, is due to a localized bronchial catarrh. Modules outside
of the bronchi, situated in the lung substance, do not provoke the act
of coughing, as we see in the calcareous and fibrous nodules of healed
tuberculosis. The irritation is not limited to the mucous membrane
of the bronchial tubes, but occurs in the mucous membrane of any por-
tion of the respiratory tract. A foreign body of any kind in the
bronchus sets up cough. It is notably present in pharyngeal and
laryngeal diseases. The cough of the latter is of peculiar character,
which renders it easily distinguished from cough due to other causes.
It must not be forgotten that the presence of an irritant does not
always excite cough. Thus, when the sensibilities are obtunded, as
in typhoid fever, in disease of the brain, or in the last stages of any
disease, the presence of mucus will not excite cough, and yet it is
known to be in the trachea, on account of the rattling which takes
place. In cases of phthisis sudden checking of the cough and expecto-
ration, on account of weakness, is of bad prognosis and denotes ap-
proaching death. It is also a bad sign in pneumonia.
Central, axd Reflex-cough. Cough may also occur from
causes outside of the air-passages. It may be of centric origin. Kohts
has found by experiment that irritation of the floor of the fourth ven-
tricle, above the centre for respiration, excites a cough. This centric
origin may possibly explain the cough of hysteria, and the short, bark-
ing cough' which arises in hysterical or nervous states, when the patient
is afflicted with the idea that he is about to have hydrophobia. Irrita-
tion of nerves which are in anatomical relation with the pneumogastric
also excites cough.
DISEASES OF THE LUNGS AND PLEURAE. 465
Ear-cough. The most characteristic cough of this form is that
due to the presence of a foreign body in the meatus of the ear, or to
disease of that organ. It is sometimes difficult to examine the exter-
nal auditory meatus, because coughing is excited. The afferent nerve
which receives the irritation is the auriculo-temporal branch of the
fifth nerve, according to Dr. Fox, and not the minute auricular twig
of the vagus.
Tooth-cough. The same authority points out the occurrence of
cough from the irritation of the stump of a tooth, and refers to cough
in infants during the first dentition.
Stomach-cough. The popular opinion that cough is very fre-
quently due to the stomach is not substantiated by the experiments
of Kohts. Nevertheless, we frequently observe cough in patients who
are suffering from mild gastric catarrh, the treatment of which relieves
the cough. This is in all probability due to the fact that with the gas-
tritis there is a secondary pharyngitis, and, as the former is relieved,
the latter, which causes the cough, disappears entirely.
It will be seen, therefore, that when investigating the cause of a
cough in diseases in which this symptom is prominent, it is necessary
not only to make examination of the respiratory tract throughout its
course, but also to examine the condition of the ears and the teeth,
and to bear in mind its possible centric origin.
Clinical Characteristics. The cough may be dry or moist. A
dry cough occurs when there is an irremovable source of irritation
(see dry cough of laryngeal disease). It is seen in the first stage of
bronchitis. It occurs in the earlier stages of phthisis. As a short,
hacking, suppressed cough it occurs in pleurisy in the first stage. In
the second stage it is superficial, as if the sound-waves were checked.
It is characteristic and most familiar, although described with diffi-
culty. It is the best type of cough due to irritation outside of the
respiratory tract. The ear-cough and tooth-cough partake of this char-
acter. In cases of emphysema the cough may be dry and unproduc-
tive for a long time, and only be relieved after a small pellet of tough
mucus is discharged. In the same category belong the nervous cough,
which is nothing but a bad habit; the cough of hysteria, and the cough
of a peculiar barking character that occurs at puberty, which Sir
Andrew Clark has described.
The moist cough is attended by expectoration of a mucus, muco-
purulent, purulent, or bloody character, which is comparatively easily
removed.
Dry and moist or loose cough may be either constant or paroxysmal,
or both. Constant cough implies a persistence of the cause, which is
strictly pulmonary, as in pleurisy, phthisis, bronchitis, and consolida-
tions generally ; paroxysmal, a recurrence of cause when pulmonary,
or a reflex or central cause.
Under some circumstances the cough is almost constant. The irri-
tation is constantly present. A large amount of secretion is rapidly
poured out, keeping up a constant cough. This is seen in bronchorrhcea
and bronchial dilatation and in the later stages of tuberculosis. In
these affections the moist cough may occur three or four times in
30
466 SPECIAL DIAGNOSIS.
twenty-four hours, during which time an enormous amount of sputum
is thrown off. The cavity is thereby emptied, the accumulation of
matter in which excites coughing only after a certain level is reached.
In this affection the cough is further characterized by aggravation on
change of position.
The moist cough may occur in paroxysms only, each paroxysm being
relieved by the removal of the irritation, the subsequent paroxysm
not taking place until the irritating secretion has reaccumulated. In
cases of bronchitis of the second stage paroxysms of cough may occur
every few hours, or the cough may take place once in the twenty-four
hours, usually in the morning on arising. The accumulated secretions
of the night are disposed of, and then the patient remains free from
annoyance. Paroxysmal coughs occur in cases of cavities, either of the
lung or of the pleura opening into the lung. Cough is excited when-
ever the cavity fills with secretion. The paroxysm may occur daily
or several times a day. The association with retching and vomiting
is of some diagnostic significance. It is seen not only in whooping-
cough, but also in phthisis. In pertussis the character of the' cough is
of special diagnostic significance ; it occurs in paroxysms. The expira-
tory efforts are frequent and rapid, followed by a noisy, prolonged
inspiration, during which the characteristic whoop is created. At the
same time the appearance of the countenance is marked. The face is
cyanosed, the eyes stare, the appearance of distress is most striking.
The labored efforts at coughing frequently terminate in an attack of
retching or vomiting.
The diagnostic significance of cough is estimated by the character ;
by the sound ; whether constant or paroxysmal ; by the frequency of
the paroxysm ; by its development at particular times or under partic-
ular circumstances, as on arising in the morning, or change to a cold
atmosphere, or speaking, or upon movement, as in phthisis. By the
sound, laryngeal and bronchial, coughs are distinguished. The diag-
nostic value of cough further depends on a knowledge of its duration
and the character of the expectoration. (See Sputum.)
The Sound. The character of the cough sound, however, is usually
modified by the condition of the larynx, for which consult the section
on Laryngeal Diseases.
Hemorrhage. Hemorrhage of the lungs occurs from disease or
from rupture of adjacent bloodvessels into the air-passages. It is not
in itself a symptom of lung disease. A hemorrhage may be small in
amount and continue over a considerable period of time, or it may be
characterized by a sudden profuse discharge, which at once terminates
the life of the patient.
Cause. A. Affections of the lungs.
1. Congestion of the lungs will lead to hemorrhage. The amount of
blood is small ; it may be limited to streaking of the expectoration, or
a few niouthfuls may be discharged. In (a) organic heart disease this
form of hemorrhage is seen. It is also a characteristic feature of
the first stage of (6) croupous pneumonia. The rusty-colored sputum
is due to the rupture of the capillaries. In (c) hemorrhagic infarcts
DISEASES OF THE LUNGS AND PLEUBJE. 467
hemorrhage occurs, and is diagnostic if attended by the sudden forma-
tion of a consolidated area in the lung. In (d) phthisis it also occurs
(see below).
2. Tuberculosis. In tuberculosis hemorrhage may occur either (a)
as the first symptom of the disease, on account of collateral conges-
tion around infiltrated areas, or (6) later, on account of ulceration of
an artery when excavation of the lung has taken place. In the early
stages the hemorrhage is usually profuse, but not fatal. It may
occur repeatedly during a series of weeks, excited, no doubt, by the
violent non-productive cough which attends the earlier stages of this
disease. In the later stages, when the vessels are ulcerated, the patient
may have repeated hemorrhages, varying from a few ounces to half a
pint or a pint. They may occur daily, or be repeated at intervals of
a week or more for a long period of time. After the hemorrhages that
occur at long intervals the patient experiences much relief. Indeed,
the dyspnoea, cough, and chest oppression subside in a remarkable
degree, and the occurrence of another hemorrhage is often predicted
by a gradual recurrence of these symptoms. Death does not usually
ensue on account of the large hemorrhage from phthisical ulceration,
and yet it may possibly take place. The writer has seen four instances
of hemorrhage into a large cavity, three with external hemorrhage,
which caused death instantly. Hemorrhage with the expectoration of
calcareous masses recurs (c) frequently in patients with healed or qui-
escent tubercle.
3. Cancer. Hemorrhage recurring frequently is significant of can-
cer of the lungs, in the absence of other causes.
4. Plastic Bronchitis. It is of common occurrence in plastic bron-
cliitis, when large bronchial casts are expelled.
5. Gangrene. In gangrene of the lung it frequently occurs, often
causing death. The odor and sputum indicate the true nature of the
primary lesion.
B. Disease outside of the respiratory tract. (1) Aneurismal disease
of the bloodvessels, which are in intimate relation with the trachea and
bronchus, frequently causes ulceration into these tubes, with hemor-
rhage. The hemorrhage is usually profuse and often induces sudden
death. Sometimes the profuse hemorrhage may be preceded for days
by small hemorrhages. The physical signs of aneurism are sufficient
to explain the cause. The bleeding can sometimes be seen in the
trachea, when an aneurism of the innominate artery or the aorta presses
upon that tube. (2) In diseases of the heart it does not usually take
place until the later stages of the disease, and is associated with second-
ary congestion of the lungs. It may, however, be an early symptom
in mitral stenosis. The hemorrhages mav amount <>nlv to staining of
the sputum, or several times during the day an ounce or more of blood
may be expectorated.
C. Affections of the blood or bloodvessels, with hemorrhages in
other portions of the body. Thus, it may occur in haemophilia, in
purpura, in scurvy, and in anaemia. It occurs in jaundice with hemor-
rhages in other situations.
468 SPECIAL DIAGNOSIS.
D. Gouty endarteritis. In the aged of both sexes, hemorrhages
take place independently of disease of the heart or of the parenchyma
of the lungs. Sir Andrew Clark and others have spoken of these
hemorrhages and attributed them to gouty changes in the vessels as
well as to degenerations of lung-tissue, on account of which the rap-
ture took place.
E. Without known cause. In certain instances pulmonary hemor-
rhages occur in which it is quite difficult to find any cause for the dis-
charge. It is quite common to see hemorrhage occur in females : some-
times at the menopause, in other cases during menstruation, or, again,
perhaps vicariously, when menstruation does not occur. A number of
cases that have come under the writer's observation have had this ten-
dency for years without the development of pulmonary disease, and,
apparently, without much influence on the general health. Indeed, it
may be said that recurrent hemorrhage from the lungs in women, in
the absence of organic disease, is not of grave significance.
The Symptoms. The only symptom may be the presence of blood
hi the expectoration, or the discharge of a small amount of blood with
slight cough. In either instance, unless the patient's mental condition
is rendered obtuse by disease, the hemorrhage is alarming to him. He
is much perturbed, and there may be palpitation of the heart, besides
other nervous phenomena. Apart from the nervousness excited by
the sight of blood, small hemorrhages, and even hemorrhages of mod-
erate amount, do not cause any other symptoms.
The symptoms of a large hemorrhage depend upon the amount of
blood that is lost. They may amount to faintness and giddiness only,
with or without pallor. If more pronounced, syncope may take place ;
extreme pallor develops ; the pulse becomes rapid, small, and feeble ;
the extremities are cold, and the face bathed in perspiration. If the
patient recovers from the syncope, he is extremely restless, sighing and
breathing hurriedly. There may be some nausea. Moderate delirium
and mild febrile symptoms often follow the restlessness. If the hem-
orrhages do not recur and the patient's fears are calmed, the color will
gradually return and the heart's action become stronger and slower.
These symptoms occur whether the hemorrhage is due to disease of the
lungs or to aneurism rupturing into the bronchus. If the hemorrhages
are large, they differ somewhat in the two conditions. If a large aneu-
rism ruptures, the blood rapidly wells up into the throat and pours out
through the nostrils and mouth with great rapidity. With such hem-
orrhage the end may come in a few minutes. In pulmonary hemor-
rhages the discharge is not so profuse, and is attended by coughing.
With each cough blood is raised to the amount of a full mouthful at a
time. The blood discharged from the lungs is bright in color, very
frothy, being mixed with air. There are no clots in the discharged
fluid. The blood from an aneurism is also bright red, but is not frothy,
unless the discharge is very slow, and becomes mingled with air in the
vessels. In rare cases of pulmonary hemorrhage an abundant stream
pours out, which is dark in color, free from clots, and not mixed with
air (large cavity).
DISEASES OF THE LUNGS AND PLEURAE. 469
Diagnosis. Hemorrhage from the lungs must be distinguished from
hemorrhage from the upper air-passages, the mouth, the stomach, and
oesophagus. Thus a discharge of blood from the mouth may occur
from cracks in the pharynx, or varicose veins. It is not abundant,
and the hemorrhage is mingled with mucus, which is streaked with
blood. Hemorrhage from the gums may be taken for pulmonary hem-
orrhage, unless there is stomatitis, or inflammation of the gums from
scorbutus or ptyalism. In stomatitis its color is somewhat different. It
is thin, fluid blood, often offensive, of cherry-juice color. Hemorrhage
from the lungs is distinguished from hemorrhage from the stomach by
the difference in the way in which it is discharged, and the difference
in the character of the blood. If from the stomach the blood is vom-
ited. It is mixed with particles of food or other gastric contents. It
is dark in color, often of the appearance of coffee-grounds ; it is not
mixed with air, and hence is not frothy. The rapid hemorrhage from
ulceration of an aneurism into the oesophagus, or rupture of varicose
veins at the lower end of the oesophagus, cannot be distinguished by
the appearance from the hemorrhage of an aneurism which may have
ruptured into a bronchus. The recognition is dependent upon the
physical signs and the previous history of the patient's illness.
Pain. Pain is rarely a symptom of disease of the lungs unless the
pleura is involved. In a case of bronchitis there may be some sore-
ness and oppression behind the sternum, but otherwise pain is absent.
In pleurisy pain occurs before the exudation. It is sharp and lanci-
nating, and so severe as to impede respiration and cause the cough to
be short and catchy. It is usually seated at the base of the chest, in
the lateral or anterior region. It occurs when the patient attempts to
take a full breath. Before the inspiratory excursion is half completed
it is checked involuntarily, on account of the pain. The patient's hand
is placed upon the affected part and he involuntarily leans to that side.
The pain of pleurisy may be increased by local pressure, but general
pressure, as from the whole hand, a broad bandage, or a large strap of
adhesive plaster, always gives relief. In the pleurisy that attends
phthisis pain is quite common. It is of the same character as the pain
of acute plastic pleurisy, but varies in situation and in degree. The
pain occurs in paroxysms. It follows a slight exposure to cold, undue
exertion, or fatigue. It may continue for twenty-four hours, and dis-
appear until a repetition of the cause brings it on again. It must be
distinguished from the myalgia of phthisis due to cough and exposure.
In myalgia the muscles and fascia? at the bony attachments are very
tender.
The pain of pleurisy must be distinguished from pleurodynia, from
intercostal neuralgia, and from the pain due to the disease of the ribs.
In pleurodynia the muscles are sensitive if pressed between the fingers
or palpated. An enlarged area is affected, but physical signs of pleu-
risy or pneumonia cannot be elicited. Cough is absent, and so, usu-
ally, is fever. It is associated with pain in other muscular or fibrous
structures. There may be a previous history of exposure to cold and
dampness. Usually there is a history of lithaemia or frequent myalgia.
470 SPECIAL DIAGNOSIS.
Intercostal neuralgia is sometimes difficult to distinguish. The pain
is sharp, localized, and may modify the movements of the chest. Gen-
eral pressure relieves it ; local pressure at the points where the termi-
nal filaments of the nerve come to the surface may increase it. The
so-called Valleix's tender points are, however, not always present in
cases of intercostal neuralgia. The patient is usually anaemic, often
the subject of uterine or other exhausting disease, and may suffer from
neuralgia in other situations. Cough and physical signs are absent.
Fracture of the rib, or caries of the rib, may be recognized by the local
tenderness and by the signs of these conditions. Localized pleurisy
may attend both, however — indicated by more severe pain on cough
or full breathing. Caries or fracture is determined by pressure upon
the diseased rib, which elicits the crepitus of fracture. An empyema
that is about to point will cause pain in some area of the chest. The
pain is usually seated at the points of election for the discharge of the
empyema, and is soon followed by swelling, with heat and redness of
the skin, and the occurrence of oedema.
More or less constant pain at the apices, undoubtedly independent
of affections of the muscles, is a suspicious sign of tuberculous disease
in that situation. It may be aggravated by pressure.
The Data Obtained by Observation.
The Objective Symptoms. By physical examination of the lungs
we ascertain (1) their degree of activity (movement) ; (2) the physical
condition of their parts subjected to examination ; but the disease is not
diagnosticated. If abnormal signs are detected, they simply indicate
an abnormal condition of the part, which condition may be due to any
number of diseases. As the lungs in health contain air, any physical
change that takes place causes either an increase or a diminution in the
amount of air. This may be general (bilateral), or limited to one side
(unilateral), or to a smaller area (local). In examining the lungs we
might be content to answer the question, Is there an increased or a
diminished amount of air in the parts suspected to be the seat of dis-
ease ? A correct answer to this question, and to an inquiry as to the
case of the increase or diminution, would explain any abnormal phys-
ical condition. The answer is determined by percussion. Fortunately,
however, we have as adjuncts the phenomena that can be elicited by
means of inspection, palpation, and auscultation. These methods of
examination depend upon the movements of the lungs and the sounds
produced in breathing and speaking.
Value of Inspection and Palpation. Too much emphasis has
been laid in the past on auscultation and percussion in the study of
lung diseases. It is the habit to rely too much on these methods, to
the exclusion of the simpler and quite as valuable methods — inspection
and palpation. The latter have been employed for a long time in the
study of the objective phenomena of disease. The former are com-
paratively modern methods, and have required special cultivation of
senses not usually employed in observation, in addition to exhaustive
DISEASES OF THE LUNGS AND PLEURAE. 471
comparative research, to put the findings on an accurate basis.
Naturally, they have been given undue prominence as methods of
diagnosis. The pernicious habit of examining the patient without
removing the clothing, either from haste upon the part of the physician
or false modesty upon the part of the patient, has unfortunately also
led to the neglect of inspection and palpation. It is proper to
insist that the data obtained by inspection and palpation are as
important and valuable as those obtained by other means. They are
even more suggestive or diagnostic of physical conditions. The phe-
nomena observed are more positive and surrounded by fewer qualifica-
tions.
The Regions of the Chest. For the purpose of bearing in mind
the relations of the organs to the surface of the chest, and the localiza-
tion and proper recording of the seat of the disease, the chest is divided
into regions. The regions correspond to anatomical points on the sur-
face of the chest, and are subdivided by transverse and vertical lines.
Knowledge of the landmarks which indicate on the surface the position
of the parts underneath is of great importance in diagnosis. The
regions in the anterior portions of the chest are : The supraclavicular
region, above the clavicle ; the infraclavicular region, below the clavi-
cle, extending to the third rib ; the mammary region, from the third
to the sixth rib. In the axilla two regions suffice— the upper and
lower — the position of the disease being more definitely determined by
association with ribs and interspaces. Posteriorly the regions are
the suprascapular, above the scapula ; the scapular region, and the
infrascapular region ; the region between the scapula and the spine is
known as the interscapular region. The vertical lines are to the
right and left of the median line : (1) The parasternal line, which is
drawn downward midway between the edge of the sternum and
the second line, which is (2) the mid-clavicular line, drawn from the
middle of the clavicle, generally passing through the nipple in males ;
(3) the anterior axillary line, drawn from the anterior fold of the
axilla ; (4) the mid-axillary line, from the centre of the axilla ; (5)
the posterior axillary line, from the posterior fold of the axilla. In
the back one line is sufficient — the scapular line, drawn through the
angle of the scapula when the arm is at rest at the side of the patient.
For transverse lines the ribs and interspaces are used. In this way
the exact location of a diseased area can be indicated. In order that
accuracy may attend its localization, knowledge of the methods of
determining the landmarks, and especially of counting the ribs, is
essential.
The Angles of the Thorax. The costal angle is the angle of
the rib. It varies during the act of respiration. In inspiration the
rib rises as the sternum projects, and apparently elongates ; the angles
become more obtuse ; in expiration the sternum falls, the ribs become
more slanting, and the angle is more acute.
The epigastric angle. This angle is formed by the convergence of
the ribs of both sides to the xiphoid cartilage of the sternum. On in-
spiration it is obtuse, increasing as the ribs rise ; in expiration it is
more acute.
472 SPECIAL DIAGNOSIS.
Method of Counting Ribs and Inteespaces. The first rib
corresponds to the clavicle ; the first interspace is the region between
the clavicle, or first rib, and the second rib ; the subsequent number
of an interspace corresponds to the number of the rib above it. The
following, from Holden, is of great importance to remember, particu-
larly when the ribs of fat persons are counted :
a. The finger passed down from the top of the sternum soon comes
to a transverse projection, slight, but always to be felt, at the junction
of the first with the second bone of the sternum. This corresponds
with the middle of the cartilage of the second rib.
6. The nipple of the male is placed in the great majority of cases
between the fourth and fifth ribs, about three-quarters of an inch ex-
ternal to their cartilages.
c. The lower external border of the pectoralis major corresponds
with the direction of the fifth rib.
d. A line drawn horizontally from the nipple round the chest cuts
the sixth intercostal space midway between the sternum and the spine.
This is a useful rule for localization in tapping the chest.
e. When the arm is raised the highest visible digitation of the serra-
tus magnus corresponds with the sixth rib. The digitations below
this correspond respectively with the seventh and eighth ribs.
/. The scapula lies on the ribs from the second to the seventh, inclu-
sive.
g. The eleventh and twelfth ribs can be felt, even in corpulent
persons, outside the erector spina?, sloping downward.
h. One should remember the fact that the sternal end of each rib is
on a lower level than its corresponding vertebra. For instance, a line
drawn horizontally backward from the middle of the third costal car-
tilage, at its junction with the sternum, to the spine, would touch the
body, not of the third dorsal vertebra but of the sixth. Again, the
end of the sternum would be at about the level of the tenth dorsal
vertebra. Much latitude must be allowed here for variations in the
length of the sternum, especially in women.
It is important to recognize the relation of the ribs to the vertebrae.
The first rib articulates with the first dorsal vertebra, which can be
located by the position of the prominent spine of the seventh cervical
vertebra ; even in very fat people this prominence can be recognized.
The remaining ribs, except the tenth, eleventh, and twelfth, have
facets of articulation on two vertebra? ; as the second rib, with the
first and second thoracic vertebra?. The eleventh and twelfth articu-
late with the eleventh and twelfth thoracic vertebra?.
Topographical Anatomy. The following anatomical points are
worthy of remembrance :
The top of the sternum is on a plane with the lower border of the
second dorsal vertebra behind. The junction of the first and second
portions of the sternum is known as the angle of Ludwig. It is oppo-
site the middle of the second rib, and is on a plane with the lower
border of the fourth dorsal vertebra. The junction of the body of the
sternum to the xiphoid cartilage is on a plane with the lower border of
the eighth dorsal vertebra.
PLATE XIII.
Ficj. 1. Anterior Aspect.
Fig. 2. Posterior Aspect.
Situation of the Viscera.
i )utlines of heart and vessels — broad red lines. Margins of lungs and ot individual lobes — dotted green lines.
Limits of pleural sacs— solid green lines. Liver — red shading. Stomach— green shading.
(In part after His-Spalteholz and Luschka.)
PLATE XIV.
Fig. 1. Right Lateral Aspect.
Fig. 2. Left Lateral Aspect.
Situation of the Viscera.
Margins of lungs and of individual lobes— dotted green lines. Limits of pleural sacs— solid green lines.
Liver and spleen— solid red lines. Diaphram — dotted red lines. Stomach (portion not
covered by lung) — green shading. (In part after Luschka.)
DISEASES OF THE LUNGS AND PLEURJE. 473
The apex of the diaphragm is on a level with the eighth dorsal ver-
tebra.
The trachea bifurcates at the plane which includes the angle of Lud-
wig and the fourth dorsal vertebra.
Purulent effusions in the left pleural sac frequently point at the
fifth interspace, beneath the nipple, because this is the weakest point
of the chest-covering. A little external to the inferior angle of the
scapula and the eighth and ninth interspaces a similar weak point is
found.
Limits of the Lungs. The apices of the lungs reach three to
seven centimetres (one and one-fifth to two and three-quarter inches)
above the clavicles in front ; behind they rise as high as a line drawn
transversely through the spinous process of the seventh cervical verte-
bra. The lower anterior margin of the -right lung, when the chest is
passive, commences at the insertion of the sixth rib into the sternum,
and runs parallel with the upper border of the sixth rib to the axillary
line. At this point it descends to the upper margin of the seventh rib.
On the left side the lower limit extends as far downward as the right.
Posteriorly both lungs reach to the tenth rib. With full inspiration
the lungs descend both in front and behind almost the extent of one
interspace, while in deepest expiration they are elevated almost to the
original position. The " complemental space " of Gerhardt is the space
at the lower margin of the lung, and at the point at which the left lung
overlaps the heart, in which, during expiration, the surfaces of the
visceral and parietal pleura come together. In inspiration the thin
layer of the lung in both situations insinuates itself into this space.
The heart interferes with the extension of the left lung. The space
is triangular in shape, extending in the median line from the fourth to
the sixth rib. The left edge of the triangular area corresponds to the
edge of the left lung, which, notched for the heart, diverges from the
median line and runs along the cartilage of the fourth rib.
Position of the Lobes. Plates XIII. and XIV. illustrate the
position of the lobes of the lungs. In the right lung the upper lobe
in front extends to the fourth rib, in inspiration laterally to the third,
and behind to the spine of the scapula. The lower lobe begins with
the spine of the scapula and extends to the tenth rib behind, and from
the fourth to the tenth ribs, when fully expanded, in the axillary
region. The middle lobe is not seen behind ; it extends between the
third and fourth ribs in the axillary region in inspiration. In front it
extends from the lower margin of the upper lobe to the sixth rib.
The upper lobe of the left lung extends to the sixth rib in front and
to the fourth interspace at the side. Behind, a small portion extends
above the spine of the scapula, while the lower lobe extends from the
spine of the scapula to the base of the lung behind. At the sides it
extends from the lowest limit of the upper lobe to the level of the
eighth rib.
Inspection. By inspection we learn (1) the appearance of the ex-
ternal surface, (2) the shape and size, and (3) the movements of the
chest. The second indicates the capacity of the lungs ; the last, the
474
SPECIAL DIAGNOSIS.
degree of functional activity. The X-rays are also employed to con-
duct inspection.
Methods. The patient must be seated, if possible, in an easy
position, with the light falling directly on the part or from the side.
He should be viewed by the observer standing, first in front, then be-
hind, and also from the side. To observe the anterior portion it is
often well to stand behind the patient and look downward over the
shoulders. The arms should fall by the side ; the breathing should be
quiet and undisturbed by talking or unusual movements.
The Skin and Subcutaneous Tissue. In health the normal
covering should be supple, elastic, and of the color previously described.
It is pale in ansemia and wasting diseases ; yellow in jaundice ; pig-
mented generally or locally from causes previously mentioned. It is
the particular seat for the parasitic disease, tinea versicolor, and is the
seat of sudamina as well as other non-specific eruptions. The veins
over the surface of the chest should not be very distinct. They are
distinct when there is interference with the circulation in the mediasti-
num from the pressure of an aneurism or morbid growths obstructing
the veins. They, along with the cervical veins, may also be enlarged
in dilatation of the right heart. The capillaries along the base of the
chest are often enlarged or more distinct than usual, and arranged in a
bow corresponding to the attachment of the diaphragm. This bow
is frequently seen in intrathoracic obstruction. (Edema, or subcutane-
ous emphysema occurs as indicated under general inspection. If there
is too much fat over the surface of the chest, the muscles may be want-
ing in tone, and an estimation, therefore, of respiratory capacity cannot
be made. Wasting of the fat and muscles is seen in phthisis, carci-
noma, diabetes, muscular atrophy, and paralysis. The degree of sqft-
FrG. 121.
Transverse section of healthy adult chest upon level of sterno-xiphoid articulation.
Circumference = 89 centimetres.
ness of the ribs can be estimated in a measure by the undue depression
of the ribs at the costo-cartilasnnous articulations, and at the base of
DISEASES OF THE LUNGS AND PLEURA.
475
the chest (about the sixth rib), during the act of inspiration. It is an
indication of rickets. Rigidity of the thorax, equal to the senile fixa-
tion, occurs in some adults in middle life, and Roberts points out that
in young subjects it may be due to congenital syphilis.
The Shape and Size of the Chest. We appreciate the shape of
the chest in health by an estimation of the relations of the antero-pos-
FlG. 122.
Transverse section of healthy male adult chest. Semi-circumference, right side, 16% inches ;
left side, 16% inches ; expansion, 3% inches. (Ward 6, Philadelphia Hospital.)
terior and the transverse diameters and by the shape of the transverse
section of the chest. The latter is an ellipse, and has been described
Fig. 123.
Transverse section of an infant's chest, aged nine months. A circle within shows the similarity.
as reniform (see Fig. 121). The antero-posterior diameter is about
one-fourth less than the transverse. Measurement with the cvrtometer
476 SPECIAL DIAGNOSIS.
(see Mensuration) verifies the result of inspection with mathematical
precision. In children the transverse section is different. It is more
circular, and the antero-posterior and transverse diameters are almost
equal. (See Fig. 123.) Marked deviations from such section, or in
the relations of the diameters, are seen in abnormal types of chest.
It is difficult to describe the shape of the chest in health. By re-
peated practice we readily form a judgment of the true shape. No
rule has been applied to the relation of the length of the chest to the
length of the body, but it would seem that there is some such propor-
tion. (See Mensuration.) In health the chest should be symmetrical,
the right side probably a little larger than the left. In the ideal chest
the muscles of respiration should be well developed and there should
be a moderate amount of subcutaneous fat. The sternmn should pro-
ject forward from above downward, and the portion joining the manu-
brium and the gladiolus should be a little more prominent than the
other part. It is not unusual to see a clearly marked demarcation
between the upper and middle portions of the sternum, or an undue
projection of one or more of the upper ribs, and some striking changes
about the xiphoid cartilage, none of which are indications of disease.
The xiphoid may be depressed, on account of which a crater form or
funnel-shaped depression is seen (occupation). The tip of the cartilage
is sometimes drawn inward, but more frequently the reverse is noted.
The Movements of the Chest. The frequency, the rhythm, the
degree of expansion, and the so-called diaphragm-phenomena are
studied. A complete respiratory act consists of two events, inspiration
and expiration. Inspiration is active ; expiration passive. The latter
act is a trifle longer than the former, as may be illustrated by the
following proportion — Insp. : Exp. : : 5 : 6. A pause follows the act
of expiration. The chest increases in circumference and in vertical
length (descent of diaphragm) in inspiration as the lung expands with
air. The term expansion is applied to the result of inspiration ; its
degree varies.
The frequency and character of the movements in health vary in the
two sexes. The respirations are from 16 to 24 in the minute in a
healthy adult. In the female they may be 20 to 22. In children the
frequency of respiration is much greater — under one year, 44 per
minute, and at five years 26. They are increased in frequency in the
standing position. They are lessened in the horizontal position, in-
creased during bodily exertion, with increased temperature of the air,
and during digestion. The hand placed on the epigastrium facilitates
counting of the respirations.
The movements of the chest in quiet breathing are more marked in
the lower half in male adults, and thus the costo-abdominal or dia-
phragmatie type of breathing is seen. The sternum rises, the ribs are
elevated, and at the same time are drawn forward and outward. The
antero-posterior and vertical diameters increase. The costal angle and
epigastric angle become more obtuse. The diaphragm acts conjointly
with the external muscles of the thorax, and, as it descends, the epi-
gastric region swells with each inspiratory effort. In expiration the
DISEASES OF THE LUNGS AND PLEURAE. 477
sternum falls, the ribs become more slanting instead of horizontal, the
epigastrium retracts, the angles become acute. The antero-posterior
and transverse diameters lessen. The upper half of the chest moves
more actively in women, and hence the costal or upper thoracic type of
breathing is seen. The areas below the clavicles and the upper por-
tion above the sternum swell more distinctly during inspiration. The
movements of the lower portion, and especially of the diaphragm, are
limited.
The costal type occurs most frequently in children. The type of
breathing is costal in both sexes during sleep ; the same type is ob-
served during deep respiration.
The Diaphragm-phenomena (Litten). The diaphragm and walls of.
the thorax approach each other during expiration, and come in apposi-
tion at the end of this act. During inspiration they become separated.
In persons whose chest-walls are not too thick the movements of the
diaphragm are indicated on the surface by the rise and fall of a
shadowy line. The patient must lie on his back with his face from
the light and head slightly elevated. The light should fall from
behind. The observer stands a distance of three or four feet with his
back to the light. The chest is scanned at an angle of about forty-
five degrees. In the act of inspiration a horizontal shadow or undula-
tion is seen to start on either side about the sixth interspace and
passes downward during inspiration over a distance of two or more
interspaces, and even to the margin of the ribs. In expiration the
shadow begins below and moves upward to the starting-point.
Absence of the phenomena is noted when there is fluid or air in the
pleural cavity, when the pleural cavity is obliterated by adhesions,
when there is pneumonia of the lower lobe ; and in emphysema of the
lungs, and intrathoracic tumors low down in the chest. Tumors or
fluid accumulations below the diaphragm do not lessen the phe-
nomena.
By this phenomena the volume or vital capacity of the lungs can be
estimated. In normal individuals the shadow should move more than
two and a half inches. If there is lessening of the extent of move-
ment the respiratory capacity is diminished. In this manner tubercu-
losis may be suspected. Limitation of the excursion of the diaphragm
— X-ray investigations have forcibly taught us — is one of the earliest
signs of tuberculosis. This limited excursion can be detected in proper
subjects by Litten's method, although it must be remembered that
general debility and emphysema lessen the excursion on both sides.
In splenic and hepatic enlargements the normal shadow continues, but
in a large collection of ascitic fluid it may be detected with difficulty,
or may be absent.
The Shape and Size of the Chest in Disease. The chest may
be enlarged or diminished in size. Such change may be general or
bilateral, unilateral or local.
General or Bilateral Changes in Shape. Enlargement. The
" barrel-shaped " chest, the type of bilateral enlargement of the chest,
is seen in health when it is in the state of full inspiration. All the
478
SPECIAL DIAGNOSIS.
diameters are increased, particularly the anteroposterior ; the length
is shortened. The diameters are almost equal, and the transverse sec-
tion approaches a circle. This occurs because in all figures of fixed
length, in order that the area may be increased, a change to a circular
form must take place. (See Figs. 125 and 126.) The ribs are ele-
vated and almost horizontal, the epigastric angle is obtuse. The ster-
num and the spine are arched ; the former at the angle of Ludwig.
The shoulders are rounded and elevated, and the scapulae lie flat against
the thorax. All the muscles of respiration stand out prominently, the
Fig. 124.
- a
Pneumocoeei from a Case of Empyema.
(Oc. 4, ob. yj immersion.) Drawn by J. D. Z. Chase.
A
9
\
K
I? ^i' stained dark red, the other objects dark blue.
When the bacilli are few in number, Biedert proposes that the fol-
lowing preliminary steps be taken : About 4 c.c. of sputum are mixed
with 8 c.c. of water and 1 c.c. of solution of caustic soda, and boiled a
1 An alcoholic solution of methyl-blue should first be made, and then added, drop
by drop, with constant stirring, to the sulphuric acid and water.
534 SPECIAL DIAGNOSIS.
few minutes, when about 15 c.c. of water are added and the whole
again boiled until a homogeneous fluid is formed. This is allowed to
stand in a conical glass for twenty-four to forty-eight hours, when the
sediment is stained by the Ziehl-Neelson or Gabbet method. Or, the
homogeneous fluid can be put at once in a centrifugal machine, and the
resulting sediment stained.
Sputa hardened in Zenker's fluid, embedded in paraffin and cut, has
proven most satisfactory in the study of the branching forms of the
tubercle bacillus, the study of giant-cells in the sputum in phthisis,
and in the study of bacteria in the sputum in cases of pneumonia.
It is well to remember that, in the absence of a proper decolorizing
agent, hot water applied for some minutes has been shown to decolor-
ize very satisfactorily.
Importance. The greatest importance attaches to the presence or
continuance of tubercle bacilli in sputa. It indicates tuberculosis of
the lung or larynx ; in the vast majority of cases of the former.
They are often to be found in the sputum when physical signs are
not yet present or are indefinite. The number varies so greatly in
different cases, and in the same case at different times, that a in recent
attack it is impossible to judge of the extent of the disease by the
number present in a given preparation.'
The absence of bacilli from sputa has no true value unless negative
results are obtained after many trials and careful examination by an
experienced observer, using good stains. Hence, too great care cannot
be taken in each and every step.
Biological Properties. The tubercle bacillus is difficult to cul-
tivate, as it grows readily only in conditions found within the body.
The best medium is blood-serum. The cheesy mass from the sputum
or the tubercular nodule from a tissue is placed on the surface of the
serum and rubbed carefully over it. It is best to make twenty or
thirty such inoculations. The tubes must then be sealed to prevent
evaporation and drying, and exposed for twelve days to a temperature
of 37.5° C. When a pure culture is obtained further cultivations may
be made on agar-agar, to which 6 per cent, of glycerin has been added.
The pure cultures appear as dry masses on the surface of the medium,
either as flat scales or clumps of mealy-looking granules. They are
of a dirty drab or brownish-gray color. (See Plate VII., Fig. 6.) The
bacillus is parasitic, aerobic, non-motile (facultative anaerobic).
Pneumococcus. Diplococcus Pneumoniae. Micrococcus Lan-
ceolatus. The causative factor in most cases of acute croupous pneu-
monia in its typical form is a paired lancet-shaped coccus, often irreg-
ular in size, with a tendency to chain formation. Frequently oval or
conical forms are present, and there is apt to be variation in the size
of the two cocci forming the pair. The organism has a distinct cap-
sule. In the sputum of croupous pneumonia these pneumococci are
usually present in large numbers. Their presence within leucocytes
1 " A Method for the Examination of the Actual Number of Tubercle Bacilli in
Tuberculous Sputum." By George H. F. Nuttall, M.D., Ph.D., Johns Hopkins
Hospital Bulletin, May, 1891. The method is of pathological but not of diagnostic
interest.
DISEASES OF THE LUNGS AND PLEURA. 535
and their tendency to chain formation has been especially noted in
such cases.
Pneumococci are stained in cover-glass preparations with the ordi-
nary aniline dyes, as given above. The capsule may be stained and
differentiated in the same way, but it more often requires a special
method. Welch recommends the following : Spread and dried cover-
glass preparations are treated first with glacial acetic acid, which is
allowed to drain off, and is replaced (without washing in water) with
aniline oil-gentian-violet solution. (See under Tubercle Bacilli.) The
staining solution is repeatedly added to the surface of the cover-glass
until all of the acid is displaced. The specimen is now washed in a
weak salt solution (about 2 per cent.), and examined in the same, not
in balsam. The capsule and coccus can then be differentiated. Spu-
tum stained by Gram's method, thoroughly decolorized by alcohol,
counter-stained with a watery solution of eosine, or a 1 per cent, aque-
ous solution of aurantia, has been found satisfactory for microphoto-
graphic work. Degenerative and involution forms are constantly met
with. There will be variations in size and shape, and the capsule may
contain only remains of a coccus, or be entirely empty. (See Plate
XV.)
Biological Properties. The pnenmococcus is not motile. It
stains by Gram. It grows well on blood-serum. The growth is
minute, transparent, colorless colonies, resembling drops of dew. A
favorable growth of very minute colonies appears in glycerin agar-
agar. Bouillon is faintly clouded. Litmus milk will sometimes
turn pink and coagulate. Growth on other culture media is usually
feeble. The tendency to form chains is especially observed in the
water of condensation on blood-serum tubes. The lancet shape of
the cocci enables them to be differentiated from the streptococcus.
The capsules are not usually observed in the cultures with ordinary
methods of staining.
By inoculation into susceptible animals a typical fibrinous pneumo-
nia is developed. The pathogenic power attenuates rapidly in cul-
tures, but recovers its virulence by passing through susceptible animals.
This micro-organism is found in nearly all cases of acute croupous
pneumonia, and in many cases of bronchopneumonia. Its presence
has also been observed in health in the saliva. It is found also in
acute pleuritis, endocarditis, pericarditis, peritonitis, acute purulent
meningitis, and otitis media. Its presence in empyema is considered
of favorable import. It has also been found in cases of synovitis,
osteomyelitis, and abscess formation in various situations. It may
cause a general septicaemia — /. e., pneumococcus septicaemia.
Bacillus Mucous Capsulatus. This organism is found in the
sputum in health in a certain number of cases. In association with
the pneumococcus it can cause pneumonia. It can also produce pneu-
monia by itself in rare instances.
In three fatal cases of pneumonia due to the capsule bacillus alone,
there have been found in the sputa large numbers of capsule bacilli.
These were frequently inside of leucocytes, and many alveolar cells
were filled with these bacilli.
536 SPECIAL DIAGNOSIS.
Bacillus of Influenza. This organism is found in the sputum
in cases of influenza or influenza pneumonia. It was first isolated
from the sputum by Pfeiffer. The organism appears as a small
bacillus with rounded ends. Its length varies somewhat, and thread-
like, involution forms may appear. It stains more deeply at the ends
than at the middle, and the long forms may show irregularity of stain-
ing. It does not grow on the ordinary media. It is best cultivated
upon agar-agar slants, upon the surface of which has been smeared a
few drops of blood. The colonies appear after twenty-four to thirty-
six hours as minute, colorless, watery, clear, dew-like colonies, best
seen with a hand lens. In the sputum these bacilli are frequently
present in large numbers in cases of influenza, and their presence fill-
ing up the protoplasm of the leucocytes and the purulent sputum of
pneumonia is not uncommon. Thin smears of the sputum, stained
with aniline oil-gentian-violet, somewhat decolorized with alcohol, and
counter-stained with a 1 per cent, aqueous solution of aurantia, have
shown these bacilli much better than the ordinary methods of staining
with Ldffler's methylene-blue or dilute carbol-fuchsin.
Whooping-cough. Minute bacilli have been discovered in the
sputum in cases of whooping-cough by Czplewski, Koplik, Zusch, and
others. At present the results are not sufficiently uniform to prove
these bacilli of etiological value in the disease.
Actinomyces. When the lungs or pleura are infected by this
fungus actinomyces may be found in the sputum. The disease in
these organs is rare. Macroscopically they appear as small kernels,
yello wish- white or greenish-yellow, and having the shape of a millet-
seed. Under the microscope they are recognized by the rounded,
club-like bodies projecting from all sides of an unformed central mass.
They are seen better when not stained. (See page 352.)
Chemistry of Sputum. As the chemical examination of the
sputum does not aid us in diagnosis, it has but little or no value.
Mucin, nuclein, and serum albumin are constituents of sputa in health.
Peptone is present whenever there is pus, and is especially marked in
pneumonia. Volatile fatty acids, such as butyric and acetic, occur at
times, markedly so in pulmonary gangrene. Glycogen has been
obtained by Solomon, and a ferment resembling one of the pancreatic
ferments has been detected, especially in pulmonary gangrene and
putrid bronchitis. Of inorganic substances, chlorides of soda and
magnesia ; phosphates of soda, lime, and magnesia ; sulphates of soda
and lime ; carbonate of soda, lime, and magnesia ; and in a few cases
phosphate of iron and silicates have been obtained (Von Jaksch).
SPECIAL DIAGNOSIS.
Pictoric Records of Physical Signs.
In order to draw accurate conclusions from the various data obtained during
the physical examination of a patient, the physician must carry iu his mind the
results of the inspection, the palpation and percussion, and the auscultation of
each individual part of the thorax and abdomen. For the beginner the grouping
PLATE XVI.
FIG. 1. — Anterior Aspect.
;iv '? /
-x
Physical Signs in Health.
Normal percussion outlines of the viscera. Normal heart and breath sounds.
Vertical lines for localization.
DISEASES OF THE LUNGS AND PLEUBJE. 537
together of these phenomena according to regions of the body, instead of by
methods of examination, is extremely difficult. He is taught to examine the
thorax, first, by inspection, then by palpation and percussion, and, finally, by
auscultation ; and in following this routine the results of the examination
naturally divide themselves into the signs obtained by this method or that. In
making the diagnosis, however, the grouping must be rearranged, for in order to
determine the condition of a certain organ or part of an organ, all the local
phenomena, by whatever method recognized, must be considered in their rela-
tion to one another and not merely as isolated facts. By weighing all the
evidence obtained by the various methods of examination, and by balancing the
relative importance of this sign or that, a verdict is finally reached in regard to
the condition of the part in question. Only after the status of each organ has
been thus separately determined can a complete diagnosis of the case be made
with certainty.
In describing in the text the physical signs of the various diseases of the
internal organs, it is necessary, in order to avoid endless confusion, to consider
data in the order in which they are elicited — i. e., grouped according to the
method of their recognition. To redescribe them grouped according to regions
would involve constant repetition, and would still fail to give a clear picture of
the sign-complex of the part. And yet it is essential that this picture should be
so clear and well defined that the physician, in summing up the examination,
has but to glance at the part in order to call up to his mind all the various data
obtained by its examination. Experience adds daily to the facility with which
this piece of mental gymnastics is performed, and it finally becomes half-auto-
matic, but for the beginner it is most discouragingly difficult. He may, how-
ever, obtain great assistance in acquiring the right habit of thought by system-
atically writing down each sign as it is perceived, and by grouping with it the
other signs belonging to the same region. This he may do by means of short
descriptions, or, better still, he may employ symbols to represent the various
sounds, etc., and may mark them directly on the patient's body, or may fill them
in on blank diagrams of the thorax and abdomen, and thus obtain a complete
and vivid picture of the results of the examination of each separate region
The practical value of this method, both as an aid to the beginner and as an
easy and accurate means for preserving records, has been widely recognized,
and numerous symbols have been devised, to represent graphically the various
physical signs. Those suggested by Wyllie, of Edinburgh, and by Sahli, of
Bern, are among the best. Many of the symbols used in the following plates
will be recognized as borrowed from the above authors.
Explanation of the Symbols Used in the Plates Illustrating Special
Diseases.
Percussion Sounds. Superficial dulness (also called absolute dulness) is
alone indicated in the following plates. As has already been stated, the per-
sonal equation enters so largely into the determination of the extent of deep
(relative) dulness that it is scarcely possible to make any positive statements in
regard to the areas over which it is obtained in health and in disease. Absolute
dulness is, on the other hand, easily recognized, and it is, therefore, far better
that the student first become thoroughly familiar with this, about which there
can be little or no question, before being taught what, in the case of relative
dulness, is after all merely the expression of the individual skill and acuteness
538 SPECIAL DIAGNOSIS.
of ear of the instructor. With a clear picture of the areas of superficial dulness
once firmly fixed in the mind, the student should for himself determine just how
far he individually is able to rely upon his perception of deep dulness. As his
skill in percussion increases, and as his ear becomes better trained, he will find
himself progressively better able to make use of deep dulness as an aid in diag-
nosis. He should, however, remember that many skilled diagnosticians are
content to rely almost exclusively upon superficial dulness.
Blue shading = Areas of superficial dulness ; the intensity of the color ex-
presses the intensity of the dulness.
HR = Hyper-resonance.
T = Tympany ; the pitch is indicated by a dot above or below
the letter.
Breath-sounds. An ascending line indicates inspiration ; a descending line
expiration. The length of the line shows the length of the sound, the thickness,
its intensity. A dot above or below the line indicates high or low pitch. Two
cross lines are used to designate bronchial breathing ; a single cross line indi-
cates bronchovesicular breathing. An interrupted line stands for cog-wheel or
interrupted breath-sounds.
/\ = Normal vesicular breath-sounds.
= Weak vesicular breath-sounds.
= Harsh vesicular breath-sounds (puerile breathing).
= Harsh vesicular inspiration, prolonged vesicular expiration.
/\
J\ = Sharp vesicular inspiration, slightly prolonged vesicular expi-
ration.
/\ = Interrupted (cog-wheel) breath-sounds.
= Bronchial breath-sounds (bronchial breathing), inspiratory
and expiratory.
= Bronchovesicular inspiration, low-pitched bronchial expira-
tion.
Rales. Dry rales are represented by undulating lines, the length corresponding
to the duration, while a dot above or below the line indicates the pitch.
^v^v^A = Sonorous rales.
^^ = Sibilant rales.
Moist rales are represented by circles the diameter of which indicates the size
of the rales. An ascending line drawn through the circle shows that the rale is
heard during inspiration, a descending line that it is heard during expiration.
The clear, sharp, moist rales heard over consolidated areas, rales with over-tones,
are indicated by large or small dots, according to their size.
o° = Small, moist (subcrepitant) rales.
° ° — Medium-sized moist rales.
jtf fo = Large moist rales heard during both inspiration and expira-
tion.
o = Large and small moist rales.
DISEASES OF THE LUNGS AND PLEURAE. 539
•;• = Small moist rales heard over consolidated areas.
%• = Medium-sized moist rales heard over consolidated areas.
• • = Large moist rales heard over consolidated areas.
0J0 = Large and small moist rales heard over consolidated areas.
•••
Crepitation.
rP^ = Crepitant rales, to be heard only during inspiration.
Friction Rub.
AVVAm = Friction rub, as heard over any serous surface.
Heart-sounds. The symbols used to indicate the feet in Latin poetry are
made to represent the heart-sounds. The straight line indicates the longer, the
curved line the shorter sound. The thickness of the lines shows the relative as
well as the absolute loudness.
— v = Normal heart-sounds as heard over the mitral and tricuspid
regions.
w — = Normal heart-sounds as heard over the aortic and pulmonic
regions,
u — = Normal first sound, accentuated second.
~ uu = Loud first sound, reduplicated second.
— "~ = Loud first and second sounds of equal intensity.
Murmurs. Murmurs are represented by short parallel lines either increasing
or diminishing in length, according as the murmur increases or diminishes in
intensity. The thickness of the lines shows the loudness of the murmur, the
number of lines shows its duration.
Illllin. = A soft murmur, commencing distinctly and gradually fading
'lllllllllll..
[Illlin. = A loud murmur of the same character.
i||| = A short loud murmur, increasing in intensity (type of pre-
systolic murmur).
= Loud first sound, slightly accentuated second sound; short
loud presystolic murmur, increasing in intensity to end with
the first sound ; long, soft, systolic murmur.
Fremitus.
F + = Increased fremitus.
F — = Diminished fremitus.
NoF = Absent fremitus.
Other Symbols.
X =. Impulse.
M = Margin (of an organ).
R = Retraction.
B = Bulging.
v = Visible.
p = Palpable.
Xvp = Visible and palpable impulse.
Mvp = Visible and palpable margin,
540 SPECIAL DIAGNOSIS.
The Neuroses.
The neuroses are affections of the lungs unattended by structural
change. To this class belong the varieties of rapid breathing, of slow
breathing, of cough and of dyspnoea which appear to arise without
structural change, and which are discussed exhaustively in the section
devoted to the subjective symptoms. Among other neuroses, asthma
is fully treated of, and other forms of dyspncea and cough are
considered. Reference need not be made further to the respiratory
neuroses other than to bear in mind that their presence may or may
not be unattended bv organic change in the lungs. On the other
hand, we are likely to find the general phenomena or stigmata which
are associated with neuroses of other organs, as well as the lungs.
Hence, the condition of neurasthenia is likely to be present on the one
hand, or the numerous stigmata of hysteria may be found on the other.
The Congestions.
Congestion of the Lungs. Active Congestion. In active con-
gestion there is an increased amount of blood, which diminishes the
air-space by encroachment and causes more or less consolidation. The
signs of that physical condition are present — increased fremitus, im-
paired resonance or dulness, and bronchial breathing. They are
observed on both sides, usually at the bases. Dyspnoea, cough, and
frothy, bloody expectoration attend the fluxion. Xo cases have vet
been reported in which bacteriological examination of the sputum was
made. Of course, the micrococcus lanceolatus is not found.
If the above signs and symptoms develop suddenly — within twenty-
four hours — a fluxion to the lung has in all probability taken place.
If the patient is subject to heart disease, or if he has been exposed to
and has inhaled hot vapors or irritants, the probability of fluxion is
increased. The occurrence of fever would point to pneumonia as the
cause of the objective and subjective symptoms.
Passive Congestion. The physical condition that results is con-
solidation, manifesting itself by slight dulness and feeble or bronchial
breathing ; the bronchial mucous membrane is also congested, giving
rise to abundant large rales. The affection is bilateral and usually
confined to the posterior portions of the bases. It is also secondary.
a. Mechanical congestion occurs when the flow of blood to the heart is
obstructed, as in organic valvular disease or insufficiency. Rarely the
pressure of tumors on the pulmonary veins acts in a similar manner.
6. Hypostatic congestion occurs in fevers, as protracted typhoid, and
in prolonged general exhaustion or adynamia. Ascites or other affec-
tions below the diaphragm, which lessen the respiratory excursion,
cause this form. Dyspnoea, cough, and expectoration of blood-stained
sputum are common. The sputum contains alveolar cells, often pig-
mented, but no micro-organisms.
CEdema. The air-cells and alveolar walls are filled with serous
exudation, as in oedema of the skin. It is frequently due to the weak-
ness of the heart, which occurs at the end of long-continued diseases
DISEASES OF THE LUNGS AND PLEUBJE. 541
of an exhaustive nature, particulaly if the heart is overtaxed. It
occurs, therefore, in the terminal stages of chronic Bright' s disease, of
organic heart disease, of the anaemias and cachexias. Both congestion
and oedema occur in cerebral affections.
Symptoms. They are those of congestion in a more aggravated
form. Dyspnoea, cough, and the expectoration of large quantities of
a seromucoid fluid are seen. The diagnosis is based upon the result
of physical examination and the history of the above causal factors.
In cases of myocarditis or acute dilatation of the heart, in valvulitis
with failing compensation, oedema of the lungs often takes place sud-
denly. It may follow some unusual exertion. Its onset is attended
with more or less collapse, increased pulse-rate, hurried, oppressed,
noisy breathing, cyanosis, and an anxious expression. The physical signs
are an unusual number of small rales throughout the chest, apparently
created in the air sacs, and imperfect resonance, showing that some
lobules are collapsed.
Pulmonary Embolism and Thrombosis. Pulmonary embolism
consists in plugging of the pulmonary artery or its branches by coagula
formed in the right heart or in the veins. The symptoms depend upon
the size of the occluded vessel and upon the nature of the embolus — i. e.,
whether septic or not. If the artery itself is plugged, death takes place
suddenly or after a short interval, with symptoms of syncope or asphyxia.
Symptoms. If a large branch is plugged, the first symptom is gen-
erally intense dyspnoea, which may amount to an agonizing craving
for air. Pain in the chest, which may or may not be acute, is com-
plained of, and may be referred to the seat of the embolus. Cough is
not a common symptom, and may be altogether absent. The breath
ing is considerably altered ; it is usually increased in frequency, and
may be much hurried ; it may or may not be shallow, and while the
patient can take a deep inspiration, it does not give relief to his dysp-
noea. At times it is irregular and gasping.
The face is pale or may be cyanosed, and is apt to be bathed in per-
spiration. The veins are swollen and prominent. The heart's action
is irregular and may be tumultuous. Exophthalmos has been ob-
served. The temperature falls below normal, but a febrile rise may
occur later. The intellect is unclouded.
The physical signs are indefinite. The respiratory murmur is rough-
ened and exaggerated in most, but not in all cases. Fox states that
rales are very rarely heard. Collapse, oedema, and bronchitis are possi-
ble results. A systolic blowing murmur may be heard over the heart
and pulmonary artery, and in protracted cases albuminuria and oedema
may be met with.
When the embolus is septic, a septic pneumonia or metastatic abscesses
are probable results in cases not immediately fatal.
When the emboli produce hemorrhagic infarcts the symptoms are
milder, and consist principally in dyspnoea, pulmonary hemorrhage,
and palpitation. The onset is sudden and accompanied by a fall in
temperature. The physical signs indicate consolidation, if the pneu-
monia or infarcted area is of moderate size. It may be discovered at
the root of the lungs in the interscapular region.
542 SPECIAL DIAGNOSIS.
Haemoptysis is a common symptom when the embolus has arisen in
the heart. The amount of blood varies from a copious expectoration
to the rusty sputum seen in pneumonia ; it may persist for weeks.
Pleurisy and. pleural effusion are frequent complications ; chills occur
sometimes, and pneumonia, with corresponding rise of temperature,
may develop.
The most important points in diagnosis are the sudden onset of the
dyspnoea and other pulmonary symptoms, and the detection of a con-
dition which would give rise to emboli, such as puerperal fever or
heart disease.
The Inflammations.
The Bronchi. Inflammations of the bronchi are distinguished from
other diseases of the lungs chiefly by the difference in the physical
signs. Except in capillary bronchitis, the general and subjective
symptoms are not so severe as in other affections.
Signs Peculiar to Inflammations of Bronchi. AVe are aided
in the recognition of bronchial affections, first, by the fact that they
are bilateral ; second, that the bases are usually affected ; third, that
there is diminution of fremitus determined by palpation ; fourth, that
there is absence of dulness on percussion ; fifth, that rales are more
pronounced in proportion to other physical signs, and more general
than in other lung affections.
Bronchitis. Bronchitis is an mflammation of the mucous mem-
brane of the bronchial tubes. It may be acute or chronic, may in-
volve any part of the bronchial tree, the large, the middle-sized, or
the most minute branches, and may be primary, or occur secondarily
to some general disease, or to disease of the heart or kidneys.
Acute bronchitis occurs most frequently by extension of the
catarrhal inflammation from the nose and throat ; but in some persons
it develops so suddenly that it appears to be primary in the tubes.
When the larger or middle-sized tube* are involved, the patient com-
plaius of soreness or rawness underneath the sternum, especially at its
upper part. There are frequently a feeling of tickling in the throat,
and a sense of weight or oppression on the chest. Chest pain is due
to myalgia or the strain upon the muscles from coughing. The cough
is at first hard and dry, and often produces pain of a tearing character
in the muscles of the chest and abdomen. The cough is apt to be
worse when the patient first lies down, and again on rising, especially
after a night's rest. Fever is usually slight and of short duration.
The respirations are accelerated, but not markedly, and there is no
dyspnoea. The expectoration is at first a white, frothy, viscid mucus,
subsequently becoming more abundant and mucopurulent.
Physical Signs. In uncomplicated case.- there arc no changes in the
physical structure of the lungs. On examination of the chest the per-
cussion-note is found to be clear ; the respiratory murmur more rough-
ened and harsher than normal, but not broncho vesicular or bronchial;
accompanying breathing there are heard sibilant and sonorous rales.
and, in the later stages, some large and medium-sized mucous rales.
The rales vary in position from time to time, and especially after
DISEASES OF THE LUNGS AND PLEUBJE. 543
coughing. Vocal resonance and fremitus are unaltered. A fremitus
may be produced by sonorous rales.
The cough and expectoration usually last for some time after fever
has subsided. The duration of the disease is from a few days to sev-
eral weeks. It is never fatal except in the very old and very young,
or in those who are much debilitated.
The diagnosis of acute bronchitis is easily made by noting the fact
that the disease runs an acute course, marked by fever, cough, and ex-
pectoration ; and that the physical signs are negative, except as to
roughening of the respiratory murmur and the existence of bronchial
rales, heard on both sides of the chest.
From croupous pneumonia and local tuberculosis of the lungs it is
distinguished by the absence of dulness on percussion, bronchial
breathing, and increase of vocal resonance and fremitus ; by the
absence, in other words, of the ordinary sigus of consolidation. From
pneumonia it is further distinguished by the milder character of the
subjective symptoms, and by the fact that in bronchitis the physical
signs are almost always bilateral, in pneumonia generally unilateral.
It is further distinguished from tuberculosis by the slow progress of
the latter, which involves the apices preferably, whereas bronchitis is
more marked at the bases ; and by the occurrence, sooner or later, of
hectic fever and emaciation, which are absent in bronchitis. Doubt
will exist only at first ; the progress of the case will in time make
everything clear. Systematic examination of the sputum is an impor-
tant diagnostic aid, and will lead to the differentiation of many cases
of bronchitis from tuberculosis and from pneumonia. In infants and
children especially, bronchitis is at times so rebellious to treatment
that tuberculosis is suspected.
In bronchopneumonia (catarrhal pneumonia) there is a diffuse bron-
chitis associated with small areas of pneumonic consolidation. It is
distinguished by having graver general symptoms and by the presence
of small areas over which there are dulness on percussion and bronchial
breathing, associated with physical signs of bronchitis already de-
scribed.
Acute miliary tuberculosis of the lungs is very easily mistaken for
bronchitis, because dulness, if present, amounts to nothing more than
tympanitic dulness, because the signs are diffused through both lungs,
and because the respiratory murmur is fainter than normal, but only
slightly roughened. Close inspection of the patient will, however,
make it evident that his condition is worse than could be accounted
for by bronchitis alone. The fever is higher, the respirations more
frequent, pallor, with a dusky or faintly cyanotic hue intermingled, is
common, perspiration is more pronounced. A primary focus or a
source of infection may be discovered.
Acute bronchitis may be mistaken for spasmodic laryngitis (Croup).
It is distinguished by the fact that the spasms are less pronounced in
bronchitis, and there is fever in addition to the physical signs. In
bronchitis the breathing is rarely so stridulous as in laryngeal spasm.
Whooping-cough cannot be distinguished positively from bronchitis
before the characteristic whoop appears ; but it may be suspected when
544 SPECIAL DIAGNOSIS.
the child has been exposed to contagion, and when the coryza and
redness of the fauces persist in spite of treatment.
In the diagnosis of bronchitis it is more often difficult to determine
the primary cause than it is to distinguish it from other pulmonary
affections. Yet the former is more important ; it must be borne in
mind that bronchitis is a frequent accompaniment of many febrile dis-
eases, such as typhoid fever, measles, and whooping-cough ; of diseases
of the heart and kidneys, and of septic diseases and blood disorders.
The primary will not be likely to be mistaken for the seconday dis-
order if one is upon his guard and insists upon finding a cause for each
case that presents itself.
Measles can usually be diagnosticated from the first by the coryza,
but especially by the red spots upon the anterior half-arches of the
soft palate, which appear usually several days before the eruption upon
the body.
Bronchitis is a common and important early symptom of typhoid
fever. The latter disease may be suspected when the fever, prostra-
tion, and headache are greater, and, especially if these symptoms coex-
ist with a loose condition of the bowels, chilliness, and occasional nose-
bleed.
Chronic bronchitis occurs most frequently in middle or later
life. Its special feature is long duration, without fever, and with
comparatively little impairment of the general health. Cough is not
constant ; there are periods when it is entirely absent ; the disease
then returns, perhaps with increased severity, and lingers indefinitely.
Chronic bronchitis in its milder form consists in what is often
called " winter cough." It attacks especially persons past middle life
who have emphysema. It appears with the cold weather, and lasts
until the following summer. The cough is not severe, though some-
times paroxysmal, and expectoration is scanty, non-purulent, and may
be confined to the morning. Dyspnoea is not marked unless there is
considerable emphysema. Acute exacerbations occur from time to
time, and the tendency of the disease is to become worse from year
to year, and to be more continuous, even persisting all summer.
In the dry catarrh, or catarrhe sec of Lsennec, paroxysms of. cough
occur on the slightest provocation, with the expectoration of small,
hard pellets, or without any expectoration. The patients are emphy-
sematous.
The diagnosis is made by noting the long duration of the disease
without impairment of the general health, its relation to season, and
the absence of physical signs of involvement of lung tissue.
The physical signs of chronic bronchitis are those of bronchitis of
the larger and middle-sized tubes. Large moist rales are more or less
abundant, depending upon the degree of swelling of the mucous mem-
brane, and the quantity and fluidity of the secretions. The respiratory
murmur is roughened and less intense than normal.
"W. Fox says that in chronic bronchitis there is commonly hyper-
resonance from coexisting emphysema, but under acute exacerbations
the bases may be dull from congestion or oedema. Respiration is
harsh, and in some cases of senile bronchitis expiration may be both
DISEASES OF THE LUNOS AND PLEURJE. 545
prolonged and high pitched, when other signs of dilatation of bronchial
tubes are absent. The percussion-note is clear.
The sputa of the severe forms of chronic bronchitis are usually
copious and mucopurulent, the latter predominating. They vary in
color from yellowish-white to ashy, greenish, or black when the lungs
are anthracotic or collapsed.
The subjective symptoms of the patient consist, in ordinary cases, of
a moderate amount of dyspnoea, and tightness across the chest. At
the onset of a fresh attack the symptoms may be those of acute bron-
chitis. The cough is paroxysmal, somewhat resembling that of whoop-
ing-cough, but without the characteristic whoop. It is usually severest
on lying down and when rising in the morning.
The quantity and character of the sputa vary more than in acute
bronchitis. Sometimes they are very copious, consisting of serum
mixed with mucus, constituting bronehorrhoea. More commonly they
are scanty, glairy, and tenacious.
Chronic bronchitis may be the result of repeated acute attacks, or,
rarely, of only one. It is frequently found in association with gout,
chronic heart disease, chronic endarteritis, B right's disease, emphy-
sema, asthma, and chronic alcoholism. It may alternate with other
gouty affections, as articular inflammation or eczema, being relieved
when the other manifestations are more marked. It also accompanies
tuberculosis of the lungs. Climate and season have a marked influ-
ence ; the disease is worse in damp, cold climates, and in the winter
months.
Chronic bronchitis can be diagnosticated from the cough of aneurism
by the absence of the stridulous breathing, due to paralysis of one-half
of the vocal cords, and by the local signs of a tumor of the vessel.
Other tumors may cause cough by pressure, and the possibility of their
existence should, therefore, be borne in mind.
Capillary Bronchitis, or Suffocative Catarrh, is bron-
chitis of the smaller tubes. It occurs most frequently as an extension
of the catarrhal process from the larger tubes, but sometimes seems to
attack the smaller tubes from the beginning, or coincidently with the
larger tubes. Infants, young children, and the aged are most liable to
it. It begins with a succession of chills or chilliness, followed by high
fever. The temperature may rise to 104°. The skin is hot, the face
flushed. The head and neck and the upper portion of the trunk may
be covered with perspiration. The pulse rapidly increases in frequency.
The aspect of the patient from the first shows that the illness is
graver than ordinary bronchitis. The face expresses anxiety, and in
children the alse nasi dilate in respiration, which is both accelerated
and difficult (dyspnoea). The respirations may be as many as 60 or
80 to the minute, the pulse not being correspondingly rapid. Dysp-
noea is more or less constant, but becomes urgent in paroxysms, and
the patient may have to be propped up in bed to enable him to breathe
(orthopncea). It is expiratory : inspiration may be free and easy, or
difficult ; but expiration is always difficult and prolonged. In children
the pause in the act of breathing takes place at the end of inspiration,
instead of expiration.
546 SPECIAL DIAGNOSIS.
Cough is more frequent and violent than in ordinary bronchitis, and
the expectoration is viscid and difficult to raise. As the disease pro-
gresses, dyspnoea becomes more intense, and signs of insufficient aera-
tion of the blood make their appearance (cyanosis). The lips and
finger-nails become bluish, and the extremities cool and clammy. If
the patient is unable to expel the tenacious secretions from his bron-
chial tubes, the further progress of the case is that of rapidly develop-
ing cyanosis ; the breathing continues frequent, but is shallow and
more labored. Children often have convulsions, followed by coma and
death, while old persons sink into coma without preceding convulsions.
The physical signs (Plate XVII.) are those of bronchitis of the larger
and smaller tubes ; sibilant and sonorous rales, if present at first, give
way to fine subcrepitant and crepitant rales, which speedily become
moist and very abundant. As an ordinary bronchitis, the bases of
the lungs posteriorly are the parts most involved. The percussion-note
of both lungs remains clear, but there is apt to be increased resistance.
The fremitus may be lessened in some areas, increased in others. If
an area of dulness appears, it may be due to pneumonia or to collapse
of the lung ; if the former, there is usually an access of fever.
The sputum contains mucus, pus, occasionally blood-cells, granular
matter, and sometimes fibrinous casts of the tubes. The micro-organ-
isms found are the micrococcus lanceolatus, streptococcus pyogenes, and
staphylococcus aureus et albus. Mixed infections are usually present.
Plastic bronchitis is a form of bronchitis, usually chronic, the
characteristic feature of which is the expectoration of fibrinous casts,
which, when unravelled under water, are found to be solid casts of
the smaller bronchial tubes. The casts are often tree-like in shape,
showing that a bronchial tube and its smaller subdivisions have been
occluded by the casts.
Persons of all ages are liable to it, but it affects males about twice as
often as females.
The subjective symptoms are cough and dyspnoea ; haemoptysis
occurs in about one-third of the cases (Biermer). 1 The cough occurs
in paroxysms, which are frequent and severe ; relief follows expecto-
ration of the casts.
Hemorrhage may appear only as streaks of blood upon the casts, or
may be considerable, and follow their dislodgement. The casts them-
selves when ejected are usually coated with mucus, so that they appear
as solid masses of sputum ; their arrangement into cylinders may not
be suspected until they are agitated in water. The size of the cylin-
der varies from that of the little finger to that of a bodkin, but they
do not often exceed the size of a goose-quill. The larger casts may
be hollow, but the smaller ones are solid, and are arranged in layers.
They are whitish or gray in color, and firm in consistence, but become
softer as the disease improves. Microscopically, the casts are nearly
structureless, consisting of a fibrillated base, with pus and mucous cor-
puscles, a few gland-cells, and, occasionally, blood-cells in the outer
layers. Charcot-Leyden crystals and Curschmann's spirals are found.
1 Virchow: Handbuch der spec. Path. u. Ther., Bd. v., Abth. 1.
PLATE XVII.
FIG. 1. — Anterior Aspect.
FIG. 2.— Posterior Aspect.
-etc
/
Capillary Bronchitis (early stage).
Rough or sharp breath sounds-expiration in places prolonged. Sonorous,
sibilant and small nioist rales. Local increase of fremitus.
DISEASES OF THE LUNGS AND PLEURA. 547
The acute form is rare, and out of ten cases accepted by Biermer six
proved fatal. The disease begins with fever, dyspnoea appears early,
severe paroxysms of cough occur, sometimes hemorrhage. Death
results from asphyxia. Grave symptoms are excessive dyspnoea,
scanty expectoration, and drowsiness. Copious expectoration is a
favorable sign.
The Physical Signs. The casts obstruct the bronchial tubes. There
is less air entering the part, hence there are diminished fremitus and
respiratory murmur over the portions of lung supplied by the obstructed
tubes. If collapse ensues, there is dulness on percussion ; if the casts
are dislodged, the murmur becomes normal, or but slightly roughened.
In unaffected portions of the lung resonance is clear or exaggerated,
and the respiratory murmur remains unaltered.
Fuller says (quoted by Peacock in Diseases of Chest) that the upper
portions of the lungs are oftener affected than the lower portions.
Fetid or Putrid Bronchitis is the name applied to the condi-
tion in which the sputa have a highly offensive odor and are copious
and semi-putrid. The odor is said by some to be due to microscopic
sloughs, and by others to a special bacillus.
Putrid bronchitis may accompany (1) dilatation of the bronchial
tubes ; (2) chronic pneumonia ; (3) phthisis or (4) empyema with a
fistulous communication with a bronchus ; or (5) it may occur indepen-
dently. The subjective symptoms are cough, irregular fever, and
occasional chills. The physical signs are those of chronic bronchitis,
or of bronchitis and the conditions with which it may be associated
(q. v.). It is diagnosticated from gangrene by the absence of physical
signs of disintegration of lung-tissue and by the absence from the
sputum of fragments of lung-tissue and elastic fibres. Nevertheless,
gangrene of the lung may be the final result of putrid bronchitis.
The sputa of fetid bronchitis have an odor of gangrene or fasces.
On standing they separate into three layers. The upper one consists
of a greenish, fluid, or frothy layer ; the second is sero-albuminous ;
and the third a thick granular deposit in which are small masses, the
size of peas (Dittrich's plugs), and flake sconsisting of granular detritus,
and containing fat-crystals and bacteria, the oklium albicans, and crys-
tals of leucin and ty rosin. (See Sputum.)
Infectious Bronchitis. In addition to the bronchitis that attends
the infectious disorders mentioned above, three forms are seen of an
infectious nature which are properly classified among the infectious
diseases. It is proper to refer to them now, as bronchitis is usually
the most pronounced local manifestation. They are influenza, whoop-
ing-cough, and hay-fever. The last only will be spoken of at present.
Hay- fever. Hay-fever is a specific catarrh of the respiratory pas-
sages, caused by the pollen of certain plants, principally the grasses.
The attack begins with itching, burning, and lacrvmation of the eyes,
and pain in the brow or eyeballs. Subsequently there is itching or
pricking of the nasal mucous membrane, frequent sneezing, and an
irritating watery discharge. The mucous membrane of the nose is
red and swollen. A similar condition obtains in the throat when that
is affected. If the disease attacks the bronchial mucous membrane a
548 SPECIAL DIAGNOSIS.
bronchitis is set up, which, if it differs at all from ordinary bronchitis,
is more persistent and attended by greater dyspnoea, with asthmatic
attacks.
Collapse of the Lung. Collapse of the lung is a condition pro-
duced by exhaustion of air from the air-vesicles. It may affect alveoli
here and there, or a large section of the lung. Formerly such collapse
was invariably looked upon as pneumonia, until Legendre and Bailly
proved by forcible inflation that the air-vesicles had simply collapsed
from absence of air. Collapse occurs most frequently in the course of
bronchitis and in cases with feeble respiratory power. The bronchial
twigs supplying certain air-vesicles, or tubes supplying sections of lung,
become occluded to such a degree that no air can enter. The air
already contained in the vesicles then becomes exhausted gradually
until the vesicles are completely airless. The vesicles or sections of
lung involved then return to the foetal condil ion. When the collapse
is congenital the term atelectasis is preferable. Anything which in-
duces great muscular weakness predisposes to collapse of the lung ;
hence, in the aged and feeble, in wasting diseases, and in low febrile
diseases of long standing, collapse is very apt to occur. But bronchitis
is the most frequent and direct cause. The secretions which are
poured out, and the swelling of the mucous membrane, occlude the
tubes, and if the patient have not strength enough to expel the secre-
tions, and by forced inspiration expand the collapsing vesicles, collapse
ensues.
Diagnosis. The diagnosis of the condition in life is difficult. The
site of collapse, being airless, is, of course, dull on percussion. The
respiratory murmur is more likely to be faint or absent than to be
increased in intensity or approach the bronchial. ^Nevertheless, there
is sometimes heard a faint bronchovesicular expiration.
"SVhen oedema is superadded to collapse, moist crepitant rales are
heard, difficult if not impossible to distinguish from those of pneumo-
nia. Respiration is embarrassed, and is accompanied by sucking-in of
the lower part of the chest in inspiration. Sometimes the plug of
mucus which occludes the tubes becomes dislodged while the physician
is auscultating, and then the respiratory murmur will be heard, accom-
panied by a succession of crepitant rales, which disappear after a few
inspirations. The dull areas, as a rule, are less persistent than those
of pneumonia ; thus it may be foimd at successive examinations that
one area has cleared up and another has become dull. Stress is laid
by some writers upon the signs of emphysema surrounding collapsed
areas. But this does not give assistance in the cases in which most
help is required — cases in which there is diffuse bronchitis with more
or less oedema.
Subjective symptoms are those of dyspnoea and insufficient oxygena-
tion of the blood. If these are developed suddenly, and are accom-
panied by the appearance of dull areas in the lung without bronchial
breathing, the diagnosis is tolerably certain ; but when scattered lob-
ules only are involved, the physical signs of collapse are absent, and
its existence must be a matter of inference.
From lobar pneumonia the diagnosis is easily made by the difference
PLATE XVIII.
FIG. 2.
Broncho- pneumonia.
Consolidation in the right upper and the left lower lobes. Physical signs
of bronchitis over both lungs.
DISEASES OF THE LUNGS AND PLEURA. 549
in the physical signs, and by the absence in pulmonary collapse of
inflammatory symptoms, by the lower temperature, and the difference
in onset.
The diagnosis from bronchopneumonia, or catarrhal pneumonia, is
beset with" greater difficulties. But here also the low temperature,
and the fact that the physical signs and the location of the dull areas
are subject to rapid changes, are of aid in diagnosis.
The Bronchi, the Alveoli, and Connective Tissue.
Bronchopneumonia, or Catarrhal Pneumonia, is a pneumonia
occurring secondarily to bronchitis, and is characterized by the devel-
opment of areas of consolidation in both lungs and the persistence of
a bronchitis of the middle-sized or smaller tubes. In proportion as
the areas of consolidation are large, the symptoms and physical signs
approach those of lobar pneumonia. It is more common in children
and in debilitated persons. It is the chief form in infants. 1. It is
frequently secondary to measles, diphtheria, scarlet fever, and per-
tussis. 2. As aspiration pneumonia, it occurs when food, septic parti-
cles, blood, or tissue enter the lungs during the loss of sensibility of
the larynx in apoplectic, ursemic, or other forms of coma, and in opera-
tions about the upper air-passages and mouth. It is a fatal complica-
tion of tracheotomy. 3. It is frequently of tuberculous origin.
Catarrhal pneumonia, except the aspiration-form, develops gradu-
ally, and it may not always be easy to mark the point at which the
bronchitis which precedes merges into pneumonia ; but as a rule there
are more or less chilliness (rarely a decided chill) and an access of
fever. There is usually greater prostration than in the lobar form, in
proportion to the amount of pneumonia present. The pulse is more
frequent and more likely to be feeble. Cough and expectoration are
marked symptoms. The sputum is tenacious and glairy, not rusty.
It contains streptococci and staphylococci in much greater numbers
than are found in ordinary bronchitis ; fatty epithelial cells, epithe-
lium, fat-globules, and diplococci.
Dyspnoea is more extreme than in lobar pneumonia. The respira-
tions are excessively rapid — 60 to 80 per minute ; cyanosis rapidly
ensues. The finger-tips become blue, the face dusky. The fever
does not rise as high as in the lobar form. At first the skin is hot
and dry ; later it becomes cold and clammy, and in the tuberculous
form sweats are common. The duration of the disease is usually much
longer than in lobar pneumonia.
The physical signs (Plate XVIII.) are those of bronchitis, with here
and there larger or -mailer areas of consolidation, over which the rales
are liner and closer set ; the percussion-note is dull, and the respiratory
murmur bronchial or bronchovesicular. An entire Lobe may be consoli-
dated. Areas of collapse and portions more or less oedematous combine
to make the more complex physical signs. While both lungs a re affected,
they are not usually so to the same extent. It is said that the apices
are more prone to involvement in this than in the lobar form ; and some
writers (Osier) look upon it almost, if not always, of tubercular origin.
550 SPECIAL DIAGNOSIS.
In the common form seen in infants the symptoms of asphyxia set
in at variable periods in the course of the disease. General cyanosis
supervenes. Stupor sets in, the hurried respirations grow shorter and
more gasping, the pulse becomes excessively rapid and feeble, the ex-
tremities cool and clammy ; with the stupor the cough abates and the
breathing becomes more shallow. The lungs fill up with fluid mucus,
and the child drowns in its own secretions, or cardiac paralysis sets in
after dilatation of the right heart.
Diagnosis. The affection is distinguished (1) by its pathological
antecedents and causal relations ; (2) its gradual onset ; (3) its distri-
bution in both lungs ; (4) the preponderance of physical signs of bron-
chitis over those of consolidation ; (5) the extreme dyspnoea and cyan-
osis with a lower temperature than in lobar pneumonia ; (6) the onset
of carbondioxide-poisoning ; (7) the long duration and gradual decline.
The tuberculous form is distinguished by (1) the history of exposure to
infection or of a focus of infection in the body, glands, or joints ; (2)
the longer course ; (3) delayed asphyxia ; (4) rapid emaciation ; (5)
diffused sweats ; (6) physical signs of consolidation and subsequently
of cavity at the apex ; and (7) absolutely by tubercle bacilli in the
expectoration coughed up or vomited. I have seen a child aged fifteen
months, of a tuberculous mother, completely recover. The tuberculous
form is common in colored infants.
Bacteriological Diagnosis. Examination of the sputum shows an
abundance of the streptococci and staphylococci and the special micro-
organism which belongs to the primary infection, as that of influenza,
diphtheria, and tuberculosis.
Lobar Pneumonia, or Croupous Pneumonia. (Plate XIX.) This
inflammatory affection of the lung may be due to one of many micro-
organisms (single infection), or it may be a mixed infection. For its
consideration, the reader is referred to the Infectious Diseases, Chapter
XX., Part I.
Chronic Interstitial Pneumonia. Cirrhosis, fibroid phthisis, and
chronic interstitial pneumonia are names given to a condition of
chronic induration of the lung, caused by interstitial overgrowth of
fibrous tissue. Obliteration of the air-vesicles and contraction of the
lung result from the overgrowth. The bronchi are frequently dilated,
and cavities and gangrene may occur. The disease is rare except as
the result of tuberculosis, but it may follow pneumonia and pleurisy, and
it is said to be caused by inhalation of fine particles of steel or cotton.
Pneumonokoniosis is the term, first employed by Zenker, for the
chronic interstitial pneumonia from the inhalation of dust.
Physical Signs. (See Plates, Bronchiectasis.) Inspection. The dis-
ease is unilateral. The chest-wall is retracted. The ribs are drawn
together, so that the interspaces are obliterated. The shoulder is drawn
over the sunken thorax. The spinal column is curved. The heart is dis-
placed. It is drawn toward the affected side. If the right lung is the seat
of disease, an impulse is seen to the right of the sternum ; if the left, the
precordial area of impulse is increased and extends upward. There is
no expansion whatever (immobility) of the affected apex or base. The
healthy lung is the seat of compensatory emphysema. (See Fig. 147.)
PLATE XIX.
FIG. 1.
FIG. 2.
Lobar Pneumonia.
Consolidation of the right lower lobe. Transmitted bronchial breathing and
signs of bronchitis over the left lung posteriorly.
DISEASES OF THE LUNGS AND PLEURA.
Fig. 147.
551
Fibroid (tuberculous) phthisis ; right apex. Heart displaced as indicated by oval.
Palpation. Inspection is confirmed. Fremitus is increased, espe-
cially at the apex. At the base, pleural thickening lessens the frem-
itus.
Percussion. The physical signs show increased density of lung
tissue, with dulness on percussion, or, over a dilated bronchus, a tym-
panitic or amphoric note.
Auscultation. The respiratory murmur is bronchial, or, over a
dilated bronchus, has a hollow sound. At the base breath-sounds are
feeble, distant, or absent. Rales are also heard.
The disease runs a very chronic course, attended by cough, and
mucopurulent and sometimes bloody expectoration, even hemorrhage ;
but there is no fever and not much loss of flesh. Dyspnoea occurs on
ascending heights only. Dilatation of the right heart is likely to
ensue, with cardiac murmurs and increased lateral dulness and increase
of dyspnoea. Death is hastened by the disease, and is often brought
on by acute pneumonia.
In pneumonokoniosis (also known as anthracosis, coal-miner's dis-
ease ; siderosis, from metallic dust ; chalicosis, from mineral dust, as
in stone-cutter's phthisis) there is a history of exposure to the irri-
tating particles for a considerable period, during which time cough
552 SPECIAL DIAGNOSIS.
develops, gradually increases, and the general health fails. Emphy-
sema simultaneously arises, causing dyspnoea. The patients wheeze,
cough in paroxysms, and expectorate sputum which contains the dust-
particles. In anthracosis it is black. On microscopical examination
the special dust-particles are often found. The symptoms of emphy-
sema and chronic bronchitis predominate. Tubercular infection may
take place late in the disease.
Pulmonary Tuberculosis. For convenience of diagnosis the specific
inflammation of the lungs caused by the bacillus tuberculosis will be
considered in this section. If a strict etiological classification were
followed, it would be considered among the infectious diseases.
Clinically, we see tuberculosis in the lungs manifesting itself in one
of the forms of acute pneumonic phthisis, acute miliary tuberculosis,
and chronic ulcerative phthisis. (See Chapter XX., Part I.)
Definition. Tuberculosis of the lungs, pulmonary phthisis, and
consumption are names applied to an infectious and mildly contagious
disease of the lungs, caused by the tubercle bacillus, appearing in an
acute and chronic form, and characterized by cough, fever, sweats,
more or less rapid emaciation, purulent expectoration containing elastic
fibres, and tubercle bacilli, and by peculiar physical signs.
Acute Pulmonary Tuberculosis, Acute Phthisis, Acute
Pneumonic Phthisis, Galloping Consumption, may be primary, or
be secondary to a localized area in the lung, causing rapid infection, or
to tubercular pleurisy, tubercular peritonitis, or to tuberculosis of some
other organ. Its onset is usually marked by cough, fever with or
without chills, dyspnoea, and sometimes haemoptysis. The fever rises
to 103° or 104°, and is of a continued type (lobar-pneumonic form),
or rapidly assumes a hectic type, accompanied by restlessness and ex-
hausting night-sweats, anorexia, and rapid emaciation. Prostration is
extreme, but the mind is at first clear and the spirits cheerful. Cough
increases, the expectoration, at first mucoid and scanty, but often tinged
with .blood, becomes more copious and mucopurulent. The bowels
may be loosened or constipated. The urine may show the diazo-
reaction.
When death takes place without more decided pulmonary symptoms
the tuberculosis has been secondary to tuberculosis elsewhere, or death
is the result of a general miliary tuberculosis.
When the acute pulmonary tuberculosis is primary, the character of
the disease is soon made clear by the early development of consolida-
tion of the lungs, usually of an apex first, rapidly followed by soften-
ing and the formation of cavities. The sputum becomes mucopuru-
lent, is frequently streaked with blood, and pure blood is often coughed
up. The sputum contains yellow elastic tissue and abundant tubercle
bacilli. The patient often presents a cachectic appearance ; emaciation
has been very rapid, and has reached an extreme degree ; there is fre-
quently a red flush about the cheek-bones, which, with the bright eyes,
contrasts strongly with the hollow cheeks and temples, and the white
wasted hands and clubbed fingers with bluish nails.
The patient's mental attitude is often peculiarly and characteristi-
cally hopeful. He expresses himself as better each day, though he is
PLATE XX.
FIG - 1-— Anterior Aspect.
FIG. 2.— Posterior Ast
'C. \t£*£,
Acute Pulmonary Tuberculosis.
Consolidation of the enti
re right upper lobe and of the left
apex.
DISEASES OF THE LUNGS AND PLEURA. 553
occasionally subject to despondency, and is sure that if he could only
gain a little strength he would soon be well.
Sometimes, especially in children, the disease is latent. The patient
suffers from weariness, the cheeks flush easily, the pulse is readily dis-
turbed, there are nocturnal fever and occasional sweats. Emaciation
proceeds very gradually, and a long time may elapse before any dis-
ease is demonstrable.
In a few cases the cerebral symptoms are so pronounced as to mask
the pulmonary, and in other cases there is actual coincident involve-
ment of the cerebral meninges.
The physical signs (Plate XX.) are those of consolidation, often with-
out conjoint pleurisy. The apex is usually first invaded. There are
diminished movement, increased fremitus, and dulness on percussion.
At first the breathing is bronchovesicular. It rapidly becomes bronchial.
At first small moist rales are detected. Later they become large and
gurgling. A pleural friction may be heard. It may be first heard above
the spine of the scapula behind, above the clavicle in front, or high up
in the axilla. The upper lobe of the right lung may be affected first,
or the anterior portion of the middle lobe. The physical signs may
be observed first in the axillary region of either side. The consoli-
dation extends to the remainder of the lung, being preceded by phys-
ical signs indicating gradual encroachment upon the air-containing
structure. The respiratory murmur is harsh, but soon becomes
bronchovesicular and then bronchial. {Lobar -pneumonic form.) As
consolidation progresses in the middle and lower portions of the affected
lung, signs of cavity or multiple cavities appear in the upper. (The
whole of a lobe may be the seat of small cavities filled with muco-
purulent or purulent fluid.) Cavernous breathing and pectoriloquy, or
the bronchial sniff of consolidation, become more pronounced. The
dull note of consolidation is relieved by a dull tympanitic or full tym-
panitic note. Xow moist rales of all degrees are heard. {Broncho-
pneumonic form.) Above they are gurgling ; below, small and large
moist rales. If the progress is not too rapid throughout the lung first
affected, signs of invasion are found in the remaining lung, usually at
a point corresponding to the primary focus in the original lung. The
apex, therefore, is first invaded in most cases. Infection of the second
may begin earlier than the signs in the first lung would lead one to
anticipate. The rapid invasion of one lung compels compensatory
emphysema of the other. The increased movement, with harsh or
puerile breathing, without change in fremitus or in pitch and tone on
percussion, masks any small consolidations.
The expectoration becomes more purulent as the disease progresses,
and may be blood-tinged. It is copious and possesses some fetor. It
is found to swarm with bacilli and to contain yellow elastic tissue.
Hemorrhage may take place. The general symptoms become more
alarming. The fever becomes of a hectic type. The patient rapidly
emaciates. Cyanosis is shown in the dusky countenance and blue
finger-tips. The exhaustion becomes extreme. Pallor, with flushed
cheeks and an anxious countenance, is seen. The sweats are profuse.
The appetite is lost. Diarrhoea may set in. Remissions may take
554 SPECIAL DIAGNOSIS.
place, even in acute cases ; for a time the fever and more aggravated
pulmonary symptoms are in abeyance. The typhoid state ensues in
some cases. Death takes place from exhaustion and heart-clot or from
meningeal tuberculosis. The duration is from two to six weeks.
Diagnosis. In the earliest stages, before the invasion of new terri-
tory is pronounced, the cases are involved in doubt. It may be con-
founded with pneumonia until the sputum is secured and bacilli are
found.
In pneumonia we have the pronounced rigor, the rapid rise of tem-
perature, the altered pulse-respiration ratio, the hot, dry skin, the sticky,
viscid sputum, containing the pneumococcus, the peculiar changes in
the urine, leucocytosis, the occurrence of herpes, the termination by
crisis, to point to the nature of the process. Emaciation is not
marked ; there are no such profuse sweats as the repeated drenchings
we see in pneumonic phthisis ; anaemia is not so pronounced. Then
cavity-formation does not take place, or at least rarely. In pneumonia
the fever is of a continued type ; in phthisis it is often intermittent
or remittent. The sputum is more purulent in acute pneumonic
phthisis. Finally, the history of exposure to infection, the primary
occurrence of tuberculosis elsewhere, the secondary occurrence of tuber-
culosis in other organs after the lung-invasion, the longer duration —
aid in determining the true affection. Inoculation of animals may be
resorted to in doubtful cases.
Acute miliary tuberculosis (pulmonary type) is attended by
high fever, rapid emaciation, hurried breathing, rapid pulse, duskiness
of face and extremities, more or less stupor, delirium, and the develop-
ment of the typhoid state, with prostration and the occurrence of pro-
fuse sweats. Intestinal symptoms, as flatulency and distention, may
be pronounced, and diarrhoea may form a prominent feature. Physical
signs are negative or are those of bronchitis. There is resonance or
hyper-resonance on percussion. The latter is not uncommon. The
onset is abrupt or may follow a period of malaise. In some instances
the tuberculous process is more advanced in some situations than in
others, giving rise to special local symptoms. Thus, recently, a patient
was admitted to the Presbyterian Hospital with stupor and moderate
delirium. He had fever, rapid pulse and breathing, and a peculiar
dry, harsh skin. There were albuminuria, casts and blood in the
urine, and it was thought he had uraemia. The temperature-range
was irregularly intermittent. The diagnosis was established later be-
cause of the development of undoubted secondary tuberculosis in
other organs. At the autopsy general tuberculosis was found, with
primary tuberculous ulceration in the bladder, the ureters, and renal
pelves.
Diagnosis. Hurried breathing and cyanosis are distinctive feat-
ures, out of all proportion to the physical signs, and, on this account,
of diagnostic significance. It must be distinguished from typhoid
fever, septicaemia or pyaemia, and malignant endocarditis. It is dis-
tinguished from typhoid fever by the absence of successive stages in
the course of the disease ; in typhoid fever the evolution of the disease
is more characteristic than its symptoms. The headache of the first
DISEASES OF THE LUNGS AND PLEURAE. 555
week finally disappearing, is noteworthy. The special range of tem-
perature, the onset, the fastigiurn, and the defervescence at definite
periods in the evolution of the disease, are of diagnostic value. Cyan-
osis is more constant and marked in tuberculosis. The skin and capil-
laries have more tone in typhoid fever than in tuberculosis, at least hi
the first two weeks. Hyperemia follows irritation in typhoid ; pallor,
with duskiness, in tuberculosis. The eruption, with its specific mode
of development, belongs to typhoid fever alone. The stools, the en-
larged spleen, the vascular tone are suggestive of typhoid fever. The
spleen enlarges earlier in the disease in typhoid fever. Bacteriological
examination may be of service. The occurrence of intestinal hemor-
rhage, pointing as it does to typhoid fever, is a welcome sign in cases
in which the diagnosis is obscure. I have never seen it in tuberculo-
sis. In typhoid fever the reflexes (knee-jerk) are never absent ; in
tuberculosis, if the meninges are involved, they are variable, present
one day, absent the next. The diazo-reaction in typhoid is of some
service, although it also occurs in tuberculosis. (See Urine.) It does
not come on until later than the fifth clay in typhoid fever. It disap-
pears at a certain time hi the involution of typhoid ; it continues in-
definitely in tuberculosis. (See Chapter XIX., Part I.)
The distinction of tuberculosis from septicaemia or pyaemia and
malignant endocarditis is often difficult. We must search for local
areas of septic or pysemic infection. The ears, the teeth, the bones,
the veins, the heart, the pelvic organs in females, the rectum, the
genito-urinary tract —must be carefully examined. Hemorrhagic in-
farcts, or metastatic abscesses, may be found which point to the origi-
nal conditions. The eye-ground may show hemorrhages. The skin
and mucous membranes may exhibit minute capillary hemorrhages or
infarcts. They are the size of a pin-head, do not disappear on press-
ure, and are not elevated. The spleen is more likely to be enlarged
in the septic affections. The respirations are not so rapid as in tuber-
culosis. Cyanosis is a distinctive feature of tuberculosis. The physi-
cal signs of endocarditis may be determined, and subsequently embo-
lism or thrombosis prove the nature of the process.
Cheonic Tuberculosis, Cheojstc Ulceeative Phthisis. Chronic
tuberculosis or phthisis is much more common than acute tuberculosis,
from which it is distinguished by its slow progress and by periods of
remission, during which the disease may be arrested temporarily or
permanently.
It may begin in a variety of ways. The most common mode of
origin is in an ordinary bronchitis with which pleurisy is occasionally
associated. Previous to this the patient may have been in good health,
but generally the health has been impaired for some time. The bron-
chitis may be simple or part of influenza, measles, whooping-cough, or
some other specific disease.
The bronchitis usually proves obstinate, and by and by there is
found at the apex of the lung a small area over which, on percussion,
there is increased resistance, with slight impairment of resonance, as
compared with the other side ; the respiratory murmur is broncho-
vesicular, sometimes jerky in rhythm, and the vocal resonance and
556 SPECIAL DIAGNOSIS.
fremitus slightly increased or unaltered. Such physical signs are met
with more frequently at the right apex than at the left, and oftener in
the suprascapular fossa than anteriorly. The next most frequent seat
is probably between the clavicle and second rib anteriorly.
The patient will be found to have lost strength, and usually some
weight. There is often a slight evening rise of temperature, and occa-
sionally nocturnal perspirations. The appetite is impaired, and ano-
rexia may exist. Cough is rarely absent, especially during the night
or on waking in the morning ; it may, however, be so slight as appar-
ently to have escaped the notice of the patient. When characteristic
it is dry and hacking. Expectoration is scanty and mucoid, but occa-
sionally it may be tinged with blood. It should be remembered that
children and old persons sometimes do not expectorate, and that, as a
rule, women are more inclined to suppress expectoration than men.
No tubercle bacilli may be found in the sputum after repeated exami-
nation ; but if examinations are continued, they will appear sooner or
later.
Instead of developing after a bronchitis, as we have just described,
it may set in suddenly under the guise of a pneumonia, more frequently
of the catarrhal form. The symptoms and physical signs do not differ
essentially from those of pneumonia, except that the expectoration is
more likely to be profuse, mucopurulent, and blood-streaked, and
bacilli are found in it ; the fever is more hectic in type, and night-
sweats are common. The consolidation is found at the apex. After
the patient convalesces from such an attack he continues weak, does
not gain flesh readily, still has a cough with expectoration, evening
fever with occasional night-sweats, and an area of consolidation usually
at an apex of the lung. Over this area, in addition to the usual signs
of consolidation (bronchial or feeble breathing, dulness, etc.), moist or
dry subcrepitant rales are heard.
In some cases fever, emaciation, and weakness progress for some
time before pulmonary symptoms arise.
In still other cases the invasion of the disease is by sudden haemop-
tysis, which is oftener copious than not. Several such hemorrhages
may occur in rapid succession, or there may be only one. Moreover,
its disappearance may not be followed, or at least not immediately, by
any farther pulmonary symptoms or physical signs ; more commonly,
however, it is followed by fever, cough, expectoration, and physical
signs of incipient consolidation, usually at the apex.
In still other, but rarer cases, the pulmonary disease is latent, being
marked by gastric or peritoneal symptoms, or by a general anaemia.
By whatever path invasion conies, the physician should be on the
lookout for it, especially in a young adult predisposed by heredity or
environment to tuberculosis. The recognition of the disease in its
early stage requires the greatest skill, which in turn is recompensed
with the highest reward, since the disease is then curable.
The further progress of a case of tuberculosis of the lungs, after con-
solidation has once become manifest, is very variable. It may be
arrested at this point permanently, cure resulting from cicatrization.
More frequently there is temporary arrest of the process ; fever lessens
PLATE XXI.
FIG. 1. — Anterior Aspect.
FIG. 2. — Posterior Aspect.
Chronic Pulmonary Tuberculosis.
Consolidation with cavity formation. Chronic pleurisy with loss of respiratory
movement of lung margins. Retraction.
DISEASES OF THE LUNGS AND PLEURJE. 557
or ceases entirely, the pulse resumes its normal rate, appetite improves,
and there is a gain in flesh and strength. Cough and expectoration
are more likely to persist than the other symptoms, but with the other
improvement they diminish in frequency and copiousness. There are
fewer rales, but the signs of consolidation are still present, though
there is no further extension of the process. Often, after a cavity has
been found, the disease is arrested, or progresses very slowly.
After a longer or shorter time, as the result of reinfection from the
old focus excited by acute bronchitis or by some depressing influence,
the tuberculosis is relighted, so to speak, and runs much the same
course, the lung being left more diseased and the general health worse
after every such attack. Nevertheless, there may be long* intervals
between such attacks, the patient in the meantime continuing in fair
health. Thus the disease may linger or recur for years, the patient
not ill enough to be confined to the house, and not well enough to
stand hard work or great exposure. Slowly, by ulceration and suppu-
ration, the lung-tissue is wasted and cavities are formed. Before there
are large cavities at an apex the base of the same lung becomes consol-
idated by the production of tuberculous material, and before one lung
is extensively diseased the apex of the opposite lung is attacked, the
process being repeated in it if the patient lives long enough. Instead
of reinfection from an old focus, new infection may take place, giving
rise to the old train of symptoms, or setting up more acute disease.
During this time the patient is liable to an attack of acute pneumonia,
pleurisy, bronchitis, or general miliary tuberculosis. He is also liable
to sudden death by hemorrhage. In a number of cases the intestines
and peritoneum become affected, and abdominal pain and diarrhoea
are superadded as symptoms.
As a rule, the patient gradually sinks. The later stages are marked
by increasing cough and dyspnoea, which are very distressing and pre-
vent sleep. Expectoration is more copious, purulent, and is raised
with increasing difficulty.
The appetite is poor and capricious, or anorexia is complete. The
heart becomes more and more feeble, the fever is hectic and accom-
panied by exhausting night-sweats, the feet and limbs swell, and acute
cramp-like pains are felt in the legs, probably caused by thrombosis of
the veins.
Emaciation is extreme, scarcely anything but skin and bone being
left. Death occurs from perforation of an intestinal or gastric ulcer,
from hemorrhage, or more commonly from exhaustion, and from
asphyxia caused by oedema of the lungs.
The physical signs (Plate XXI.) depend upon the lesions. It is often
possible to detect all stages of the tubercular process, from early consoli-
dation to large cavity, in the same patient. The signs of consolidation
have been sufficiently dwelt upon. When softening begins, the percus-
sion-note continues dull and the breathing bronchial ; but it is often
difficult to make out the quality of the breath-sounds because they are
feeble and obscured by numerous moist crackling rales and moist sub-
crepitant rales from disintegration of lung-tissue and bronchitis. After
the patient has coughed several times and expectorated, and then takes
558 SPECIAL DIAGNOSIS.
a long breath, the quality of the breathing becomes perceptible. As
the lung-tissue is further softened and removed by expectoration cavi-
ties are formed. These, if large enough and superficial, give a tym-
panitic note on percussion, and, if there is communication with a bron-
chus, a cracked-pot sound. The breath-sounds are hollow and the
rales are bubbling and gurgling, or large and mucous.
The normal vocal resonance is replaced by bronchophony and pec-
toriloquy. Tactile fremitus may or may not be increased. (See Cavi-
ties.)
But if the walls of the cavity are thick from indurated tissue, the
percussion-note will be dull and the breathing bronchial. If the tissue
composing the wall is less thick and dense, percussion produces a
wooden sort of resonance. If much normal lung-tissue intervenes, the
percussion-note will be clear.
As tuberculosis of the lungs progresses, the clavicles and ribs be-
come more and more prominent from the loss of fat, and local flatten-
ing of the chest, with impaired expansion, marks the seat of the disease.
The Diagnostic Features. The striking phenomena of tuberculosis
which are considered in the diagnosis are emaciation, anaemia, fever,
cough, dyspnoea, chest-pain, hemorrhage, the expectoration, and the
objective symptoms. Of less diagnostic value, but important as col-
lateral data, are the aspect, the occurrence of vomiting and diarrhoea,
and of symptoms of secondary tuberculosis in other organs. Age and
occupation may, to a certain extent, aid in the diagnosis.
Emaciation. This is always seen, even in acute forms of tubercu-
losis. It is rapid in the acute, slow and progressive in the chronic
forms. In the latter there may be a temporary improvement in this •
respect. It must not be confounded with muscular atrophy, and the
emaciation of carcinoma, diabetes, anorexia nervosa, and other exhaust-
ing diseases. Ancemia is always pronounced. It may be associated
with leucocytosis if there is cavity formation. The reduction of red
cells and diminution of haemoglobin are marked. Fever. This symp-
tom is always present. The temperature should be taken every two
hours for a time, to determine accurately the degree and course. It
may be intermitting, remitting, or continuous. It may be intermitting
in some acute forms, the morning fall reaching, or going below, normal.
The difference between morning and evening temperature may not be
more than a degree. In the acute form it is high and continuous, and
soon may be attended by the typhoid state. In the more chronic cases
it may be intermittent at first, then continuous, and finally intermittent
again. In the later stages the intermitting fever is due to a mixed
infection, or saprremia, from the purulent contents (staphylococcus and
streptococcus infection) of the lung cavities. 1 (See Fig. 148 and Fig.
149). The intermittent fever of the early stages has frequently been
mistaken for malaria. (See Fever.) The occurrence of fever in a
1 Leyden has pointed out that intermitting fever is part of the tuberculous process,
and not a streptococcus or staphylococcus infection, as formerly held, because pus micro-
organisms are not found in the purulent contents of cavities, and because in other
forms of tuberculosis, as empyema or joint-disease, they are notably absent, and yet
such form of fever exists. — Deutsche medicin. Wochenschnft, Sept. 14, 1894.
DISEASES OF THE LUNGS AND PLEURAE.
559
patient who has been losing flesh, and is otherwise in poor health,
excludes cancer and diabetes and other afebrile causes, and points
strongly to tuberculosis. It must not be forgotten that in chronic
tuberculosis in the aged the temperature may not rise above 100° ;
often, indeed, it is subnormal.
Fig. 148.
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Intermitting fever of tuberculosis.
We must consider, therefore, that fever, the cause of which is not
obvious, may be due to tuberculosis ; and that if, when such probable
causal conditions as gastro-intcstinal catarrh or infectious disorders
(malaria) and suppurations are eliminated, the fever still persists, then
the fever is probably of tuberculous origin.
8weats. Frequent sweating may be the first symptom complained of
by the patient. It may occur with the tripod of symptoms of the
intermitting febrile range — chill, fever, and sweat. It would be likely
to occur at night under these circumstances. It may occur at any
time, however. " Night-sweats " are alarming to the mind of the
560 SPECIAL DIAGNOSIS.
laity, and are really of diagnostic significance. The perspiration
awakens the patient at night because it is so profuse. It may be only
moderate, not rousing the patient until morning. It may be general
or local. Local sweats are confined to the head and neck. Anaemia.
This quite rapidly becomes marked. It is recognized by the color of
the surface and by an examination of the blood. When collateral
inflammation is present, leucocytosis is seen. Cough. Cough is one
of the earliest symptoms. It may be the only symptom for some time.
It is often dry and hacking at first and may continue so for a long
time. Later it is accompanied by mucoid and then mucopurulent
sputa, which contain the characteristic elements. (See Sputum.) Dysp-
noea is almost always present. The degree varies with the association
of fever. When the latter is present dyspnoea is more pronounced.
It is more pronounced in acute cases. In miliary tuberculosis the
frequency of respirations that attends the dyspnoea is out of all pro-
portion to the physical signs. In this form cyanosis is more marked.
In chronic localized phthisis the dyspnoea may only occur on exertion,
after eating, or upon excitement. The bloodless lips may have a con-
stant bluish hue. The fingers are dusky and become " clubbed." In
the later stages the dyspnoea is constant and in proportion to the extent
of involvement of the lungs and the degree of fever. Although of
diagnostic significance only when associated with other symptoms, it
is most distressing, and is the cause of constant demand for relief.
Chest-pain. This is due to localized pleurisy or to myalgia. The
latter may be seated in muscles strained by coughing. Pleuritic pains
may occur in any situation, and vary in position from time to time.
They may be due to extensive inflammation or to tuberculous pleurisy.
Constantly recurring and unilateral chest-pains, with or without signs
of pleurisy, with cough and emaciation, are significant of the disorder
under consideration. (See Pain.)
Hemorrhage. This symptom is alarming, and, in the large majority
of cases, is due to pulmonary tuberculosis. It may mark the onset of
the acute disease, and continue irregularly throughout its course or
recur several times before the advent of more common symptoms of
the chronic form. It may occur at intervals of a few months or a
year, before emaciation, cough, and characteristic expectoration set in,
or before bacilli are found in the sputum. Each attack is attended
by fever, usually, and followed by anaemia and prostration. If hemor-
rhage of the lungs (see Symptoms) occurs in a young adult without
cause (as aneurism or cardiac disease, etc.), it must be looked upon
with suspicion. The likelihood of tuberculosis is increased if the
bleeding occurs in a patient of tuberculous aspect in whom a family
history of tuberculosis is found, and who has been exposed to infec-
tion. In the aged it may occur from a localized area of disease.
Hemorrhage is also common in the late stages of tuberculosis. It is not
at this period of diagnostic value as to the primary cause. It is usually
due to the erosion of an artery in a cavity. Hemorrhage also occurs
in tuberculosis during the quiescent period. The progress of the disease
is arrested. The discharge of blood is accompanied by the expectoration
of pulmonoliths, calculi formed by the degeneration of caseous areas.
DISEASES OF THE LUNGS AND PLEURA. 561
Vomiting (see Gastro-intestinal Disease) is a symptom which is often
present in the early stages of tuberculosis of the lungs, and frequently
masks the true condition. The vomiting may lead to the belief that
a local gastric catarrh or diarrhoea is to blame for the general symp-
toms. The occurrence of fever with the gastric symptoms should lead
to an examination of the lungs.
The occurrence of diarrhoea and symptoms of tuberculosis in other
organs may thoroughly establish the diagnosis in tuberculosis of the
lungs with otherwise obscure pulmonary symptoms. The intestinal
discharges may contain tubercle bacilli, or they may be found in the
urine, in joint-suppuration or glandular enlargement.
The Sputum (q. v.). The diagnosis is absolute when tubercle bacilli
are found in the expectoration. Nummular sputa are more common
in phthisical excavation. The sputum is discharged in tough coin-
shaped masses, which sink when expectorated into a vessel containing
water. Fragments of lung-tissue (yellow elastic) point to tuberculo-
sis but are possible under other circumstances.
The Physical Signs. The aspect of the patient is always suggestive,
and is an aid to the recognition of the condition. The tuberculous or
phthisical chest, the long neck and arms, the pale face, the occasional
hectic flush, the clubbed fingers, the emaciation of the many subjects
Ave see in our infirmaries, fix in our minds a composite picture the
recognition of which goes far to diagnosticate the insidious disease.
The objective signs point to an invasion of air-containing structure
by solid material, with collapse of lobules, leading to consolidation,
followed by cavity-formation, and in both stages by the occurrence of
pleurisy. Local contraction (flattening) and impaired movement at an
apex, with inspiratory depression above the clavicles, with suppressed
breath-sounds and prolonged expiration, with impaired resonance, are
the earliest signs of tuberculosis. In the chronic cases, contraction,
impaired movement, dulness and increased resistance from thickened
pleura may override the signs of consolidation. No one physical sign
is of diagnostic significance. The combination of signs, and the orderly
procession by which they advance as the physical conditions progress,
are the most diagnostic.
The Size of the Lung. In the diagnosis of pulmonary tuberculosis
the physical examination must be directed to a determination of the
size of the lung, and of the extent of its expansion, by which we judge
of the amount of air entering the lung, as well as to the presence of
consolidation.
The tuberculosis process is associated with diminution in the bulk
of the lung usually. We can estimate the size and the degree of ex-
pansion by inspection, palpation, and percussion. The so-called dia-
phragm-phenomena is studied and the X-rays employed. Any dimi-
nution in the excursion in the shadow of the diaphragm is evidence of
diminished bulk of the lung or of diminished expansion. By palpa-
tion, with mensuration, measurements are taken. By percussion we
estimate the lung boundaries. The degree of expansion can be deter-
mined by securing the limits of liver dulness and cardiac and splenic
dulness in ordinary breathing, and then at the end of full inspiration
36
562 SPECIAL DIAGNOSIS.
and expiration. Valuable information is thus secured. Of course,
employing inspection and palpation the two sides of the lung must be
compared. Percussion enables one to determine fairly early the pres-
ence of consolidation. In thin subjects the change in the note is more
readily elicited than in fat or muscular subjects.
On auscultation in the early stage of tuberculosis roughness of
respiratory murmur with prolonged expiration, feeble respiratory mur-
mur, and jerking or cog-wheel respiration are common signs. These
signs change gradually into bronchovesicular and then bronchial types
of breathing. Crackling rales or clicking sounds and consonatiug rales
attending these modifications of breath-sounds are of the greatest diag-
nostic importance. They must be brought out frequently by cough
and then full inspiration.
The Site of the Lesion. The situation of the physical signs is diag-
nostic. Percussion should be directed especially over those parts of
the lung in which an infection is liable to occur, as the clavicular and
subclavicular spaces, the anterior border of the upper lobe, the tongue-
like part of the left upper lobe, which overlaps the heart, the supra-
spinous space, the upper interscapular region, and the upper borders
of the lower lobes posteriorly. The latter is best secured by having
the patient place the hand of the arm of the side percussed on the
shoulder of the opposite side. The scapula is thus removed from the
surface of the lung to be examined.
It is necessary also to consider carefully the general conditions.
We inquire the age, adolescence and early adult life being the common
periods in which pulmonary tuberculosis develops. The occupation, 1
the history of exposure to the disease, the history of predisposition to
tuberculosis in the family, the history of previous, now arrested, tuber-
culosis, as in joint-disease, or glandular tuberculosis (scrofula), are
data deserving special consideration, as they may furnish corroborative
evidence of the presence of the disease.
Diagnosis. The presence of tuberculosis is presumed upon in a
patient with pulmonary symptoms — as a hereditary predisposition,
abnormalities in the form of the chest and imperfect development, or
hypoplasia of the circulatory organs. If the patient is under weight
and has a poor appetite, and at the same time is undergoing unusual
strain or anxiety, the possibility of tuberculosis is increased. Often,
before the physical signs of tuberculosis can be established, the shrewd
physician will fear recurrence of tuberculosis if there are signs of
anaemia, progressive loss of weight, slight fever, disturbed digestion, a
frequent pulse, and persistent and localized bronchial catarrh. The
examination of the lungs, the examination of the sputa, and the tuber-
culin test must be employed as soon and as often as practicable. (See
Diagnosis of Tuberculosis, Chapter XX., Part I.)
The diagnosis is established by finding tubercle bacilli in the sputum.
Their absence, in spite of the most careful search, is against the tuber-
1 Several undoubted instances are recorded in which hospital residents and young
physicians working in laboratories in which tuberculosis is studied, or constantly ex-
amining sputum, have been infected in the course of their studies.
DISEASES OF THE LUNGS AND PLEUEJE. 563
culous origin of the disease. (See Diagnosis of Tuberculosis, Chapter
XX., Part I.)
In subsequent chapters the differential diagnosis of tuberculosis and
other diseases will be pointed out. It must not be forgotten that the
disease may set in as the terminal affection in many diseases. Tims,
in diabetes, in insanity, in chronic cerebral or spinal disease, and in
other affections, tuberculosis may develop insidiously, and finally cause
death.
It must be distinguished from chronic gastric disorders, and partic-
ularly anorexia nervosa. It must not be confounded with malaria.
It must be distinguished from simple anaemia, the cause of which may
be recognized with difficulty. It must be distinguished from chronic
bronchitis with bronchiectasis, from pulmonary gangrene and carci-
noma. Finally, it must not be mistaken for cancer of the oesophagus
and aneurism of the aorta, two divergent conditions which may have
pulmonary symptoms simulating phthisis.
Gangrene of the Lung. Gangrene is a rare disease of the lung,
and, like abscess, always secondary. It may be produced by any cause
which so obstructs the circulation that a portion of the lung dies in
bulk. The gangrene may be circumscribed or diffused ; it results
most frequently from pneumonia, but may be due to injury, to a gen-
eral septic condition, or to embolism. It is rather frequently met with
in the insane, possibly owing to particles of food which have found
their way into the lung. Aspiration bronchopneumonia, bronchiectatic
and tuberculous cavities, sometimes lead to gangrene. Gangrene in
the lung, as elsewhere, occurs in diabetes.
Symptoms. When it occurs in the insane, or is of embolic origin,
it may remain latent, and in septicaemia it may be overlooked, on
account of the general symptoms. In well-marked cases, however,
the symptoms are characteristic. Symptoms and physical signs of
pulmonary disease precede the specific symptoms of gangrene. With
the onset of a moderate fever haemoptysis may occur at once or be
preceded by the expectoration of a brownish, purulent sputa having a
most intense and persistent gangrenous odor. It contains fragments
of lung-tissue, altered blood, and putrid debris. (See Sputum.) It
separates into the three characteristic layers in a conical glass. The
fetor of the breath and the characteristic sputum is diagnostic.
The disease usually occupies the lower or middle lobe of the lung.
The physical signs are those of cavity. The disease could with diffi-
culty be distinguished from abscess were it not for the characteristic
sputum, though in gangrene there is greater tendency to a general
septic condition, with profuse sweats and collapse.
Abscess of the Lung. Abscess of the lung may originate in causes
outside the lung, or in causes within the lung. To the former class
belong those produced by suppurating bronchial glands, abscess of the
mediastinum opening into the lung, cancer of the oesophagus with
ulceration, and abscess of the liver, suppurating hydatid cyst, or sub-
diaphragmatic abscess in general, bursting into the lung. Intra-pul-
monary causes are tubercle, septic emboli, in which case the abscesses
are multiple and subpleural, and pneumonia. In the aspiration form
564 SPECIAL DIAGNOSIS.
of lobular pneumonia abscesses occur. Rarer causes are the presence
of tumors and obstruction of the bronchi.
Abscess of the lung is therefore always secondary. Its diagnosis
depends upon the demonstration of a consolidation in which a cavity
subsequently forms, taken in connection with the history pointing to a
definite cause. The sputa are copious, purulent, often odorless, some-
times offensive, but always without the fetor of gangrene. They
contain elastic fibre, but no bacilli except in tuberculous cases. (See
Sputum.) In embolic abscess the signs of pleural friction can only be
detected at times. Of course, the constitutional symptoms of suppura-
tion are present.
The Degenerations.
Emphysema. Emphysema consists in an " excessive, permanent,
and unnatural distention of the air-cells," or in " extravasation of air
into the interlobular or subpleural cellular tissue." (Lsennec.)
Emphysema may be unilateral or bilateral. Local and unilateral
forms are usually compensatory. Bilateral emphysema may be hyper-
trophic or atrophic.
It is more common in men than in women. Its symptoms are more
common in childhood and after middle age. Two factors are essential
in its causation. First, defective development of the elastic tissue of
the lungs. Second, increased intra-alveolar air-pressure. The latter
is due to a number of causes. In childhood, no doubt, nasal and naso-
pharyngeal obstructions are operative. In adults occupations which
necessitate continuous and severe muscular effort, especially if coupled
with forced expiration with closed glottis, act as causes. Such occupa-
tions are blacksmithing and playing upon wind instruments. Diseases
which cause much coughing or respiratory effort, such as chronic bron-
chitis and whooping-cough, act in the same manner. Chronic mitral
valvular disease and the lessened elasticity of the lung-tissue of ad-
vancing age both favor congestion of the lung, and thereby predispose
to emphysema. The disease is hereditary ; several members of a
family are affected. It occurs in many in childhood, is in abeyance
in adult life, and reappears in old age.
Symptoms. The prominent symptoms in hypertrophic emphysema
are dyspnoea, cyanosis, and cough, with expectoration from associated
bronchitis. There is no fever. The dyspnoea is in proportion to the
degree of emphysema, and is aggravated by the coexistence of bron-
chitis, asthma, and eccentric hypertrophy of the right ventricle, which
are very frequent complications in cases of long standing. When
the degree of emphysema is only moderate, dyspnoea is not complained
of except upon climbing or walking briskly, or after a hearty meal.
But when the degree of emphysema is great, dyspnoea is constant ; it
interferes with all exertion, frequently necessitates orthopnoea, and
prevents continuous speech, so that patients speak in broken sentences
or syllables.
Cyanosis is marked. The livid lip is common in the asylums for
old men. The face is of a dingy pale color, but becomes bluish on
exertion. The extremities are also dusky, and the blueness is general
PLATE XXII.
FIG. 1. — Anterior Aspect.
FIG. 2. — Posterior Aspect.
Emphyzema.
Hyperresonanee. Enlargement of lungs and diminished respiratory movement
of margins. Diminished fremitus. Signs of bronchitis.
DISEASES OF THE LUNGS AND PLEURJE. 565
in severe cases. This cyanosis, the round shoulders, and the drawn,
chronically anxious expression, if I may so term it, make it easy to
pick out the emphysematous subjects in a ward of chronic cases.
Respiration is not accelerated, and may be diminished in frequency.
It is often accompanied by wheezing when chronic bronchitis coexists.
The cough varies greatly in frequency ; it may be altogether absent,
since its presence simply indicates an associated bronchitis. This bron-
chitis may for years be present only in the winter. In children it may
be associated with asthma. It may arise on changes of the weather ;
finally it becomes chronic. The expectoration is that of chronic bron-
chitis (q. v.). It is rarely stained with blood.
Physical Signs. (Plate XXII. ). The physical signs of emphysema
depend upon its degree and upon whether it is complicated with
chronic bronchitis or not.
Inspection: In well-marked cases the chest is barrel-shaped (see
under Inspection). There is little movement of the chest in respi-
ration, because the lung is already in a condition of full inspiration
(expiratory dyspnoea). Vocal fremitus and resonance are usually dimin-
ished. Percussion : The percussion-note is abnormally clear, and may
even be tympanitic. Hyper-resonance is typical of the disease. When the
distention is extreme the note may be woodeny. The lungs are enlarged.
The heart-dulness becomes obliterated by the overlapping lung. The
upper margin of the liver falls one or two interspaces below the normal.
The resonance extends higher above the clavicles than normal.
On auscultation the inspiration is found to be distant and feebler
than normal, while the expiration is prolonged, and may become three
or four times the length of the inspiration. Grazing or rubbing
sounds have been described and attributed to the friction of distended
vesicles against the pleura. Other adventitious sounds are due to an
associated bronchitis, pleurisy, or tuberculosis. But bronchitis is such
a common accompaniment of emphysema that the rales of the former
become almost symptomatic of the latter. Their character in emphy-
sema does not differ from that in chronic bronchitis (q. v.).
The Heart. The apex-beat is absent. There is epigastric pulsation
or systolic shock. The normal area of heart-dulness is encroached
upon by the distended lung, and the heart itself is pushed to the right,
the apex-beat being frequently at the xiphoid cartilage. If the em-
physema attain a very high degree, there may be no perceptible dulness,
except on very strong percussion over the cardiac region. The heart-
sounds appear feebler and more distant than normal. The right ven-
tricle becomes dilated and hypertrophied, as the result of the pulmo-
nary congestion produced by emphysema. The pulmonary second
sound is accentuated. A tricuspid regurgitant murmur may be heard.
Venous congestions are common in the later stages. Albuminuria is
common. QEdema of the feet and limbs may occur, but general ana-
sarca is rare.
The general health suffers by loss of strength and capacity for
physical and mental work, rather than by loss of flesh . The patients
are large-chested, stoop-shouldered, and short-breathed, and have an
anxious expression of countenance.
566 SPECIAL DIAGNOSIS.
Diagnosis. This is based upon the history (heredity, occupation,
long duration), the occurrence of dyspnoea and cyanosis, and of winter
cough or chronic, bronchitis, and upon the physical signs.
Emphysema can be distinguished from pleural effusion and from
aneurism, which may cause dyspnoea, by the universal hyper-resonance
ou percussion. Pleural effusion, which also causes bulging, is usually
unilateral, and the percussion-note is flat. The area of dulness of the
heart and aorta is diminished in emphysema,
Pneumothorax, which most resembles emphysema in its physical
signs, develops suddenly, affects one side, and has a hollow, tympan-
itic note on percussion. The succussion-splash, metallic tinkling, and
coin-test have no counterpart in emphysema ; moreover, the antecedent
history and mode of development are different.
Atrophic emphysema is due to the degeneration of age. The lung is
reduced in size. The diameters of the chest are lessened. The ribs
are oblique. There is atrophy of the chest-muscles. The patients
have dyspnoea, There are other signs of senility.
In interlobular emphysema the physical signs are the same as those
of vesicular emphysema, but it develops suddenly and is liable to be
followed by emphysema (intercellular) of the neck, which on palpation
gives a peculiar crepitation. The friction-sound and crackling which
have been described as occasional adventitious sounds in vesicular
emphysema are more commonly heard in the interlobular form.
It is caused by rapture of the air-cells, and hence occurs in diseases
in which a great strain is put upon them — especially, therefore, in
whooping-cough, but also occasionally in pulmonary hemorrhage and
pneumonia ; violent coughing and laughing, and great straining, as in
child-labor, are capable of producing it.
Bronchiectasis. Dilatation of the bronchi occurs secondarily to
affections which tend to weaken the walls of the tubes and to lessen
their elasticity. Hence, it is found in chronic bronchitis with emphy-
sema, in chronic phthisis, in catarrhal pneumonia in children, in
chronic obstruction from external pressure or foreign bodies. (See Ob-
structions.) It also occurs when the lungs contract in fibroid pneu-
monia, or in pleural thickening. It occurs in two principal forms :
the simple, in which the affected tubes are uniformly dilated ; and the
saccular, in which larger or smaller pouches are formed. It is com-
moner in males than in females, and probably begins most frequently
in adult or middle life. One lung only is affected in about one-half
the cases, and when both lungs are affected (chronic bronchitis and
emphysema) it is not often to the same degree.
The subjective symptoms consist of cough, expectoration, and a
variable amount of dyspnoea. Eventually there may be some loss of
flesh and strength.
The cough is usually paroxysmal. It may occur only in the morn-
ing after the dilated tube fills. It may follow change in position. A
paroxysm is followed by copious expectoration, sometimes amounting
to a pint and a half in twenty-four hours. It is grayish-brown and
mucopurulent, faintly or extremely fetid. The sputa contain mucus,
pus, casts of the tubules, and various salts. Charcot-Leyden and fatty
PLATE XXIII.
FIG. 1. — Anterior Aspect.
FIG. 2. — Posterior Aspect.
Bronchiectasis.
Chronic pleurisy with, induration of the right lower lobe and bronchiectasis.
Vicarious emphyzema of the left lung. Bronchitis.
DISEASES OF THE LUNGS AND PLEURjE. 567
crystals, vibrios, leptothrix, and bacteria (Fox) can be found on micro-
scopical examination. Elastic fibres are found only if the tubes are
ulcerated. In a conical glass the sputum separates into three layers —
a frothy brown top, a thin mucoid layer in the middle, and a granular
layer below. Hemorrhage is rare, but may occur even when tubercu-
losis is absent.
Dyspnoea is not usually severe, except when the dilatation is compli-
cated by disease of the heart or lungs, or during an acute attack of
bronchitis.
Physical Signs. (Plate XXIII.) The physical signs differ according
ti> the extent and variety of the dilatation. In simple dilatation there
may be nothing different from the signs found in chronic bronchitis,
except a tendency to more bronchial respiration, with rales having a
metallic quality. Percussion will vary according to the degree of altera-
tion of the lung-tissue surrounding the affected bronchi, and according
to the extent of the dilatation and its proximity to the surface. In the
simple forms the percussion-note, if altered, is somewhat less resonant
and higher in pitch, whereas in saccular dilatations, favorably situated
for percussion, the note is tympanitic if the pouch is empty. On aus-
cultation in simple dilatation the breathing approaches the bronchial,
and is accompanied by bronchial rales. In saccular dilatation the
sounds are practically those of a cavity, respiration varying from bron-
chial to amphoric. Vocal resonance and tactile fremitus are usually
both increased, but the latter may be diminished.
Diagnosis. The diagnosis of simple dilatation from chronic bron-
chitis may be impossible, but copious and fetid expectoration indicates
the former. The diagnosis of the saccular form from tuberculosis of
the lung with cavity is difficult. Wilson Fox says the severe cases
are usually associated with consolidation of the lung or with tubercle ;
but even without the presence of the latter they often present phthisi-
cal symptoms — retraction of the chest, with the physical signs of exca-
vation, pains in the side, haemoptysis, pyrexia, nocturnal perspiration,
and diarrhoea — which may all coexist with only an induration of the
lung and dilatation of the bronchi. The diagnosis must be made by
noting the persistency of the physical signs, which change but little
and are not progressive as are those of tuberculosis ; the protracted
course of the disease ;• the character of the sputum ; and the compara-
tively slight impairment of the general health.
The Morbid Growths.
Cancer and Other New Growths of the Lung. The new growths
may be primary or secondary. The latter arc most common. Of
primary cancer, the epithelioma is most common ; encephaloid and
scirrhus come next. Sarcoma is sometimes primary. Secondary new
growths succeed disease in the abdominal organs, the genito-urinary
tract, the bones, the breast, and the eye.
Symptoms. The general symptoms of malignant growths accom-
pany the thoracic symptoms. Chest-pain, dyspnoea, cough, and a
peculiar expectoration belong to the latter. The pain is due to asso-
568 SPECIAL DIAGNOSIS.
ciate pleurisy ; the dyspnoea is paroxysmal. (See Dyspnoea from Press-
ure on Bronchi.) The expectoration is dark, like prune-juice. Signs
of intrathoracic pressure are seen. The external thoracic veins are
enlarged. The face and arms may be cyanosed, or one arm only may
be affected. The heart may be dislocated, the trachea changed in its
course ; compression of trachea and bronchus causes dyspnoea.
Physical Signs. In primary cancer the affection is unilateral ; in
secondary forms, bilateral. The physical signs are those of pleural
effusion or of local consolidation. The consolidation may be massive
and not partake of the shape of a lobe. Often signs of effusion and
consolidation are combined (enlargement, immobility, absent fremitus,
but bronchial breathing). In the secondary forms the disease is bilat-
eral. The signs are mixed. They indicate diminished air in the lung
structure. Care must be taken not to overlook the pleural effusion
which accompanies the process, the removal of which gives temporary
relief. In both forms external lymphatic glands, particularly the
cervical, may be enlarged.
Diagnosis. The diagnosis is based upon : (1) The age (after forty) ;
(2) the occurrence of emaciation ; (3) the duration of the disease, often
rapid, rarely beyond eight months ; (4) the presence of primary disease
elsewhere ; (5) the presence of moderate fever ; (6) the signs oi intra-
thoracic pressure ; (7) the involvement of lymphatic glands ; (8) the
occurrence of irregular areas of consolidation and of pleural effusion,
alone or combined ; (9) the characteristic expectoration ; (10) dyspnoea
due to pressure on the bronchus or trachea ; (11) the absence of bacilli
from the sputum.
An effusion can often be recognized only after puncture. Hemo-
thorax is not necessarily present.
Gross Parasites.
Hydatid Disease of the Lungs. The lungs are affected in about
11 per cent, of the cases of hydatid disease. The symptoms, according
to Wilson Fox, consist of dyspnoea, pain hi the chest, cough, occasional
haemoptysis, and sometimes the expectoration of hydatids, the sputa
being otherwise bronchitic, or presenting the characteristics of pneu-
monia or gangrene when these complications are present. Gradually
weakness increases, sometimes with pyrexia, which, when combined
with emaciation, may impart to the case a considerable resemblance to
phthisis ; pressure-symptoms occasionally occur, and the physical signs
are either of consolidation of the lung or of pleural effusion, together
with certain peculiarities depending on the size and site of the tumor.
Graham states that they are more frequent in the right lung and more
common at the base, causing marked bulging of the thoracic wall.
When the physical signs are those of pleural effusion, localization of
the fluid to a definite area takes place, and hence is not related to the
shape of the pleural cavity. The breathing may be tubular ; there is
condensed lung between the hydatid and the thoracic wall. The symp-
toms present — cough, dyspnoea, anaemia, emaciation, and clubbing of
fingers — too often lead to the diagnosis of phthisis. Hsemoptvsi>
DISEASES OF THE LUNGS AND PLEURA. 569
occurs in many cases. The temperature is normal — an important
point in diagnosis. If the cyst ruptures, the sputum is diagnostic.
Complications often mask the diagnosis. It must be distinguished
from pleurisy, localized empyema, pulmonary abscess, phthisis, actino-
mycosis, and mediastinal tumors.
Diseases of the Pleura.
The large lymph-structures which coyer the lung and line the inside
of the thorax are often the seat of disease. It is usually of an inflamma-
tory nature. Hence, pleurisy, or pleuritis, is the most common affec-
tion of the pleura. It may be, as to distribution, bilateral or unilateral ;
as to extent, local or general ; as to the nature of the inflammation,
plastic, serous, or purulent. The inflammation may be acute or chronic.
It is rarely primary. It arises in the course of general disease, or is
the result of the extension of inflammation, chiefly of an infectious
nature, from neighboring structures.
1. Disease of the ribs or vertebrae, diseases of the mediastinum, of
the aorta, oesophagus, and especially of the lung, give rise to various
forms of pleurisy, depending upon the nature of the primary affection.
2. Diseases below the diaphragm. Abscess of the liver ; perfora-
tive inflammation of other viscera adjacent to the diaphragm • abscess
of the spleen or pancreas ; pus in the pelvis or about the appendix,
may give rise to purulent pleurisy by the pus burrowing upward or
by infection through the lymph-channels.
3. Disease of the lungs. In the large majority of cases pleurisy in
some form occurs in the course of pulmonary disease. In all surface
inflammations of the lungs there is associate pleurisy. It is seen in
pneumonia, in tuberculosis, in gangrene, and in abscess.
Pleurisy may be simple or purulent. Empyema is always due to
infection from the exterior, as the ribs ; from the lungs (pneumonia) :
suppuration below the diaphragm ; or to general infective processes,
as septicaemia, pyaemia, and tuberculosis.
The general diseases in the course of which pleuritis arises are
usually infective, or of such nature as to cause irritating products to
circulate in the blood. Of the former, the most common is tuberculo-
sis ; the next most common are septicaemia and scarlatina ; Avhile to the
latter class belong Bright' s disease, gout, diabetes, rheumatism, and
scurvy. Purulent pleurisy is more common in children than in adults ;
in males than in females ; and more common in tuberculous pleurisy
and pyaemia than in rheumatism and Bright's disease.
Acute Pleurisy. Acute pleurisy may be primary, or may be sec-
ondary to disease of the lung, or be part of a general infection. Three
stages in the morbid processes usually occur, although it may be
arrested in the first stage.
8ymptoms of the First Stage. Dry Pleurisy. The onset of the dis-
ease is usually abrupt, and is marked by fever, which may or may not
be preceded by chill, and is followed by pain in the side, dyspnoea,
and eough. The pain is sharp, stabbing, or tearing in character, and
is usually, but not always, referred to the seat of pleurisy. This is
570 SPECIAL DIAGNOSIS.
mast frequently on a level with the nipple, or a little below this, and
more often anteriorly or in the axilla than posteriorly. The pain is
caused by the rubbing together of the inflamed surfaces of the pleura,
and hence' is excited by respiration and cough. For this reason the
patient is inclined to restrict the motion of the affected side as much
as possible ; he does this by leaning over toward that side and by
pressing his elboAV in against the chest-wall. Pain is usually the first
symptom noticed by the patient. The cough is dry and painful.
Fever is moderate.
Physical Signs. The physical signs in primary cases are a friction-
sound heard on inspiration and expiration. This friction-sound may
be a nest of fine, dry, crepitant rales, which are very superficial, and
appear to be just under the ear ; or a coarse rubbing sound, heard over
a larger surface, and resembling a bronchial rhoncus, from which it can
be distinguished by its persistence after the patient has coughed. The
lungs themselves present nothing abnormal.
If the inflamed surfaces ' become glued together by plastic lymph,
recovery usually occurs very soon, though pain often persists for a
long time in lessened degree, and the pleurisy is liable to be re-
lighted.
Symptoms of Second Stage, or Stage of Effusion. If effusion takes
place, the two layers of the pleura become separated ; hence, . pain and
friction-sound cease, and physical exploration shows that a collection
of fluid intervenes between the chest-wall and the lung.
The physical signs (Plates XXIV. and XXV.) of this stage are
(1) enlargement of the affected side, increase in semi-circumference,
with fulness of interspaces ; (2) diminution of movement ; (3) absence
of vocal fremitus and resonance ; (4) dulness or flatness (deadness) on
percussion, with great increase in the resistance to the pleximeter
finger ; (5) absent or greatly diminished respiratory murmur ; (6) dis-
placement of organs.
The dead percussion-note being caused by fluid, it follows that its
upper level will change with the position of the patient if the fluid is
free. If the upper level is at the third interspace when the patient is
sitting up, it will fall to the fourth or lower when he is lying down.
This change of level cannot be appreciated when the effusion is very
large. Moreover, above the line of dulness the percussion-note is hyper-
resonant or tympanitic — Skoda's resonance. Toward the spine on the
affected side there may be partial resonance and bronchial breathing,
because here the lung is compressed against the vertebrae. In large
effusions the tympanitic resonance in the second interspace does not
change when the mouth is opened — that is, " Williams 5 tracheal tone "
can often be elicited. The upper limit of dulness in large pleural
effusions is higher at the spine and slopes downward, and is lowest in
front. This parabolic line is only obtained when the patient is in the
erect posture. In moderate effusions the line of dulness is lowest near
the spinal column, rises in the middle of the scapula and slopes down-
ward, assuming the shape of the letter S as it passes toward the front
(Garland). The patient should take deep breaths before the percus-
sion is performed. At the left base in front the semilunar space is
PLATE XXIV.
FIG. 1. — Anterior Aspect.
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Pleurisy with Effusion (right-sided).
PLATE XXV.
FIG. 1. — Anterior Aspect.
:
FIG. 2. — Posterior Aspect.
V
Pleurisy with Effusion (left-sided).
DISEASES OF THE LUNGS AND PLEURA.
571
obliterated, dullness continuing to the margin of the ribs. In small
effusions the dulness may be limited by the posterior axillary line,
resonance being present in the lateral and anterior regions.
On auscultation below the upper level of the effusion posteriorly the
voice frequently has a metallic quality resembling the bleating of a
g 0a t — cegophony. It occurs usually when the effusion is moderate,
and may be heard only over a limited area. It is commonly heard at
or above the angle of the scapula. Bronchophony may be heard when
tubular breathing is present.
While the respiratory murmur is, as a rule, absent, breath-sounds
may be heard, and are then weak and distant, or bronchial. In such
cases there may or may not be adhesions. Bronchial breathing may
be present along the spine in small effusions, and in large effusions in
the interscapular region. Bronchial breathing, tubular in character,
is said to be almost constant in children. It may also occur when
pneumonia coexists. In one of the cases in my ward the signs were
like those of a large cavity at the right base, but the immobility, the
absent fremitus, the enlargement, and the exploratory puncture dis-
proved its presence.
At the level of the fluid a friction-sound may persist. Above the
level of fluid anteriorly the breath-sound may be bronchial or broncho-
vesicular, associated sometimes with fine rales, due to compression and
slight cedenia.
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Displacement of Organs. If the effusion is on the left side, the
mediastinum and heart become displaced to the right, and the apex-
beat may be found in the epigastrium, or even to the right of it. The
occurrence of displacement of the heart must also be judged by the
position of maximum intensity of the heart-sounds, as the heart may
be behind the sternum. At the same time the semilunar space (Traube's
line) is lower than usual or entirely effaced. On the left side inaction
of the diaphragm maybe observed, and the tissues at the costal margin
fall in with each inspiration. If the effusion is on the right side, the
572 SPECIAL DIAGNOSIS.
diaphragm, and with it the liver, is depressed, and the mediastinal
contents are moved to the left.
The subjective symptoms during this stage are slight or moderate
fever, sometimes intermittent in character, with recurring chills ; con-
siderable dyspnoea, occasionally amounting to orthopncea when the
effusion is very extensive ; and dry cough, which adds greatly to the
dyspnoea. There is frequently some evidence of insufficient oxygena-
tion of the blood ; when this amounts to cyanosis, the condition is one
of great danger. The urine presents changes in amount. In ad-
vancing effusion the amount lessens very much ; it increases in amount
with the decline of the fluid. Pleurisy may be complicated with bron-
chitis, pneumonia, and pericarditis.
Empyema. The above-mentioned physical signs apply chiefly to
serous effusions. They are also present in effusions of pus. Other
physical phenomena, however, and different general symptoms distin-
guish the two kinds of effusions, although it must be confessed that
aspiration must often be resorted to before a positive diagnosis can be
made.
Physical Signs. The physical signs of empyema are the same as
those of other effusions within the pleura. In addition, especially in
children, local oedema of the chest-wall may be found. Another sign
was pointed out by Bacelli, and is held by others to be of diagnostic
significance. In purulent effusions the fremitus produced by the whis-
pering voice is not transmitted to the hand laid over the effusion,
whereas in serous effusions such vibrations are transmitted. In locu-
lated empyema the diagnosis is very difficult. In one of my cases
dulness continuous with that of the heart extended to the second rib
and laterally to the post-axillary line. The dulness occupied three
interspaces. Additional physical signs were immobility, prominence
of interspaces, localized above the heart, absent fremitus and resonance.
There were no breath-sounds, but an abundance of rales, apparently
very superficial. The rales complicated the physical signs. Martin
operated for me and removed two ounces of pus from a small abscess
above the heart and between the lobes.
In empyema a local area may become more prominent and the sur-
face assume an inflammatory appearance. It is an indication of dis-
charge of the abscess through the chest-wall. It is usually found in
the fifth interspace in front, or below the angle of the scapula, behind
— empyema necessitatis. (For a microscopical and chemical description
of the " Effusion within the Pleural Sac," and of the morphological
elements of the purulent effusions, see Chapter XXL, Part I.)
General Symptoms. The general symptoms are more marked hi
empyema than in simple serous effusion. The temperature is higher
from the onset. It soon becomes intermittent or remittent. Chills
or chilliness may attend the beginning of each febrile paroxysm, and
sweats occur with the daily fall of temperature, or at irregular periods
during the twenty-four hours. The heart's actum is more rapid and
the pulse more feeble, soon becoming dicrotic. Examination of the
wrine may aid in the distinction of the two forms of the effusion.
Albumosuria occurs in purulent pleurisy. It must be remembered
DISEASES OF THE LUNGS AND PLEURAE.
573
that albumosuria occurs in suppuration from other causes. Thus, in
phthisis with suppuration of a cavity pleural effusion may develop.
The albumosuria that attends the primary process must not be mis-
taken for that which occurs in empyema. Indiean is also present in
excess in the urine in suppurations. Before a decisive conclusion is
arrived at two or more examinations of the urine should be made.
Examination of the blood may aid in arriving at a conclusion. In
purulent effusion there is usually leucocytosis.
Fig. 151.
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Empyema following pneumonia. (Fever absent from seventh to fourteenth day.)
Notwithstanding the positive physical signs of effusion the character
of the effusion may not be recognized until perforation into the bron-
chus has taken place. The peculiar character of the expectoration that
attends this accident is described in the section on Sputum.
Hydrothorax. This is an accumulation resulting from a transuda-
tion. (For character of the fluid, see Chapter XXL, Part I.) It
occurs in the course of diseases which produce anasarca, as failing
organic heart disease, chronic Bright's disease, and debilitating diseases,
as -curvy. Locally, it may attend carcinoma of the pleura or obstruc-
tive disease of vessels within the mediastinum.
The physical signs of hydrothorax are those of effusion in acute
pleurisy. The general symptoms belong to the primary disorder.
Dyspnoea may develop gradually and even amount to orthopnoea.
It is distinguished from inflammatory effusions by the character of the
fluid, by the absence of the general symptoms of inflammation, by its
insidious development, and by its bilateral distribution.
Hemothorax. The transudation of blood into the cavity of the
pleura occurs rarely from the rupture of an aneurism into the sac.
The fluid is then pure blood. Serous effusions in which a large amount
of blood is found point to primary carcinoma of the pleura, or to tuber-
culous disease. Both specific processes of this serous membrane may
occur, however, without the transudation of sero-bloody fluid.
Thickened Pleura. Chronic inflammation, with thickening of the
574 SPECIAL DIAGNOSIS.
pleura from excessive development of connective tissue, occurs in
tuberculosis and in cases of combined pleuritis and peritonitis. The
thickening of the pleura is usually more marked at the base.
The physical signs (Plate XXVI.) are pronounced, and are those
of effusion, but without enlargement of the chest. There are marked
contraction and diminution in movement of the affected side. The
fremitus is absent. There is dulness on percussion, or even flatness.
The breath-sounds are distant or are absent. Along the vertebra?,
especially opposite the angle of the scapula, bronchial breathing may
be heard. The subjective symptoms of cough and dyspnoea are pres-
ent. The degree of cough * depends upon the condition of the lung.
If there is bronchitis or tuberculosis, the cough is excessive. The
amount of dyspnoea depends upon the degree of compression of the
lung by the thickened pleura.
Tuberculous Pleurisy. 1 The affection may be acute or chronic.
It may occur primarily, be a part of general tuberculous infection, or
occur "secondarily to disease of the lungs. It may give rise to all forms
of the inflammatory process : First, dry pleurisy ; second, pleurisy
with effusion ; third, pleurisy with great thickening. Often the dis-
tinction between tuberculous pleurisy and pleurisy due to other causes
cannot be determined positively. If it is associated with tuberculosis
in other organs, or the patient is of tuberculous habit and exposed to
infection, or if there has been a history of previous tuberculosis, the
pleuritic infection is probably of tuberculous origin. If the affection
is bilateral and associated with peritoneal inflammation, and at the
same time no other cause exists for serous membrane inflammation,
the probability of its tuberculous origin is very strong.
Pulsating Pleural Effusion. Wilson has made the most recent
studies of this rare affection. The effusion within the pleura pulsates
synchronously with the ventricular systole ; the pulsation is detected
usually by inspection and palpation. In some instances its presence
is onlv determined by palpation. It may be confined to two or three
interspaces, or occupy the anterior aspect of the thorax and the axil-
lary region on the left side. Earely the pulsation is behind. It is
usually situated on the left side. The original effusion is purulent in
the large majority of cases. The physical signs and general symptoms
of empvema are present. Nevertheless, the disease simulates aneurism
of the aorta. The latter affection, however, is accompanied by vascu-
lar symptoms and physical signs in the course of the aorta. Pulsating
empyema is distinct in movement from the pulsation of the aorta and
occupies a different anatomical site.
Diaphragmatic Pleurisy. In diaphragmatic pleurisy there is in-
tense pain in the epigastrium. Gueneau de Mussy 2 regards a paid
along the tenth rib, extending from the anterior extremity to the
sternum and xiphoid cartilage, as pathognomonic. Other symptoms
are nausea, vomiting, and hiccough. The dyspnoea often amounts to
orthopnea, or the patient sits stooping forward. The anxiety of the
1 Sec "Notes on Tuberculous Pleurisy. " Musser, American Climatological Associa-
tion, 1893.
2 Arch. gen. de MeU, 1853, vol. xi. Quoted by Fox.
PLATE XXVI.
FIG. 1. — Anterior Aspect.
\
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FIG. 2. — Posterior Aspect.
•
Fibroid Phthisis with Chronic Pleurisy.
Heart drawn toward the right and aorta uncovered by retraction of lung
margin. Vicarious emphyzema of left lung.
DISEASES OF THE LUNGS AND PLEURAE. 575
patient is very great. The fever is usually higher than in ordinary
pleurisy, and there may be delirium. Effusion may lessen the pain.
Peritonitis may occur at the same time, or be secondary to the pleurisy.
Diagnostic Features. The special features of diagnostic impor-
tance that are observed in the course of pleurisy are the pain, the
dyspnoea, the cough, the fever, the physical signs of effusion within
the pleura, and the results of exploratory puncture. Pain: The pain
is short, sharp, lancinating, and is usually recognized quite readily by
its character and location. It must be distinguished from the pain
due to pleurodynia and intercostal neuralgia. The pain of pleurisy is
associated with cough and is increased by breathing. It causes dimi-
nution of movement of the affected side. The patient is compelled to
sit up in bed, or lie on the side which is the seat of pain. Cough: In
the first stage the cough is short, suppressed, dry, and painful. It is
constant. In the second stage it changes in character. There is no
pain, there is no expectoration. It is frequent and irritating, and of
a peculiar sound which is difficult to describe, and yet, when once
heard, is most suggestive in subsequent cases. It is short and lacks
resonant quality, as if the fluid hi the chest stopped the sound-waves.
Dyspnoea in the first stage is due to pain, in the second stage to the
large effusion which encroaches upon the normal air-space. It is not
diagnostic. The physical signs of pleural effusion have been frequently
reiterated. The most decisive are diminution or absence of move-
ment, enlargement of the affected side, absence of fremitus, flatness on
percussion, fulness of intercostal spaces, and the displacement of organs.
The latter is of the greatest diagnostic importance in the distinction
between consolidation and effusions. The results of exploratory punc-
ture lead to decisive conclusions usually, although it must not be for-
gotten that effusions may be loculated and therefore missed by the
aspirating-needle. Or the enormously thickened pleura may intervene
between the exudation and the surface of the chest, and prevent with-
drawal of the fluid. Finally, effusions may complicate inflammatory
processes, as pneumonia, tuberculosis, or abscess of the lung. Securing
fluid for diagnosis by aspiration, therefore, does not necessarily exclude
these conditions, and hence, before the process is decided to be within
the pleura alone, the sputum and other conditions must be taken into
consideration.
Differential Diagnosis. Acute plastic pleurisy is diagnosticated from
acute 'pneumonia by the friction-sound and the maintenance of the clear
percussion-note and normal respiratory murmur, with unaltered vocal
resonance and fremitus. When effusion takes place the chest is en-
larged and immobile, especially on the affected side; the interspaces
are filled out and the diaphragm is depressed ; these changes do not
occur in pneumonia. Moreover, the percussion-note in pleural effusion
is flat, with greatly increased resistance ; the shape of the upper line
of dulness is diagnostic ; the respiratory murmur is feeble and distant,
or entirely absent, except along the spine, where the compressed lung-
yields bronchial breathing, and also above the line of effusion, where
the lung yields exaggerated breathing. In pneumonia, on the other
hand, the percussion-note is dull, without greatly increased resistance,
576 SPECIAL DIAGNOSIS.
and the breath-sounds are bronchial. In addition, in pleurisy, the
vocal resonance and fremitus are usually almost if not entirely absent,
and posteriorly at the level of the effusion segophony may be detected.
In pneumonia, on the contrary, vocal resonance and fremitus are
increased in intensity. In pleurisy with effusion the movable organs
are dislocated and Traube's line is obliterated.
Finally, the fever of pneumonia is much higher and more continu-
ous than that of pleurisy, the respirations more frequent, the cough
looser, and in typical cases followed by rusty sputa. (Compare the
temperature chart in article on Pneumonia. ) A crucial test is aspiration
with a hypodermic needle : in pleural effusion, serum is withdrawn ;
in pneumonia, a few drops of thick blood.
In pleurodynia there is also severe pain in one side ; but the pain is
more continuous than that of pleurisy, and consists of a constant aching
or a burning sensation. It is made worse by twisting or turning, as
well as by breathing. The side is also tender to the touch. The pain
is not so sharply localized as that of pleurisy, and may leave one side
and affect the other. It is unaccompanied by fever or friction-sound,
and is frequently found in rheumatic subjects.
In intercostal neuralgia, there is the same absence of fever and fric-
tion-sound. The pain, however, is sharply localized, as in pleurisy,
but is of the darting, neuralgic character, and is associated with tender-
ness at the points of exit of the intercostal nerves. It is most common
in women, especially if they have uterine disturbances. It is more
frequent on the left side, and just beneath the mammary gland.
Chronic Pleurisy. Chronic dry, or plastic, pleurisy is the result of
an acute attack, or develops insidiously if tuberculous. It causes
great deformity of the chest from contraction, and compensatory
emphysema of the healthy lung. The heart is dislocated or cannot
be found on physical examination, because it is overlapped by lung or
is drawn behind the sternum. There is considerable spinal curvature,
dislocation of the scapula, deformity of the shoulder, and indrawing
and overlapping of the ribs at the base of the chest.
('hronic pleurisy with effusion results from an acute attack of pleurisy,
in which the fluid remains unabsorbed, or from subsequent attacks.
The physical signs are the same as in acute effusion. So far as subjec-
tive symptoms go it may remain latent ; patients so affected not infre-
quently go about their work with comparatively little dyspncea. There
may be an evening rise of temperature and acceleration of the pulse.
Chronic effusions are more likely to be purulent in children than in
adults. AVhen empyema results, the fever becomes hectic ; there are
chills and sweats, pyaemia develops, and death is likely to occur from
-nine intercurrent suppuration, as cerebral absce>-.
After ehronic effusion the chest is rarely restored to its original shape,
even if the effusion is finally absorbed. The affected side becomes
motionless and retracted. In process of time the spine may be bent.
The opposite lung becomes hypertrophied. The patient is usually in
precarious health, liable to acute attacks of pain hi the affected side,
and liable also to be carried off by phthisis or some intercurrent affec-
tion. Rarely the patient may maintain good health ; complete cure
PLATE XXVII.
FIG. 1. — Anterior Aspect.
FIG. 2. — Posterior Aspect.
ES3
Pneumothorax (left-sided).
DISEASES OF THE LUNGS AND PLEURAE. 577
is even possible, with restoration of the retracted side to, or almost to,
normal dimensions, especially in children.
Pneumothorax. Pneumothorax consists in an accumulation of air
in the pleural cavity, accompanied or followed by an outpouring of
fluid, which may be serous or purulent, constituting respectively hydro-
pneumothorax and pyo-pneumothorax.
Pneumothorax may originate : 1. In causes external to the chest,
by perforation of the chest-wall and pleura. 2. In perforation of the
lungs, bronchi, or oesophagus. 3. It may be caused by gases devel-
oped from an existing effusion.
The most frequent cause is tuberculous disease of the lung, and next
an empyema ; out of 121 cases collected by Saussier, 81 were due to
phthisis and 29 to empyema. It may occur very early in tuberculosis
of the lung, and may even be the first symptom of that disease.
(See cases referred to by Fox and recorded by Louis and Chomel).
The left side is affected not quite twice as often as the right ; the
disease is usually unilateral. The onset of the condition is usually
sudden. During a paroxysm of coughing or vomiting, or without
immediate cause, there is an escape of air into the pleura, and hi the
majority of cases the patient at once complains of acute pain in the
chest and excessive dyspnoea with great dread of impending suffoca-
tion. The patient often sinks into collapse from shock, but sudden
death is rare. If the escape of air mto the pleura is gradual, there
will be less pain and dyspnoea.
Physical Signs. (Plate XXVII.) The chest is distended, especially
on the affected side ; the percussion-note is a bell-like tympany except
when the distention is excessive and the air contained is under great
tension, when the note is proportionately duller and higher in pitch; the
diaphragm is depressed and the heart displaced, unless adhesions pre-
vent it. In left pneumothorax it may beat on the right side, the whole
mediastinum being pushed to the right ; in right pneumothorax the
mediastinum may be pushed to the left nipple ; hence there is reso-
nance over the normal cardiac region. The pitch of the percussion-
note may be raised when the mouth is closed, and lowered when it is
open (Wintrich's change of note), and a cracked-pot sound can be
elicited in some cases, but this occurs only when the communication
with the pleura remains open.
A valuable sign of pneumothorax is the coin-test, or, as Trousseau
named it, the Bruit cFairain. A silver coin is laid upon the chest and
struck with another, while the auscultator applies the stethoscope oppo-
site to the point struck, or over any part of the side distended by air.
The ringing coin-sound is reproduced with great intensity. It is path-
ognomonic, and the outlines of the cavity can be traced by it.
When fluid is present, as it usually is, there will be the ordinary
signs of a pleural effusion, which have been sufficiently dwelt upon.
The fluid is more mobile in pneumothorax, however, than in simple
pleurisy, so that its level changes more quickly with change of posture
of the patient, and Hippoeratic succussion is readily obtained. This
movable dulness is a very valuable sign — indeed, almost pathognomonic.
As the lung is compressed against the spine by the air, as it is by
37
578 SPECIAL DIAGNOSIS.
the fluid in pleurisy, the breath sounds are feeble or absent, except
over the root of the lung, where the breathing is bronchial. But if
the lung is not completely collapsed, amphoric breathing may be heard,
the air-chamber of the pleura acting as a consonance-box ; it may be
heard with both inspiration and expiration, or only with expiration.
Metallic, tinkling is a sound believed to be due to the vibration of
bubbling bronchial rales re-echoed through the air-chamber, or to
drops of fluid falling from above upon the surface of the effusion. Re-
echoing, with metallic quality, may also accompany the heart-sounds,
and in cases in which the respiratory murmur is amphoric the vocal
resonance is of the same character. Vocal fremitus is generally
absent.
Differential Diagnosis. Pneumothorax is most likely to be
confounded with (1) emphysema ; (2) tuberculosis of the lungs with
large cavities ; (3) cases of pleural effusion in which above the upper
level of the fluid the lung is markedly hyper-resonant ; and (4) abscess
below the diaphragm containing air (pyo-pneumothorax subphrenicus).
1. Emphysema can be distinguished by its slow onset, its relatively
slight impairment of the general health, by the fact that it is bilateral,
whereas pneumothorax is almost always unilateral, and by the exist-
ence of feeble breathing with greatly prolonged expiration. Amphoric
breathing and resonance, metallic tinkling, and signs of fluid are all
absent in emphysema.
2. When the pneumothorax is circumscribed the physical signs re-
semble those of pulmonary cavity. But over a large cavity the chest
is usually flattened ; cracked-pot sound and alteration in pitch upon
opening and closing the mouth are more common in cavity than in
pneumothorax. Displacement of viscera does not necessarily occur
in phthisical cavity, the coin-test is negative, succussion cannot be pro-
duced. Fremitus is absent in pneumothorax and increased over a
cavity.
3. The hyper-resonance above a pleural effusion develops with a very
different clinical history, is accompanied by increase of fremitus with
bronchial or, at times, amphoric breathing, and changes when the
patient's mouth is open or closed. The percussion-note usually lacks
the metallic quality heard in pneumothorax, metallic tinkling is absent,
the coin-test is negative.
4. Pneumothorax must be distinguished from abscess below the dia-
phragm containing air (pyo-pneumothorax subjihrenicus). Often the
distinction is difficult. The constitutional symptoms of suppuration
are present. Leyden points out the importance of remembering the
sequence of events in the development of the disease. When the
abscess is situated below the diaphragm, abdominal symptoms precede
its development, and early in the course of the disease there is absence
of respiratory symptoms. If the patient has had gastric ulcer, this
would point to subphrenic abscess, as most of the cases of subphrenic
abscess are secondary to gastric ulcer. Moreover, in subphrenic abscess
the heart is not displaced nor the interspaces bulging. Indeed, the
viscera below the diaphragm are more likely to be displaced than those
above it. In pneumothorax, according to Leyden, the respiration is
DISEASES OF THE LUNGS AND PLEURAE. 579
normal under the clavicle, and the transitions from the normal to the
metallic and amphoric sounds lower down are abrupt. In pyopneu-
mothorax on the left side the semilunar space disappears. In sub-
phrenic abscess the amphoric sounds laterally or posteriorly may be
above and below the diaphragm, or they may be loudest at the epigas-
trium. In addition, in pyo-pneumothorax subphrenicus, as Mason
points out, adhesions of the lung to the diaphragm and parietes can be
made out, particularly if the case has been under observation in its
earlier stages and dry pleurisy has been discovered. Abscess in this
location and slight fluctuation are likely to develop with associated
effusion. The limited extent of the effusion is of diagnostic import in
favor of sub-diaphragmatic inflammation.
CHAPTER III.
DISEASES OF THE HEART, THE BLOODVESSELS, AND THE
MEDIASTINUM.
The symptoms of disease of the heart are due to the anatomical
structure of the organ, to its physiological offices, and to the morbid
process. The heart is a hollow muscular structure which hangs in a
cavity and encloses cavities separated by valves. Both sets of cavities
are lined by serous membrane. The serous membranes are subject to
the same diseases, and present the same symptoms as diseased serous
membranes elsewhere. In inflammation of the external membrane
the surfaces rub together and create a sound of friction. The external
serous cavity may also become filled with the products of exudation or
transudation. Physical signs are produced. They are the physical
signs of a localized increase of contents as determined by inspection,
palpation, and percussion, and of physical interference with the heart's
action. The heart-muscle is also subject to the same morbid processes
as other muscular structures. They are hypertrophy and atrophy ;
inflammation, acute and chronic, with overgrowth of connective tissue ;
and degenerations. The symptoms are likewise the same. Increase
or diminution in the power of the muscle is associated with correspond-
ing change in size, which is determined by physical signs. Above
all, however, such change modifies the heart's action so that strength
or weakness of the muscle shows itself in excessive or deficient vascu-
lar pressure. The latter is more particularly an object of observation
because of the congestions, dropsies, and cyanosis that ensue.
The heart is constantly subjected to internal pressure. Dilatation
of the cavities or a portion of cavity (aneurism) follows previous dis-
ease of the muscle or increase of internal pressure, and causes physical
signs of enlargement. Degeneration of the heart-muscle, nearly always
secondary to deficiency of vascular supply, is also attended by symp-
toms of weakness and physical signs of enlargement (dilatation), or of
diminution in size (atrophy). When dilatation occurs the orifices of
the cavities enlarge, the valves cannot close them, and symptoms of
incompetency and of blood-regurgitation result.
The serous membrane that lines the cavities of the heart and, with
the subserous tissues, makes up the structure of the valves, is subject
to inflammations, the symptoms of which are common to all serous
inflammations. The swellings and outgrowths that attend such in-
flammation occlude the orifices and prevent closing of the valves. A
physical interference with the heart's function is produced, recognized
by physical signs. The successful effort of the heart-muscle to over-
come such obstruction on the one hand (hypertrophy), or its failure on
the other (dilatation), again leads to the production of symptoms and
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 581
signs. The serous membranes, and hence the valves, are exposed to
causes which excite inflammation. By virtue of the position of the
heart at the centre of the circulation, the blood, infectious or irritative,
as in rheumatism and Bright's disease, constantly bathes the vulnerable
structure. For the same anatomical reason positive symptoms arise.
not common to serous membrane inflammation — that is, embolic phe-
nomena. (See Symptoms of Morbid Processes.) Hence, the physical
signs (objective symptoms) of cardiac disease may be due to primary
and secondary morbid anatomical changes. They may be due (1) to
valvulitis as indicated by signs of (a) obstruction or regurgitation at
the valve-orifice, or (b) of embolic phenomena ; (2) to secondary changes
in the heart-muscle as seen in (a) change in the size and strength of
the organ (hypertrophy or dilatation), and (b) in consequence of the
latter, signs of congestion, oedema, cyanosis, etc.
It is the function of the heart to propel the blood. It has been
shown how interference with the action of the muscle and with the
consequent flow of blood through the cavities and orifices modifies the
function. The functional power is increased or diminished by the
physical changes. The evidence of increased power is increased force
of the heart-beat, and increased pressure in the arteries (pulse).
Diminished power shows itself in symptoms of diminished blood-
supply to parts, and in stagnation of the blood that is sent to the
periphery. The former is more pronounced in cerebral anasrnia, and
physiological weakness of organs or the organism as a whole ; the
latter, in congestion and dropsies.
The functional activity of the heart is controlled by a nervous mech-
anism, any alteration of which alters cardiac action and consequently
produces symptoms. Just as with the larynx, a break in the cardiac
mechanism may be in the centres in the medulla, the centres in the
muscle, or in the sympathetic nerves to and from the heart. The rich
anastomosis of these nerves exposes the heart to disturbance by reflex
influences. We should suppose such extensive innervation would in-
vite frequent cardiac perturbation. In a measure it does, but, fortu-
nately, so perfect is this mechanism that the inhibitory fibres control
such perturbation to a large extent, and we do not see such pronounced
symptoms as occur in the larynx. The symptoms which point to dis-
turbance of the cardiac mechanism are alterations in the rhythm of the
heart. Its action may on this account be increased or diminished in
frequency, or it may be irregular or intermittent. Such alterations of
rhythm may be due to organic disease of the centres, notably the pneu-
mogastric from apoplexy, softening, or tumor in the medulla, or to
stimulation or depression of the centres by toxic substances in the blood,
as in unemia, aeetomemia, or autogenetic or other toxemias, or by nico-
tine or other extraneous material. The altered rhythm may be, and most
frequently is, of reflex origin. It may be due to disease of the nerves,
as the pneumogastric or sympathetic, from pressure upon the nerve-trunk
by tumor or inflammatory growth. The most pronounced symptom of
altered rhythm of which the patient is cognizant is palpitation. The
exciting cause of this, as well as other rhythmical changes, must, in the
great majority of cases, be sought for beyond the domain of the heart.
582 SPECIAL DIAGNOSIS.
While the symptoms or signs of cardiac disease are often due to
morbid processes in the organ or its membrane, it must be remembered
that grave and persistent subjective and objective symptoms may be
caused by, or at least associated with, disease of contiguous structures
outside of the pericardium. The symptoms are not excited through
the nervous system, but are produced by mechanical encroachment upon
the organ, as in pleurisy with effusion, mediastinal disease and disease
of subdiaphragmatic viscera. They will be referred to in the study of
objective symptoms. Care must be taken never to overlook the possi-
bility of their presence.
In the study of the symptomatology of cardiac disease the student
must bear in mind two things : first, that the cause of the morbid pro-
cesses and of the symptoms (pain and palpitation) may be elsewhere
than in the heart ; and, second, that the ultimate object of the exami-
nation is to determine the muscular power of the heart. He will soon
learn that with that power intact the functions can be performed, not-
withstanding the presence of marked physical abnormalities.
The recognition of disease of the heart is not usually attended by
much difficulty, except in some special lesions. The non-recognition
of cardiac disease is due to faults in the examination. The physician
is too often satisfied with the recognition of the remote process, as a
congestion or functional weakness in some organ. Safety lies, as has
often been said, in the examination of all the organs of the body.
Often, for instance, indigestion from gastric catarrh is not relieved, for
the cause, mitral regurgitation, is not recognized.
The Data Obtained by Inquiry.
The Social History. The incidents in the social history to be
considered in the determination of the presence of cardio-vascular dis-
ease are those which notably influence by strain, excitement, or wear
and tear, the cardio-vascular mechanism — those which alternately in-
crease and diminish cardiac action, open and shut, dilate and contract
peripheral vessels. Whether it be symptoms of functional disorder or
of organic disease we wish to unravel, we must inquire as to the use
of stimulants, of tea, coffee, tobacco, and other narcotics or poisons ; as
to mental anxiety or physical strain ; as to excesses of various kinds.
Excess in any form induces vascular wear and tear. Tersely put by
one of our most distinguished clinicians, the devotee at the shrine of
Venus, Bacchus or Mars, is too frequently the victim of vascular dis-
ease. Occupations which invoke such vascular excitations are sugges-
tive diagnostic factors.
The age in which we are wont to find cardio-vascular affections
varies with the character of the lesion. Apart from congenital cardiac
affections, acute inflammations are more common at the age when infec-
tions are more operative, as in the early decades. On the other hand,
and it goes without saying, degenerative lesions are found in later life.
But as man is no older than his arteries, and as these degenerative
lesions may occur in comparatively early life, from a cardio-vascular
stand-point, a man may be senile at thirty-five or even earlier. Sex
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 5§3
influences diagnosis in so much as the one sex is more exposed to the
causal influences of cardiac lesions. Females are more prone to acute
infectious processes and to the neuroses from immobile nervous systems.
Males to degenerative lesions and the intoxication neuroses.
Family History. Inquiry in this direction yields information of
great diagnostic value. The gouty and rheumatic diatheses, with
their long train of associated disorders, which predisposes to cardio-
vascular affections, are notably inherited. Moreover, the tendency to
atheroma of vessels is itself pronouncedly hereditary.
The History of Previous Disease. The occurrence of any one
of the numerous infections may have been the initial step in the pro-
duction of the affections we are considering. The determination of
the nature of a cardiac lesion may hinge upon the correct decision of
this question. The infection of acute rheumatism is of course to be
eagerly sought for. A history of chorea, of various skin affections
related to gout and rheumatism, of eye affections, of tonsillitis, of other
affections related to the so-called uric-acid diathesis, must be sought
for. If found, such history is more than suggestive.
The Subjective Symptoms. A. Symptoms Referred to the
Heart. Pain. 1. In Disease Outside of the Heart. Although pain
in the region of the heart may be a symptom of disease of that organ
or of the pericardium, in the large majority of instances it is due to
other causes. The physician is frequently consulted by the anxious
patient on account of pain, other than heart-pain, but referred to this
region, or more precisely to the fifth or sixth interspace on the left
side. The causes of such pain are various : (1) Xeuralgia ; (2) pleu-
rodynia; (3) myalgia; (4) local pleurisy; (5) periostitis. The neu-
ralgias may be associated with points of tenderness, which are usually
the seat of the greatest intensity of the pain. These points of tender-
ness correspond with the positions at which the nerves have their
exit through the fascia to the surface, and are found along the
sternum, in the course of the mid-axilla, and along the vertebra?. The
pain is paroxysmal, occurs at variable periods of the day, and in
anaemic subjects or in the course of neurasthenia. It may precede the
development of herpes zoster. In these cases the exact nature of the
pain is not known until the eruption appears. In gout or diabetes we
may have local neuritis, which causes neuralgic pain in this situation.
Pleurodynia, which is thought to be an affection of the pleural
nerves, is more general. The pain is increased by pressure of the
finger-tips, although it is not localized. It is relieved by pressure of
the whole hand. In myalgia, which is seen so frequently in phthisis,
on account of severe coughing, in rheumatism and in debilitated subjects
generally, the pain is more or less diffuse, interferes more or less with
movements of the chest, is relieved by uniform general pressure, and
is usually associated with myalgia in other organs. The pain of pleu-
risy is recognized by the fact that it usually inhibits the act of breath-
ing, and is associated with cough, and because friction-sounds may be
detected. Periostitis. In disease of the ribs of the prrecordia the pain
is associated with tenderness and swelling. One or more of the costo-
sternal articulations may be extremely tender. The pain and tender-
584 SPECIAL DIAGNOSIS.
ness are due to the periostitis of syphilis or to that which follows
typhoid fever. In one of my cases the rib had to be resected. It
may be due to the internal pressure and erosion of ribs in aneurism.
The same affection may cause neuralgic pains in the nerves. Abscess.
Pain in this region may, in rare instances, be due to localized tuber-
culous abscess between the pericardium and the walls of the thorax.
One such case was under my care. The abscess developed secondarily
to empyema and occupied the precordial region, causing bulging.
The pain was intense, and was only relieved after the caseating pus
w T as removed by incision.
Pain in the epigastrium is often held to be due to cardiac disease.
It is usually due to gastralgia, or, as it is sometimes termed, cardial-
gia. It is recognized by the location of the pain and its association
with gastric symptoms, as flatulency, weight, fulness, and acidity. In
gastric ulcer the epigastric pain is localized, accompanied by tender-
ness on pressure, and is increased by food. However, acute, severe,
and excruciating pain in the epigastrium may be due to rupture of the
heart and also to pericarditis.
2. In Disease of the Pericardium. Pain in the region of the heart
is sometimes clue to affections of the pericardium. Pericarditis is the
most common. While centralized in the heart-region, it may radiate
to the left shoulder and extend down the arm. It is paroxysmal and
may have some of the characteristics of angina. It is increased by
movement, by pressure, and by the action of the diaphragm. The
patient is often obliged to sit up in bed and suffers from orthopncea.
It may be referred to the epigastrium. A pericardial friction-sound is
usually detected. Pain due to disease of the aorta. Acute inflammation
of the aorta is also the cause of cardiac pain. The pain extends along the
course of the aorta, may be referred to the sternum, and extends along
the spine. The pain is severe, causing an anxious countenance and
an expression of extreme suffering. In gouty subjects with atheroma
pain may occur in this situation in paroxysms. There is usually val-
vular disease at the aortic orifice. Similar pain occurs in syphilis and
in alcoholic subjects, and may be due to malaria. It is a visceral
neurosis, or a form of neuralgia.
Pain in the region of the heart is frequently due to aneurism. The
pain is usually due to pressure of the aneurism upon adjacent struc-
tures. If it presses on the bone and causes erosion, the pain is of a
boring character, localized at one point. It has been previously re-
ferred to. In aneurism alone, without pressure, the pain is of a dull
aching character, increased by movement, relieved by rest, or by
change of position. When nerves are pressed upon, pain may be acute
and of a neuralgic nature. It may follow the course of the nerves and
be associated with numbness or sensations of tingling. The long dura-
tion of the pain, its localization, and its aching character are sufficient
to exclude angina pectoris. When the pain is unilateral it may be
due to pressure of an aneurism upon the nerves at their exit from the
canal ; the pain extends along the course of the intercostal nerves. It
is severe and burning, but there are no localized points of greater in-
tensity. The pain may extend down the arms, and, when the abdomi-
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 585
nal aorta is affected, it may extend down the legs. If rupture of the
aneurism takes place, the pain is sudden and sharp. Death, however,
ensues quickly, so that the pain will rarely be complained of.
3. In Disease of the Heart. Three forms are seen : (1) Pain due to
disturbances of the rhythm ; (2) pain due to valvular disease ; (3) pain
due to angina pectoris.
Disturbance of the Rhythm. Palpitation, intermission, and irregu-
larity of the heart occur in the large majority of cases without pain.
Paroxysms of palpitation are sometimes attended with severe precor-
dial pain and distress. This occurs in the reflex palpitation, which,
as will be seen, is due to disease in other situations ; in the palpitation
of Graves' disease and of anaemia. The palpitation of organic disease
is induced by exertion. The rapid action of the heart is painful and
the throbbing is complained of as causing distress.
While intermission and irregularity may continue without pain at
times, the patient is conscious of this disturbance of the rhythm, and
complains of the stoppage, which then is attended by distress, some-
times amounting to severe pain. This is particularly the case when
the heart-action is tumultuous, as the disturbance of rhythm seen in
pericarditis and in valvular disease.
Pain due to Valvular Disease. In disease of the aortic valves pain
is of more frequent occurrence than in other valvular lesions. It is
usually complained of in the region of the aorta at the base of the
heart, and is aggravated by exertion. (See Atheroma.)
Pain due to Angina Pectoris. Heberden was the first to describe the
attacks of angina pectoris, which, in its typical form and in association
with disease of the heart, is not of common occurrence. The pain of
angina is severe and is associated with the most intense anguish. It
comes on suddenly, and may occur in paroxysms. The patient real-
izes that the pain is in the heart, and complains of feeling as if the
organ Avere held in a vise. From the heart it radiates to the neck
and down the arms. It extends particularly to the left arm, and may
be severe in the wrist or in the ends of the fingers. With the pain
there is a sense of impending death with sinking and depression. The
pain lasts but a few seconds or minutes, and during that time the face
of the patient becomes pale or of an ashy hue, perspiration breaks out
on the forehead, the extremities become cold, the breathing is short.
Prostration usually follows the attack, but the precordial distress dis-
appears entirely. The attack may occur in patients who are entirely
free from organic disease of the heart. It is most commonly, however,
associated with some lesion. The lesions frequently found are disease
of the coronary arteries, atheroma of the aorta, aortic valvular disease,
and myocarditis with fatty degeneration. It occurs after middle life,
and is more frequent in males. It may occur without exciting/cause,
or follow undue exertion, exposure to cold, mental excitement, or pro-
found emotion.
The points upon which the diagnosis is based are : 1. The seat of
the pain. This is usually behind the middle or the lower part of the
sternum, and more to the left than to the right. Thence it extends to
the posterior portion of the axilla or it may radiate up to the neck.
586 SPECIAL DIAGNOSIS.
In some instances it extends to the occiput. Frequently the pain ex-
tends to the left arm as far as the elbow or even the fingers. It may
extend to the abdomen or to the right arm. I have seen it affect both
arms. It is not influenced by external pressure. 2. The sense of
constriction with the indescribable torture are most characteristic. 3.
The respirations are shallow, or may even cease, but there is no dysp-
noea. 4. The patient is terrified and restless. 5. The pale face, ex-
tremely anxious countenance, the cold sweat on the forehead, make a
striking picture, which when once seen can never be forgotten. 6.
Such extreme depression and sensation of impending death occur in no
other affection. Particularly characteristic is the immediate relief,
without hysterical manifestations or dyspeptic symptoms of any kind,
which follows an attack. 7. During the attack the frequency of the
pulse is not much influenced, and the action of -the heart may be uni-
form and regular. Rarely its frequency may be lessened. The tension
of the pulse is increased during the attack.
Some authors speak of various grades of angina, and call all forms of
precordial pain and oppression, with radiation of the pains to the arms
and neck, mild forms of angiua. Such attacks have often obvious
causes in disturbance of digestion and in emotional excitement. When
associated with increased arterial tension and signs of arterio-sclerosis,
they may be of an anginoid nature. The greatest difficulty exists in
distinguishing them from true angina. Hysterical or pseudo-angina
can be distinguished only with extreme difficulty. It occurs much
more frequently than true angina. One attack seems to predispose to
others. It occurs in females who present other symptoms of hysteria.
It occurs usually before forty years of age. The attacks most fre-
quently come on at night, and may be periodical. They are particu-
larly associated with menstrual disorders. The pain is less severe and
the oppression is not so marked in pseudo-angina ; coldness of the
hands and feet, with the occurrence of syncope, or a general feeling of
sinking, are common symptoms. The pain is of long duration and is
associated with great agitation. It is preceded by neuralgia, and
neuralgic pains persist after the attack. Low tension, feeble second
sound, and soft arteries may be present, although the opposite is also
seen. The disease is never fatal. In one of my patients attacks of
hysterical haemoptysis alternated with the anginal attacks.
Palpitation. In palpitation the patient is conscious of the action
of the heart. Although it may occur in organic disease, it is more
frequently due to disease outside of the heart.
Symptoms. The symptoms vary in degree. In mild forms the
patients may complain of a fluttering or a sensation of sinking in the
precordial region. In the more severe forms the heart beats violently
against the chest. The arteries throb, the action of the heart is in-
creased, and the area of impulse against the chest-wall is enlarged and
visible. The patient complains of distress in the precordial region.
The pulse may be increased to 150. In nervous palpitation the face
becomes flushed, and after the attacks large quantities of urine are
passed. Sometimes, in this form of palpitation, exertion relieves the
attack. On examination, the sounds are found to be normal, but they
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 587
are clear and metallic in character. The diastolic sounds are greatly
accentuated. If anaemia is present, murmurs due to that condition
are increased in intensity. The attack may last but a few minutes or
continue for hours.
(a) It is most common in cases in which the nervous system gener-
ally is in a state of increased excitability. Attacks occur at puberty
and at the menopause. It is very common in hysteria and neuras-
theniac It follows emotional disturbance. It is more frequent in women.
(b) It is due to the action of the toxic substances, as tobacco, tea and
coffee, and alcohol.
(c) From strain and over-exertion, particularly if associated with ex-
citement, palpitation may occur and continue for a long period. This
is the form of irritable heart described by Da Costa, common in young
soldiers during the war.
(d) In valvular disease of the heart when compensation fails, and
in myocarditis, attacks of palpitation occur, distinctly from exertion.
Intermission and Irregularity. When the patient feels the alter-
ation in rhythm, it is usually due to nervous disturbance. In organic
disease it is not, as a rule, appreciated by the patient. Although not
a subjective symptom alone, it may be well to speak of irregularity in
this connection.
■ Arrhythmia is the general term applied to irregularity of the action
of the heart. When the heart intermits — that is, when one or two
beats are dropped at intervals of half a minute, a minute, or longer ;
when the beats are unequal in volume and force, or occur at unequal
distances in time, the heart's action is irregular. The causes of dis-
turbance of the rhythm have been classified by Baumgarten 1 as follows :
1. Central causes in the medulla either from organic disease, as
hemorrhage or concussion, or from physical influences. 2. Reflex
influences, as in dyspepsia and diseases of the liver, lungs, and kid-
neys. 3. Toxic influences — tobacco, coffee, and tea are common causes ;
various drugs, such as digitalis, belladonna, and aconite. 4. Changes
in the heart itself. Mural changes, as in dilatation, fatty degeneration,
and myocarditis ; changes in the cardiac ganglia ; sclerosis of the cor-
onary arteries.
It must not be forgotten that both irregularity and intermittency
may occur in persons otherwise in good health, and continue for a long
period of time without any evidence of arterial or cardiac disease.
(For the varieties of arrhythmia, see The Pulse.)
B. Symptoms Referred to the Circulation. 1. Pulsation of
the Arteries. Pulsation of the arteries, especially the carotids, the
abdominal aorta, and the brachial arteries, occurs in anaemia, and is
common in emotional disturbances. Such pulsation, as of the abdomi-
nal aorta, may be reflex from organic disease in the vicinity. Similar
localized pulsation in the innominate arteries may be mistaken for
aneurism. The pulsation that attends organic heart disease may be
due to hypertrophy of the heart, but is particularly characteristic of
aortic regurgitation.
1 See Transactions of the Association of American Physicians, vol. iii.
588 SPECIAL DIAGNOSIS.
2. Hemorrhages. In the description of valvular lesions it will
be seen that hemorrhages from the lungs occur quite frequently in
disease of the mitral valve. The hemorrhage may be due to conges-
tion, to actual rupture of the vessels, or to hemorrhagic infarct. (See
Pulmonary Hemorrhage.) It may simulate hemorrhage due to tuber-
culosis.
3. Cyanosis. Cyanosis is a symptom of common occurrence in the
course of organic heart disease.
4. Dropsy. The dropsy of heart disease occurs after failure in
compensation in the course of valvular disease, and in dilatation of
the heart. It may disappear entirely, if the conditions are improved
or become permanent and progressive. In general, it may be said t<
be distinctly a phenomenon of mitral regurgitation and secondary
tricuspid regurgitation. It occurs in a lesser degree in mitral obstruc-
tion, and still less in disease at the aortic orifice.
C. Symptoms Referred to the Luxgs. The chief subjective
symptom is dyspnoea. Dyspnoea, due to disease of the heart, is clini-
cally divided into (1) dyspnoea caused or increased by exertion ; (2)
paroxysmal dyspnoea ; (3) orthopnoea ; (4) rhythmical dyspnoea, or
Cheyne-Stokes respiration. The dyspnoea of effort comes on after
the slightest exertion. In paroxysmal dyspnoea the attack comes on
without apparent cause. It must be distinguished from the paroxys-
mal dyspnoea of uraemia, asthma, or emphysema. The physical signs of
lung disease usually point to the latter. The paroxysmal dyspnoea of
heart disease is attended by more violent efforts in breathing than the
physical state of the lungs admits, and the difficulty attends both in-
spiration and expiration. Wheezing is not so marked as in forms of
asthma. There is some obstruction to the outgoing: of air : but, on
account of air-hunger, all the efforts of the patient are exerted to fill
the chest. In paroxysmal dyspnoea the breathing usually becomes
quiet if the patient is placed in a comfortable position, provided there
is no lung or pleural complication. The position does not modify the
severe dyspnoea of asthma or emphysema. Orthopnoea has been
described previously.
Cough. Cough is of frequent occurrence in heart disease. The
causes are various. It may be due to pressure upon the bronchus or
the pneumogastric nerves, as in pericardial effusion. It may be due
to the passive congestion of the lungs which occurs in failing compen-
sation. If hemorrhagic infarcts take place, cough may be present. It
attends the bronchopneumonia that follows. In cough from pressure
of an aneurism a metallic brassy sound is created. (See The Larynx.)
It occurs in paroxysms, and may be associated with alterations in the
voice. It may result in the expectoration of blood-tinged sputum,
which may be due to the gradual rupture of the aneurism.
D. Symptoms Referred to the Nervous System. The symptoms
are usually due to disturbance of the cerebral circulation, because either
an insufficient quantity of blood or improperly oxygenated blood is
supplied to the brain. Vertigo, faintness, and languor are complained
of in the first instance. Dulness, stupor, and moderate delirium (car-
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 589
bon-dioxicle poisoning) may occur in the later stages in the second
instance. In the course of organic heart disease epilepsy or epileptiform
convulsions may arise, on account of embolism or thrombosis. Chorea
is of common occurrence, and apparently of the same cause as the
heart disease. Coma may be due to hemorrhage into the brain, to
embolism, or to thrombosis. Hemorrhage occurs in patients in whom
there are usually found hypertrophy of the left ventricle, atheroma of
the arteries, and renal disease. Embolism occurs in valvular disease,
particularly in aortic regurgitation and mitral obstruction. We may
have the occurrence of paralysis for the same reason, with or without
coma. The Stokes-Adams syndrome of vertigo, syncope, loss of con-
sciousness, and slow pulse — pseudo-apoplexy — is seen in myocarditis
and endarteritis.
Thrombosis in the course of heart disease is usually due to disease
of the bloodvessels rather than to disease of the heart itself, although a
weakening of the heart, as in dilatation, is a factor predisposing to the
development of thrombosis.
E. Symptoms Referred to the Alimentary Canal. In the
course of organic heart disease dyspepsia and forms of catarrhal gastritis
and enteritis are of common occurrence. Patients complain of various
forms of indigestion, or of nausea and vomiting. While water-brash and
flatulence are caused primarily by the condition of the heart, they may
in their turn cause symptoms of palpitation and cardiac distress. These
gastric difficulties are more particularly seen in diseases of the auriculo-
ventricular valves, and are associated with congestion and secondary
cirrhosis of the abdominal viscera.
F. Symptoms Referred to the Throat. The patient may com-
plain of pain in the throat. This may be paroxysmal, and is some-
times said to be due to angina pectoris. Hoarseness or modifications
of the voice are occasional symptoms of pericarditis. They are of fre-
quent occurrence in the course of aneurism due to pressure upon the
recurrent laryngeal nerves.
G. Symptoms Referred to the Kidneys. The kidneys are inti-
mately related with the heart at a distant point in the circulation, and
are frequently the seat of changes due primarily to disease of the central
organ of circulation. The changes in the urine will be referred to
again ; suffice it to say, that in the course of mitral and tricuspid
disease and dilatation, scanty urine, of high color, loaded with urates,
containing a small amount of albumin, is quite common and indicative
of passive congestion of the kidney. It may result in cyanotic indura-
tion or interstitial nephritis. On the other hand, the urine may be of
low specific gravity and pale in color. There may or ma} r not be
traces of albumin. The change is due to a granular, contracted kidney,
which is associated with hypertrophy of the left ventricle and arterial
sclerosis. Bloody urine is usually due to renal embolism when it occurs
suddenly in the course of organic heart disease. It may be due to
the emboli that are found in septic endocarditis. Renal disease in all
forms may complicate disease of the heart. (See Kidney Disease.)
The Subjective Symptoms of Arterial Disease. The patient
may have symptoms of congestion or of anaemia of the brain. Headache,
590 SPECIAL DIAGNOSIS.
vertigo, photophobia, tinnitus, and paresthesia, due to either cause, may
prevail. (See also Cerebral Thrombosis.) The diseased vessels prevent
the blood from reaching the extremities, hence they are cold. Pain is
common only when atheroma or aneurism is present (q. v.). Throbbing
or pulsation is complained of. It may be a striking feature of hysteria
and neurasthenia. The abdominal aorta is frequently thus affected.
The pulsation may be constant or intermittent. There may be dys-
peptic symptoms. The pulsation of the carotids may cause disagree-
able sensations in the head, and the beating transmitted to the ear be a
source of extreme annovance.
The Data Obtained by Observation.
Before describing the methods of observation it is well to review
some of the facts of anatomy and physiology essential to the accuracy
of any observations.
Topographical Anatomy. (Plate XIII.) Outline of Heart
on Chest- wall. 1
To have a general idea of the form and position of the heart, map
its outline on the wall of the chest as follows :
(a) To define the base— i. e., the part to which its great vessels are
attached — draw a transverse line across the sternum, corresponding
with the upper borders of the third costal cartilages ; continue the line
half an inch to the right of the sternum and one inch to the left.
(b) To find the apex, mark a point about two inches below the left
nipple, and one inch to its sternal side. This point will be" between
the fifth and sixth ribs.
(c) To find the lower border (which lies on the central tendon of the
diaphragm), draw a line, slightly curved downward, from the apex
across the bottom of the sternum (not the ensiform cartilage) as far
as its right edge.
(d) To define the right border (formed by the right auricle), continue
the last line upward with an outward curve, so as to join the right
end of the base.
(e) To define the left border (formed by the left ventricle), draw a
line curving to the left, but not including the nipple, from the left
end of the base to the apex.
Such an outline shows that the apex of the heart points downward
and toward the left, the base a little upward and toward the right ;
that the greater part of it lies in the left half of the chest, and that
the only part which lies to the right of the sternum is the right auricle.
A needle introduced in the third, fourth, or fifth right intercostal
space close to the sternum would penetrate the lung and the right
auricle.
A needle passed through the first intercostal space close to the right
side of the sternum would pass through the lung and enter the supe-
rior vena cava above the pericardium.
1 From Holden : Landmarks, Medical and Surgical.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 591
The best definition of that part of the precordial region which is
less resonant on percussion was given by Dr. Latham years ago in his
" Clinical Lectures." " Make a circle of two inches in diameter round
a point midway between the nipple and the end of the sternum. This
circle will define sufficiently, or for all practical purposes, that part
of the heart which lies immediately behind the wall of the chest and
is not covered by lung or pleura."
Valves of the Heart. The aortic valve lies behind the third
intercostal space, close to the left side of the sternum.
The pulmonary valve lies in front of the aortic behind the junction
of the third costal cartilage with the sternum, on the left side.
The tricuspid valve lies behind the middle of the sternum, about
the level of the fourth costal cartilage.
The mitral valve (the deepest of all) lies behind the third intercostal
space, about one inch to the left of the sternum.
Thus these valves are so situated that the mouth of an ordinary-
sized stethoscope will cover a portion of them all, if placed over the
sternal end of the third intercostal space, on the left side. All are
covered by a thin layer of lung ; therefore we hear their action better
when the breathing is for a moment suspended.
Physiology. Action of the Heart. The heart beats — that is, alter-
nately contracts and dilates or relaxes — 65 to 85 times per minute in
an adult. In females, the frequency varies from 75 to 85 ; in males
from 65 to 75. With each beat, blood is propelled throughout the
vascular channels of the body, and drawn from them to the heart-
chamber. The first effect is produced by the contraction of the heart,
or the systole ; the second by the relaxation, or diastole. Other events,
as the act of respiration, contribute to the completion of the outflow
and inflow of blood, particularly to the latter.
The completion of the act of contraction and the act of dilatation
make up one revolution of cardiac action, or, as it is termed, a cycle.
Events of the Cardiac Cycle. The following events make up the
cardiac cycle. The act of contraction is the systolic period of the
cycle ; that of relaxation is the diastolic period. During the systole
(1) the ventricles contract ; (2) the auriculo-ventricular valves close ;
(3) the blood is propelled from the ventricles into the vessels, the
columns of blood in the aorta and pulmonary artery receive a shock
from the impact of the new volume of blood, and their bulk increases.
The movement of the blood-wave from this cause and from the con-
traction of the large vascular trunks produces pulsation of the periph-
eral vessels, which is known as the pulse. The contraction is imme-
diately followed by relaxation — the diastole. (1) The blood-columns
in the aorta and in the pulmonary artery fall back upon the valves
guarding their outlets, the aortic and pulmonary valves. At the same
time (2) the auricles are filled by the blood pouring in from the veins.
(3) The auricular muscles contract upon the blood in the chamber,
driving it into the ventricles.
The systolic and the diastolic periods of a cardiac cycle are nearly
equal in the length of time occupied in their occurrence. The systolic
period occurs at the same time, or is synchronous with the apex-beat
592 SPECIAL DIAGNOSIS.
and carotid pulse, and precedes by a fraction of a second the radial
pulse. It is immediately followed by the diastolic period, which,
therefore, follows the carotid and radial pulse.
Inspection. The Heart. The Method of Examination. The
patient should be stripped, and a good light should fall directly, as well as
obliquely, on the surface. The patient can be examined in any position,
and indeed for accuracy should be examined both in the upright and
recumbent postures. This is particularly true when the pulse-rate is
taken and when auscultation is practised. The sounds vary frequently
in different positions. Some diagnostic significance is attached to
these variations. It is necessary sometimes to have the patient lean
forward, to bring the heart into more immediate contact with the
chest- wall.
The examination should not be confined to the heart and vessels.
The reader will remember that in the account of the exterior and
of local areas it was pointed out that various abnormal conditions
may be due to disease of the heart. In the examination, therefore,
of a case of suspected heart disease, observation is made of the gen-
eral and of the local color, as of the lips, the fingers, and the con-
junctivas, to determine the presence of cyanosis, pallor, or jaundice ;
of the feet, to discover dropsy ; the face, to note the appearance of
the countenance ; the neck, to note the state of the vessels ; the eyes,
to note their prominence ; the thorax, to ascertain the presence of
dyspnoea.
The Pilecordia. The prsecordia is the region of the chest which
overlies the heart. In the study of the appearance of the preecordia
we observe : 1. The degree of prominence or swelling. 2. The impulse
and other pulsations. 3. The interspaces. 4. The hue of the surface.
The Prominence. The prsecordia may be unduly prominent in
children who have had rickets and possibly some cardiac hypertrophy
in childhood. It persists in later life. The ribs as well as the soft
tissues are prominent. The lower end of the sternum may project.
Swelling also occurs in hypertrophy or dilated hypertrophy of the
heart, in pericardial effusions, localized pleural effusions and pointing
empyema, and in aneurisms in the region of the heart. In pericardial
effusion ribs and interspaces project. The latter are full or even with
the surface. The prominence of cardiac disease is observed between
the third and seventh ribs on the left side, and extends from the left
nipple to the sternum, and even as far as the right nipple. The dis-
tance from the middle of the sternum to the mid-axilla is greater on
the left than on the right side. Local bulging may be seen at the
apex in cases of aneurism of the heart.
The prascordia may be sunken. Old pericarditis, bat more fre-
quently old empyema, causes sinking in of the region. It may be a
result of rickets or of spinal curvature.
The Impulse. The normal impulse is that portion of the heart
which strikes the chest- wall, and is improperly known as the apex-beat.
It is evident in health in the fifth interspace just inside of the mid-
clavicular line. It can readily be detected by inspection with a good
light, in patients with moderately thick chest-walls. It is due to the
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 593
impulse of the right ventricle, three-fourths of an inch above the apex,
against the chest-wall when the heart contracts, and hence it is systolic
in time.
Changes of Position in Health. It is not a fixed point in
health. It moves with the movements of the body, and hence, when
the trunk is inclined to the left, the impulse falls toward the left
axilla as far outward as the mid-clavicular line or even beyond that
point. It moves toward the right and downward in full inspiration,
or may disappear entirely toward the completion of that act. It may
not be observed if there is a large amount of subcutaneous fat, or if
the mammary gland intervenes. It becomes more conspicuous at the
end of expiration or when the body is inclined forward. In children
it is higher (fourth interspace) and more to the left. It is depressed
in old people. It must be remembered that in transposition of the
viscera the position of the impulse is changed.
Change of Position in Disease. The apex-beat, or the lowest
point of impulse, may be displaced or may be absent entirely.- These
changes are due either to (a) disease outside of the pericardium, to (6)
disease within the pericardium, or to (c) disease of the heart itself.
I. Displaced to the Left. This occurs from (a) Alterations
outside of the Pericardium. When the right lung is the seat of exten-
sive compensatory emphysema, or the right pleura is filled by a large
effusion, the impulse is displaced to the left. On the other hand,
fibroid phthisis of the apex of the left lung, or pleural adhesions which
have become attached to the pericardial sac, with, probably, coincident
pericarditis, pull the heart to the left, thereby changing the position of
the impulse. In disease of the mediastinum the heart is pushed down-
ward and toward the left. An aneurism, an abscess, or enlarged glands
in this situation may invade the normal cardiac territory and cause
dislocation of the heart.
In disease of the abdomen the impulse is displaced. If the liver
and spleen are enlarged, or the abdomen distended by ascites, the
diaphragm is raised, and, therefore, also the heart. The impulse is
then seen to the left of the normal position, and may be one or two
interspaces higher than normal. A common physical change in the
stomach — dilatation — is a frequent source of displacement of the im-
pulse. The dilatation may be temporary from flatulency or may be
due to organic disease.
(b) Alterations within the Pericardium. In cases of pericardial
effusion the impulse is shifted to the left and upward. It is seen in
the fourth and even as high as the third interspace, and sometimes
only an impulse is noted in the second interspace. This, however, is
not the true apex. Instead, we undoubtedly see in pericardial effu-
sions the impulse of the right auricle and the conus arteriosus against
the chest-wall.
(c) Diseases of the Heart. The impulse is diplaced to the left in
dilatation and hypertrophy of the heart. In the latter it is also dis-
placed downward. It may be as low as the sixth or seventh interspace
and extend as far to the left as the anterior axillary or the mid-axil-
lary line.
38
594 SPECIAL DIAGNOSIS.
II. Displaced to the Right, (a) Alterations outside of the Peri-
cardium. The heart is dislocated to the right in left pleural effu-
sion, and in emphysema of the left lung. We find, moreover, in
pleural contractions and fibroid phthisis of the right lung the heart
drawn to that side. Under these circumstances the impulse is noted
either in the epigastric region, along the margin of the ribs, or even
Fig. 152.
Normal and abnormal impulses.
1. Normal position of impulse. 2. Displacement to left and downward. 3. Displacement to left
and upward. 4. Impulse from enlarged right ventricle. 5. Displacement to right. 6. Dilated
right auricle. 7. Displacement in fibroid phthisis. S. Impulse of conns arteriosus. (Errata :
"8 " should he in 2d interspace parasternal line.) 9. Fibroid phthisis, right lung.
to the right nipple-line, in any interspace from the third to the sixth,
along the right edge of the sternum. The impulse in the epigastric
region usually represents the hypertrophied right ventricle, which
usually attends the lung-changes that cause displacement of the apex-
beat. The impulse along the right edge of the sternum may be the
apex-beat, or the right auricle and the right ventricle brought in appo-
sition to the chest-wall by the cardiac dislocation. The apex or the tip
of the heart is, in all probability, displaced but little beyond the mid-
sternal line. (6) The impulse is not displaced to the right in alter-
ations within the pericardium, or (c) in disease of the heart.
III. Absent. Following the same order, we find that the impulse
may be absent entirely in (a) disease outside the pericardium, on account
of which something intervenes between the heart and the chest-wall.
Hence, in emphysema of the lungs and in compensatory emphysema
of the left lung the impulse is entirely effaced ; in (6) disease of the
pericardium the impulse is absent when there is large effusion. The
absence here succeeds the dislocation to the left, and with its efface-
ment the impulse in the second and third interspaces disappears. In
(c) disease of the heart the impulse is absent when the heart is dimin-
ished in size, as in atrophy, or in myocarditis, or when weakened by
fatty degeneration or dilatation
The Extent of the Impulse. In health the impulse is limited
in extent to about one square inch. The area of impulse may be in-
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 595
creased when the individual leans forward, and at the end of expira-
tion. It is more evident when the chest-walls are thin, and less when
they are thick.
Extent in Disease. The area of impulse may be increased. The
causes are : (a) Diseases outside of the pericardium. The area is in-
creased in chronic phthisis with fibrous adhesions, and in pleural adhe-
sions when the lung is drawn away from the surface of the heart. It
is increased when the heart is pushed against the chest-wall, as in
aneurism or in diseases of the mediastinum, from inflammation or
cancer, or other mediastinal growth. The impulse is seen not only in
the third and fourth interspaces, but also as high as the second, and is
not limited to the spaces between the sternum and parasternal lines,
but may extend beyond the mid-clavicular line. It may not be systolic in
time only, but diastolic, presystolic, and systolic, and have the appearance
of a peristaltic wave from base to apex. The time coincides not only
with contraction of the ventricles, but also of the auricles, and of the
closure of the semilunar valves. (b) Disease of the -pericardium tends
to increase the area of impulse if moderate effusion is present. It will
be seen as a diffuse wave occupying the second, third, and fourth in-
terspaces. It is also increased in pericardial adhesions, without increase
in strength, (c) Disease of the heart. The heart must be enlarged,
and hence must either be hypertrophied or dilated. The extent of
impulse varies. In hypertrophy the impulse may be communicated
to the sternum, so that the lower part heaves with each contraction.
It falls below the fifth interspace and toward the left, particularly if
the left ventricle is the seat of the enlargement. If the right ventricle
is hypertrophied, the impulse is very marked in the third, fourth, fifth,
sixth, and even the seventh interspaces near the termination of the
cartilages, or in the epigastrium along the border of the ribs of the
left side. It may be seen in ansemia in this situation, particularly in
persons whose respirations are habitually shallow. Sometimes, when
associated with and displaced by lung disease, it is seen to the right
of the xiphoid cartilage.
New Impulse. New areas of impulse, the heart not dislocated,
arise from enlargement of one of the cardiac chambers or from disease
of the bloodvessels. A new area of impulse in the second or third
interspace on the left is from the conus arteriosus, or is due to hyper-
trophy and dilatation of the right ventricle ; or it may be due to
retraction of the lung in that region. It may be due to a dilated right
auricle, and is then seen in the fifth right interspace along the sternum.
If the impulse is noted in the course of or adjacent to the aorta, it is
indicative of aneurism.
The INTERSPACES. They are retracted possibly from pericardial
adhesions ; they are full or bulging in effusion. This retraction may be
limited to the apex or may occur in each interspace over the precordial
region. It may occur with the systole or with the diastole. It may
occur in hypertrophy of the heart, and is then systolic in time. It is
of some, although doubtful, diagnostic significance when it is systolic
in time, as it is said to indicate adhesions of the pericardium. The
traction at the systole of the heart causes the interspaces to be drawn in.
596 SPECIAL DIAGNOSIS.
On inspection behind, a systolic retraction of the interspaces is seen
in adherent pericardium, known as Broadbent's sign.
Color of Surface. Only when purulent pericardial effusion is
about to rupture, or an empyema to discharge, do we note redness or
other change in hue of the surface of the prsecordia, not observed over
the remainder of the thoracic surface.
The Arteries. By inspection we may be able to determine pulsa-
tion or any undue swelling or other change in the course of the vessels.
With the exception of pulsation in the carotids, which may temporarily
increase under excitement, pulsation of the vessels is not usualy seen
in health. In old people we can see the pulsation of the aorta (rarely)
at the episternal notch, and often in others, the temporals, the innomi-
nate, the carotids, the subclavians, the brachial and radial arteries, the
abdominal aorta in thin subjects, the femoral arteries and the posterior
tibials.
The Arteries in the Neck. Temporary pulsation of the carotid
arteries from excitement has been mentioned. It is commonly seen
in anosmia, and is quite marked in exophthalmic goitre. It is striking in
aortic regurgitation. It often attends the vascular changes of old age.
It may be due to atheroma or aneurism. It is always suggestive of
aortic valvular disease. The innominate artery, as well as the carotids,
often pulsates visibly in the neck, and may be so large as to simulate
aneurism. The subclavians may pulsate for the same reasons ; they
may also be seen to pulsate if the lungs are consolidated or shrunken
by disease. If the patient is young, the throbbing is more likely to be
of neurosal or hsemic origin. In later life, if such pulsation is asso-
ciated with a more or less defined swelling or tumor, with other phys-
ical signs of aneurism, that disease is doubtless present.
The Thoracic Aorta. An impulse of the thoracic aorta is usually
from aneurism. The pulsation is not always due to disease. The aorta
may be pushed against the chest-wall, or the lung-structure which over-
laps it normally may be withdrawn.
Tumor. An enlargement or swelling in the course of the aorta may
be due to aneurism of that vessel. It must be distinguished from
the tumor of mediastinal disease, and of empyema.
The Abdominal Aorta. Pulsation of the abdominal aorta is
often the cause of serious distress. The violent throbbing keeps the
patient awake at night, and makes him more and more nervous and
irritable. The pulsation is usually seen in the epigastrium. It is
more frequent when the vessel is not diseased, in neurasthenic subjects.
It occurs reflexly in patients with dyspepsia or organic disease in the
tipper abdominal tract. The shock of the pulsation is transmitted to
the hand with considerable violence. The impulse is diffused, but
not expansile.
Epigastric pulsation also may be due to the transmission of the im-
pulse of the aorta by enlargement of the pancreas, or tumors of the
stomach or the omentum. The transmitted pulsation is distinct. The
impulse is a transmitted one when the tumor can be defined and when
a sensation of lifting is transmitted to the hand. The physical signs
of ansurism are absent. If the patient lies on the abdomen, or in the
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 597
knee-chest position, the tumor falls away from the aorta, and the im-
pulse is not readily transmitted. Epigastric pulsation is also caused
by aneurism of the abdominal aorta. The pulsation is distensile or
expansile, and the aneurismal sac can be denned at times. The other
physical signs of aneurism are usually present — namely, thrill, dulness
over the tumor, a murmur on auscultation. In these conditions, how-
ever, we cannot always rely on the physical signs alone ; the history
of the subjective symptoms and of disease of other structures must be
carefully inquired into. Aneurism rarely occurs without some evi-
dence of arterial sclerosis or some physical effect upon the circulation.
Accentuation of the aortic second sound, variations in the femoral
pulse, high arterial tension, and the usual evidences of sclerosis favor
aneurism. While functional epigastric pulsation usually occurs in
neurotic subjects, and, hence, in the earlier periods of life, yet such
pulsation is frequently seen at the climacteric and in the neurasthenia of
old age. Late in life, with such impulse, fibrous thickening about
the pylorus, or contraction of the omentum, may easily be confounded
with malignant disease. Cancer of the stomach has been diagnosticated
under these circumstances when the pulsation was simply reflex from
chronic gastritis. Some time ago a private patient in the Presbyterian
Hospital had extreme pulsation of the abdominal aorta, with great
local discomfort, on account of the throbbing. She was sixty-five years
of age, and had within the past two years nursed her son through
tuberculosis. She failed in health, and came to the hospital emaciated,
with some chronic gastritis and diarrhoea. On examination, a distinct
tumor was felt above the umbilicus, which she had been told was due
to carcinoma. It was hard and painless ; the physical signs of aneurism
were not present ; the pulsation was extreme. A second tumor, not so
large, was felt in the right hypochondriac region. Both tumors were
dull upon percussion and surrounded by tympanitic areas. They were
also movable. While it was impossible to be sure of the nature of the
tumors, it seemed to me they were tuberculous, or simply fibrous, and
would not influence the patient's immediate welfare. Under treat-
ment, the pulsation disappeared ; the gastro-intestinal symptoms were
relieved entirely ; the patient rapidly gained in weight and strength ;
the tumors continued, but they are not so distinctly outlined because
the previously scaphoid abdomen has become distended (two years
under observation). The questions arose for decision : Was the epi-
gastric pulsation due to a throbbing aorta or transmitted by an ob-
scurely defined probable tuberculous mass in that region ? No doubt
it was the vessel alone that caused the impulse. The diagnosis must
be made by carefully weighing all concomitant circumstances and phe-
nomena that surround cancer. (See Symptomatology of Morbid Pro-
cesses.) Fecal accumulations in the colon may be made to heave by
the beat of the aorta and cause exaggerated epigastric impulse. The
bowels must be emptied before definite conclusions are arrived at.
An epigastric impulse due to one of the above-mentioned causes
must not be confounded with the impulse of hypertrophy of the right
ventricle, or to the shock of the hypcrtrophicd heart transmitted to
the left lobe of the liver. In hypertrophy of the right ventricle or
598 SPECIAL DIAGNOSIS.
dislocation of the heart from disease within the chest, the impulse may
be seen to the right or left of the xiphoid cartilage. The symptoms
and signs of right-ventricle hypertrophy explain the pulsation.
The Smaller Arteries. By inspection of the arteries beyond
the abdominal aorta we can often recognize more distinctly the condi-
tion known as arterio-sclerosis. Examination of the femoral, poplit-
eal, tibial, brachial, and radial arteries reveals dilated, tortuous, hard,
often pulsating vessels in endarteritis. Elongation of the artery, so
that instead of a straight tube it becomes a sinuous canal, turning
and twisting at short intervals, is seen. (See Arterio-sclerosis.) But
pulsation of the above-mentioned peripheral arteries may be due to
other causes. In hypertrophy of the left ventricle arterial pulsation
is prominent, although more marked in the vessels near the heart, as
the carotids. In regurgitation at the aortic orifice, pulsation is also
frequently seen.
Capillaey Pulse. The capillary pulse is seen under the finger-
nails or in the skin after hyperemia is induced by firmly stroking the
skin with the nail. It may be seen inside the lips, if a piece of glass is
pressed against them. There is rhythmical pulsation of the capillaries,
from which the surface becomes alternately white and red. It is a
sign of aortic insufficiency.
The Veins. Diseases of the veins are largely surgical and do not
frequently come under the notice of the physician. Alterations in the
veins from physical causes in the circulation, local or general, are of
frequent occurrence, and are of the greatest diagnostic significance.
The " venous phenomena " are physiological and pathological evidences
of the circulation of the blood in the veins.
Examination is limited largely to the jugular veins in general affec-
tions of the circulation ; to other subcutaneous veins in addition in
local affections. The examination is made by inspection, to determine
the size and degree of pulsation of the veins ; by palpation, to confirm
the results of inspection and to determine the presence of a thrill ; by
auscultation, to determine the presence of murmurs.
By inspection we note the presence of : A. Enlargement of the veins.
The change in size may be general or local. In both instances there
is interference with the venous return of blood.
1. General enlargements may be observed in all the veins, but
is more readily studied in the jugular veins of the neck. Associated
with the enlargement, general venous engorgement is observed, and
hence oedema (which obscures external veins), cyanosis, effusions in
serous cavities, and congestion of internal organs attend the pathologi-
cal venous phenomena. It must follow that a central disturbing influ-
ence upon the circulation is present, and so we find interference with
the circulation in the right heart to be the causal factor. This inter-
ference is due to dilatation of the right auricle and ventricle, which in
turn may have arisen from valvulitis, myocarditis, pericarditis, or, on
account of increased pulmonic blood-pressure, from emphysema and
other pulmonary obstructions. In rare instances pressure upon the
cavse by a mediastinal tumor may cause general over-fulness of the
veins.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 599
The jugular veins, both internal and external, are seen to be dis-
tended, even in stout people. The observation can better be made by
viewing the head when it is turned to the opposite side from the vein
which is under examination. The external jugular can almost always
be seen; the internal jugular frequently when engorged. They may
also be felt under these circumstances. The position of the veins can
be more readily distinguished by observing their relation to the sterno-
cleido-mastoid muscle. The internal jugular vein is seen in the inter-
sterno-cleido-mastoid fossa, just behind the sterno-clavicular articula-
tion. Here the jugular bulb is seen, and at this point in the veins
the bulbar valves are situated. When abnormally full it may project
beyond the surface and rise one-fourth or one-half inch above the
articulation. The over-fulness is more marked in the dorsal than in
the upright posture.
Local Enlargements. Local increase in fulness of the veins is due
to narrowing or closure of the venous trunk by pressure or by throm-
bosis. A mediastinal tumor pressing upon the cava will cause abnor-
mal fulness of the jugulars. The veins of the scalp become distended
and tortuous in thrombosis of the longitudinal sinus. Enlargement
of the veins of the arm or leg points to compression or thrombosis
of the axillary or femoral vein respectively. The enlargement is
associated with oedema of the respective extremity. Enlargement of
the superficial veins of the thorax is seen in intrathoracic pressure
from tumor or aneurism, rarely in dilatation of the heart. En-
largement of the veins of both legs may be due to obstruction of
the vena cava or both iliac veins. The latter is liable to occur in
pelvic tumors. When there is engorgement of the portal vein collat-
eral circulation is frequently carried on through the abdominal veins.
The veins are enlarged ; and, in some instances, the veins about the
navel enormously distended, because of a permanent patulous umbilical
vein. The crown of veins — caput Medusa — is significant of cirrhosis
of the liver and of pyelo-thrombosis. Enlargement of the veins of
the extremities, from the causes above mentioned, must not be con-
founded with the unilateral or bilateral varicosity that occurs during
and after pregnancy, after prolonged intra-abdominal pressure from
other causes, or in inflammation of the veins in the course of septic
diseases, as typhoid fever.
B. Pulsation of the veins. The circulation in the veins differs from
that in the arteries. The blood-flow is continuous. Two circumstances
modify it — respiratory movements and cardiac action.
Pulsation due to Respiratory Movements. The modification is par-
ticularly seen in the veins of the neck. During inspiration all of the
veins empty rapidly, while in forced expiration, or with strong effort,
as seen in coughing, the discharge from the veins is checked and
they become full and even over-distended. When the fulness of the
veins is normal the respiratory alterations are not observed, except
the swelling that occurs in severe coughing, as in whooping-cough.
When they arc abnormal, as from right-sided cardiac dilatation (q. v.),
they show a corresponding to-and-fro swelling synchronous with respi-
ratory movements. Upon coughing, the jugular bulb may appear as
600 SPECIAL DIAGNOSIS.
a rounded pulsating bunch between the heads of the sterno-mastoid
muscle. The internal jugular may also swell and contract. Increased
pulsation with fulness of the veins is seen during the labored expira-
tion of asthma and emphysema.
Alteration of the respiratory movements of the veins is observed in
cases of pericarditis or of mediastino-pericarditis. Normally the vessels
are drawn upon and bent during the act of inspiration — inspiratory
collapse. In the above pathological conditions they swell up in inspira-
tion and empty during expiration, directly opposite to the normal state.
Pulsation due to Cardiac Movements. The Venous Pulse. The car-
diac movements also modify the movements of the blood in the veins.
They cause rhythmical pulsation, or the venous pulse. This may be
communicated from the carotids underneath or occur in the veins.
The so-called true avid false pulses are thus produced. The true venous
pulse is divided into the (1) negative and (2) positive pulse, the former
being the pulse of health, the latter the pathological venous pulse.
1. The normal or negative venous pulse is so designated because it is
not due to positive action of the heart, causing retrogression of blood.
It can be demonstrated by pressure of the finger on the middle of the
veins. Pulsation ceases below because the blood does not regurgitate
from the heart ; it does not pulsate above, or the pulsation lessens
materially, indicating non-transmission from the carotid. The negative
venous pulse is presystolic in time, and can only be seen in the external
jugulars. The vein collapses during the systole and distends or pul-
sates before the systole, hence is presystolic. This may be observed
by inspection, keeping in view also at the same time the apex or
carotid pulse. The systolic collapse occurs quickly. The presystolic
pulsation follows slowly, with an appreciable interval between the
two. The presystolic distention occurs during the time that the auri-
cle is filled with blood ; the collapse occurs when the auricle is empty
— that is, during the ventricular systole. When the auricle is dis-
tended the flow of blood from the veins is impeded, and hence the
jugulars are overfilled. "When the auricle is empty the flow of blood
from the veins is favored, hence the vein collapses (the systole).
Diagnosis It may be distinguished from pulsation in the artery
by the time, by the greater size of the surface-pulsation on account
of the greater size of the vein, by the impression of undulation rather
than shock received by the finger, by the impression of passive force
rather than of active power. Sometimes it is extremely difficult to
recognize the normal or negative venous pulse on account of undula-
tions in the veins produced by the blood-flow and transmitted carotid
impulse.
2. The positive venous pidse is systolic in time. It is due to positive
action of the heart. It is pathognomonic of tricuspid regurgitation
(q. v.). When the right ventricle contracts the regurgitant blood-
wave is transmitted into the cava through the incompetent valves.
It appears first in the internal jugulars or their bulbs, because of the
direct course of the innominate and right jugular from the cava. Sub-
sequently the left may become affected. If the valve in the vein is
competent, the systolic regurgitant wave is seen there only. The pul-
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 601
sation of the enlarged bulb is seen in the inter-sterno-cleido-mastoid
fossa. Usually the valve is insufficient, or rapidly becomes so, and
the systolic back-wave therefore extends upward. The same wave is
transmitted to the viens of the liver, causing systolic swelling and dias-
tolic collapse of the liver. These conditions are produced, as pre-
viously mentioned, in right-sided dilatation of the heart, providing
there are moderate force and slowness of the heart's action. When
the heart becomes very weak and rapid the pulsations disappear.
Diagnosis 1. The negative, true, or normal pulse is distinguished
from the pathological or positive pulse, and from the transmitted pul-
sation, by its time. It is timed by the apex-beat, or the carotid pulse
of the opposite side. The negative pulse (normal) is presystolic, the
collapse of the vein systolic ; the positive pulse (pathological) is sys-
tolic in time. The patient should hold his breath, as increased respi-
ratory movement will modify the venous pulsation. 2. The imparted
or false puke is transmitted from the carotids, and can be recognized
by stopping the flow of blood by pressing the finger or barrel of the
stethoscope on the vein in the middle of the neck, after it has been
emptied by pressure upward. If the pulsation is communicated (false
pulse), the vein remains empty in the portion nearest the heart, and
fills up in the peripheral portion, while the pulsation ceases toward the
centre (below) and increases in the periphery (above the finger). If
the carotid artery is pressed upon as near the heart as possible, the
transmitted pulse will cease. In the positive pulse the portion near
the heart slowly fills from below upward.
In congenital heart disease with patulous foramen ovale the positive
venous pulse may sometimes be seen, but is extremely rare.
Diastolic collapse is seen in pericarditis, as observed by Friedreich.
The collapse occurs at the time of the cardiac diastole. It is distin-
guished from the true pulse as follows : compress the jugular vein,
pulsation ceases above and below the seat of compression.
Pulsation of other veins. Quincke has described venous pulse in
the hand and back of the foot, with the capillary pulse in aortic re-
gurgitation and in anaemia. It is probably only the arterial pulse
propagated through the capillaries. The positive pulse may be seen
in the veins of the face, in the cutaneous veins of the arm and hand,
and in the superficial mammary veins, and in the veins of the legs.
Palpation. The Heart. Palpation confirms inspection as to the
shape of the prsecordia, the position and the extent of the impulse, and
the condition of the intercostal spaces. In addition, we determine by
palpation the character and strength of the impulse, and the presence
or absence of valv&shock and of thrills or of friction. Palpation also
reveals oedema of the surface and fluctuation.
The [mpulse. In a normal chest with moderate walls a, slightly
prolonged, moderately strong shock is transmitted to the hand when
placed over the pra?cordia. It is synchronous with the cardiac and
precedes the radial pulse. It is, therefore, systolic in time. It is
stronger when the patient leans forward, exhales freely, removing the
lung from the surface, and when the chest-walls arc thin ; it is weaker
in opposite conditions.
602 SPECIAL DIAGNOSIS.
Character and Strength of Impulse. A. Strength increased. 1.
Overaction. In the violent action of the heart that attends palpita-
tion, and in the increased action in the early stages of fevers or of in-
flammation, the force of the cardiac impulse is much increased. 2.
Disease, (a) Alterations outside of the pericardium. Increase in the
extent of the impulse is attended by increased strength when the heart
is hypertrophied or the lung retracted. (6) Alterations within the peri-
cardium. In pericardial adhesions the heart is held more firmly
against the wall and may give the appearance of strength to the im-
pulse, (c) Disease of the heart. True increase in force of the impulse
is seen in disease of the heart. When the organ is hypertrophied or
the seat of dilated hypertrophy the force of the impulse is increased,
sometimes to an almost unbearable degree. Uplifting of the precor-
dial area or even of the lower half of the anterior part of the chest is
seen. The hand or the head laid over the heart is forcibly lifted with
each systolic contraction. This great force is most pronounced in
the enormous hypertrophy that occurs in cases of aortic obstruction.
It is the impulse and force of the so-called cor bovinum. In dilatation
the impulse is diffused and wavy.
Fro. 153.
Abnormal palpable impulse and thrills.
1. Diastolic impulse palpable from closure of pulmonic valve. 2. Presystolic impulse in mitral
obstruction in third, fourth, and fifth interspaces. 3. Thrill at aortic orifice ; systolic, obstruction ;
diastolic, regurgitation. 4. Thrill at pulmonary orifice ; systolic, obstruction; diastolic, regurgi-
tation. 5. Thrill at mitral orifice ; systolic, regurgitation ; diastolic, obstruction ; presystolic, ob-
struction." 6. Thrill at tricuspid orifice.
B. Strength lessened. This occurs from causes which diminish the
extent of the impulse or cause it to be absent entirely, as when mate-
rial intervenes between the heart and the chest-wall, or the heart
is weakened by disease. Hence (following the classification above) (a)
in emphysema of the lung ; (6) in pericardial effusions ; (c) in fatty
heart, or myocarditis, in dilatation, and simple weakness of the heart,
the strength of impulse is lessened.
Valve-shock. The shock of the closure of the valves can be felt
by the hand when placed evenly over the proecordia. The shock from
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 603
the pulmonary aud aortic valves is best transmitted. It is felt most
distinctly in persons with thin chest-walls, and when there is height-
ened tension either in the aorta or pulmonary artery. The shock
follows the impulse. It may be localized more accurately with the
finger-tips in the third or fourth interspace along the left edge of the
sternum. The shock of the auriculo-ventricular flaps is also trans-
mitted. The shock is synchronous with the first sound. It is felt in
the left fourth interspace near the sternum, sometimes over it. It is
due to dilatation of the heart, and is more readily felt in thin-chested
persons.
Thrills. A thrill is produced when the blood is thrown into
vibration by passing over a rough surface. It may be created with
the systole or during the diastole. It can only be created at the time
blood is passing through the orifices. 1. The most common seat of
the thrill is the apex. If the hand is placed in close proximity to the
surface of the chest at this point, a vibration or tremor is transmitted
to it in most cases of mitral obstruction. The blood is passing from
the auricle to the ventricle ; as this takes place before the systole, the
thrill is felt before the impulse or carotid pulse. It is 2^' e systolic in
time. It is sometimes difficult, however, to distinguish it from the
impulse. Its character cannot well be described. The hesitating,
jogging manner of the vibrations or the thrill is clearly transmitted to
the hand. 2. The next most frequent seat of thrill is the second costal
cartilage on the right. Here the thrill or vibration is systolic in time
and is caused by obstruction at the aortic orifice. It may be felt away
from the heart, in the aorta, or in the carotids. The aortic cusps are
thickened, contracted, and stiffened by a sclerotic endocarditis, or the
orifice is occluded by valvulitis. 3. Sometimes a thrill is felt at the
apex with the systole — -first sound. This occurs rarely, but must not
be confounded with the before-first-sound thrill. It is never so dis-
tinct, and is not made up of a series of vibrations. It is due to re-
gurgitation at the mitral orifice. 4. Rarely a thrill is felt at the second
costal cartilage on the right, with the second sound. It may be felt
along the course of the sternum also, and is due to regurgitation
through the aortic orifice. The systolic thrill must not be confounded
with the thrill elicited over the aorta or at the aortic cartilage, which
is due to aneurism. 5. At the second costal cartilage on the left a
thrill is sometimes felt. It is systolic in time and is not transmitted.
It is due to obstruction at the pulmonary orifice. 6. At the lower
portion of the sternum a thrill systolic in time is also felt, due to tri-
cuspid regurgitation. Care must be taken not to confound the above-
mentioned thrills with those due to aneurism. (See Aneurism.)
Pericardial Friction. In addition to the thrills, a friction or
to-and-fro rubbing is transmitted to the hand in cases of pericarditis,
in the first stage. The friction may be felt all over the heart region,
but is pronounced in the third or fourth interspace. It may be de-
tected on slight pressure or only when the tips of the fingers are pressed
firmly against the interspaces.
It is important to remember that the posiiioyi of the patient weakens
or modifies the thrill or friction. When the patient is lying down it
604 SPECIAL DIAGNOSIS.
may not be felt. The upright posture or leaning forward makes it
evident, and hence the patient should be instructed, if possible, to
assume this position in the examination.
The Arteries. The results of inspection are confirmed. In addi-
tion, the artery is examined, to determine its tension, the character of
the coats, and the presence of thrills. Pulsation of organs. It is said
that in aortic regurgitation an arterial liver-pulse, similar to the venous
liver-pulse, can be felt when the hands are placed over that organ.
Similar pulsation may be felt in the spleen.
In examining the arteries it is important, as will be detailed in the
chapter devoted to the pulse, to compare the arteries of the two sides.
Often the pulse-wave is found to be unequal in force, in volume, and
in time. This is almost always due to obstruction to the passage of
the blood. "When not due to endarteritis or to aneurism, it is due to
the pressure of a tumor on the vessel somewhere in its course. A
thrombus or embolus in the artery may likewise cause the condition.
A difference in the radial and the femoral pulse points to obstruction
in the thoracic or abdominal aorta. Anatomical variations must be
remembered.
The Pulse. The pulse is an index to the force, frequency, and
rhythm of the heart's action and of the pressure, or tension, which is
maintained in the arteries.
General Observations. The frequency of the pulse before birth
is from 120 to 140 beats in the minute. From this time it is dimin-
ished in frequency up to adult life, 72 being then accepted as an aver-
age ; the number of beats, however, is often under 72, and sometimes
over that. In old age the pulse-rate is again increased. Sex has some
influence. The rate is slightly higher in females than in males of the
same age.
The frequency of the pulse is subject to diurnal variations, at times
corresponding with the diurnal rise and fall of temperature. The rate
will, therefore, be highest in the afternoon and evening and lowest in
the earlv mornino; hours.
The position of the body has also a modifying influence. The pulse
is more frequent when a person is standing than when he is sitting,
and more frequent when he is sitting than when he is lying down.
Walking, running, bodily and mental exertion, fear, and excitement
all tend to accelerate the pulse.
During and for one or two hours after a meal the pulse-rate is higher,
especially if an alcoholic or other stimulant, such as coffee, has been
taken.
How to Take the Pulse. To make a correct count of the fre-
quency of the pulse, the conditions just mentioned, as normally modi-
fying its rate, should be borne in mind. If the object of the count
is to determine the rate which is normal for a particular individual,
several counts will be necessary at different times and under different
conditions, such as sitting and standing. The best time for the physi-
cian to take the pulse will have to be determined by his own judgment
in each case. If the patient comes to his office and is excited by the
prospect of an examination, it will be well to wait until he becomes
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 605
calm. On the other hand, if he is calm at first, a count at that time
is to be preferred to one made after the patient has been disturbed by
a physical examination. In the same manner, on visiting a patient at
his house, the judgment of the physician must decide whether to count
the pulse immediately on his arrival or to postpone it until, by general
conversation, all apprehension and alarm on the part of the patient
have been allayed. In general, it may be said that if the physician
finds upon his arrival that the pulse is more frequent than the condi-
tion of the patient would lead him to expect, he should wait a while,
endeavor to find out whether anything has served temporarily to dis-
turb the circulation, and then make the count when the conditions are
most favorable. Some patients are so nervous that the mere act of
placing the finger upon the wrist sends the pulse-rate up ten or twenty
beats in the minute. In such cases an effort should be made to obtain
a count without the patient's knowledge by observing the pulsations
of the temporal or carotid. In other cases it may be well to entrust
the counting of the pulse to the nurse or to a member of the family.
In infants and young children, count while they are asleep. In
febrile conditions the count is more likely to be too high than too low.
In hospital practice, or when a nurse is constantly in attendance, the
pulse and respiration should be taken at the same time as the temper-
ature. But the nurse must be warned against taking them under
dissimilar conditions upon successive days. For example, the pulse
should not be taken one day while the patient is lying down, quiet
and comfortable, and compared with the count of the next day when
the j^atient is sitting up or has just had some hot liquids, or a spell of
coughing, or been subjected to some other disturbing influence.
The preferable position is the recumbent one in the case of patients
in bed, and in the sitting position in those not confined to bed. Care
should be exercised in all cases to see that the patient's position is
comfortable and that nothing obstructs the artery or interferes with
the unimpaired flow of the blood.
The wrist is the place usually selected at which to feel the pulse.
At this point the radial artery passes over the radius, and can readily
be compressed and its character made out. An old-fashioned rule
prescribes that three fingers should be applied to the artery, the index-
finger of the physician being nearest the heart. In particular cases it
may be advisable to count the pulse at the temporal or carotid artery.
The fingers should be applied so that the beats can be most distinctly
felt. The beats are counted for fifteen seconds by the second hand of
a watch when only an approximate count is desired, or when time is
a factor, and then multiply by four. It is better to count the pulse
for half a minute, and still better for a full minute.
The arteries of the two sides must be compared. Difference in the
force, volume, and time may be due to the anomalous distribution of
arteries. In disease, it may occur in aneurism and atheroma, in press-
ure on the trunk from external disease, and in embolism and throm-
bosis.
Condition of the Walls of the Artery. The condition of
the artery is often of more importance than the pulse-rate. A health)"
606 SPECIAL DIAGNOSIS.
radial artery, in a person not advanced in } 7 ears, can be compressed
easily against the radius without the finger being able to differentiate
the artery from the other tissues. But as age advances, and as the
result of certain constitutional diseases — syphilis, gout, chronic endar-
teritis, alcoholism, and others — the artery tends to become thicker, so
that in pronounced cases it cannot be obliterated, but is rolled like a
cord or pipe-stem between the compressing fingers and the bone.
Small specks or plates of atheroma, feeling like hard particles in the
coats of the artery, may be detected. The artery has a beaded feeling.
Fatty degeneration of the organs is likely to occur when the arteries
are in this condition, and apoplexy is to be feared.
Tensiox. Tension is the word used to express the degree of blood-
pressure — that is, of distention of the arteries. Normally, the pulse
nearly or quite subsides between the beats, but little pressure being
required to obliterate it. High tension may be said to exist when the
artery remains continuously full between the beats (Broadbent). It is
produced by plethora ; increased heart-action ; contraction of the
arterioles, as by chill ; and obstruction in the capillaries. The condi-
tions which bring about obstruction in the capillaries in the order in
which they are enumerated by Broadbent are : 1. Age. The liabil-
ity to high arterial tension increases with the age, especially after
middle-life. 2. Heredity. There is in some families a marked ten-
dency to high tension. The younger members show its effects in head-
aches and bilious attacks, while the older ones develop chronic heart
disease and apoplexy. 3. Disease of the kidney. Parenchymatous,
but especially interstitial nephritis, is associated with high arterial
tension ; this, with accentuation of the aortic second sound, is one of
the early and, therefore, one of the most valuable indications of chronic
Bright's disease. 4. Gout. Gout and lithsemia are almost always
accompanied by high arterial tension. 5. Diabetes in old persons
associated with gout. 6. Lead-poisoning. 7. Pregnancy. 8. Anaemia.
9. Emphysema and chronic bronchitis. 10. Mitral stenosis.
As regards arterial tension in persons presenting signs of angina
pectoris, Sansom asserts that if the tension is increased, even though the
signs are not typical, the fear, present or remote, of true angina is justified.
On the other hand, if there is persistent low tension, especially during
the painful crisis, it is almost certain the affection is a false angina.
Low tension of the pulse is characterized by a softness and a com-
pressibility in excess of the normal. This, like the high tension pulse,
may be 'a family peculiarity. It is met with in conditions of great
depression and exhaustion, and wherever there is a marked cardiac
weakness. It is most common in fever, particularly in typhoid, in
which also an accompaniment of low-tension pulse — namely, dicrotism
— is met with in a marked degree. Fat persons are apt to have low-
tension pulses, and it may occur in any person temporarily under the
influence of external warmth and moisture, such as a hot bath, or after
taking hot drinks, or under the influence of depressing emotions, and
after diarrhcea, or copious urination.
Volume. The volume of the pulse should be noted. It is usually
large in conditions of pyrexia and when the tension is low. A small
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 607
pulse is met with in many conditions other than weakness of the
heart-muscles. In aortic stenosis the pulse is small, and in mitral
stenosis it is small, of high tension, and frequently irregular. In gen-
eral contraction of the arterioles, as happens under the influence of a
chill, the pulse is small. In Bright's disease it is sometimes very
small, slow, and hard. Some care will be required to differentiate such
a pulse from a weak pulse. In acute peritonitis the pulse is apt to be
small and hard.
Rhythm. The rhythm of the pulse is of diagnostic importance.
In health one beat succeeds another at equal intervals of time, and the
successive beats are of the same force and quality. Here, also, how-
ever, as in other conditions, there are variations within physiological
limits. In some persons the pulse-rate is somewhat accelerated during
respiration and becomes slower in the pauses which follow breathing.
In disease, disturbance of the rhythm occurs as intermission or as
irregularity. Intermission signifies a dropping of a pnlse-beat ; sev-
eral normal pulse-beats succeed each other, and then the pulse is absent
during the time occupied by one or two beats. The intermission may
occur at regular or at irregular intervals — that is to say, every third,
fifth, or sixth beat may be wanting, or the intermission may be irregu-
lar — now a second, the next time a fifth or a third beat being absent.
Moreover, the intermittent pulse may be constant, or it may, and more
frequently is, only occasional. It is not characteristic of any one dis-
ease or condition, and it may exist without the patient's knowledge
and without producing any perceptible effect upon his health. Some-
times it is met with in a fatty heart, and this disease may be suspected
if the intermittent pulse is associated with a weak first sound of the
heart without valvular lesion, and evidences of failing circulation, such
as oedema of the feet. More frequently, however, the intermittency
is a symptom of nervous depression, or is caused by tea, coffee, tobacco,
or digitalis. So far as prognosis is concerned, it is much less serious
than irregularity. Broadbent says he has met with it at the age of
eighty, when it was known to have existed for forty years.
Irregularity is characterized by differences in time, force, or volume
of successive beats. A full beat is succeeded by another, which is
smaller and weaker, or successive beats occur at irregular intervals
of time. Irregularity may or may not be associated with intermission.
In advanced cases of mitral stenosis the pulse is both irregular and
intermittent. The irregularity may be habitual or occasional ; the
former is due most frequently to mitral lesions, but sometimes occurs
without assignable cause, and is attributed to disturbance of the nerve-
supply ; the latter is due to digestive disturbances and to the effect of
nicotine and digitalis. Irregularity is not incompatible with health,
but is much more likely to be of serious import than intermission. It
occurs in diseases of the brain, in degeneration of the heart as well as
in valvular lesions, and in grave cases of febrile diseases, such as
typhus and typhoid, when the heart-muscle is involved. Some cases
of Graves' disease arc characterized by great irregularity instead of
excessive rapidity of the pulse. Irregularity may occur in rheumatoid
arthritis also, though increased frequency is the rule.
608 SPECIAL DIAGNOSIS.
Frequency. The frequency of the pulse is of aid in diagnosis.
Increased frequency. 1. The pulse is increased in frequency in all
the febrile diseases, and generally in the proportion of eight to ten
beats for each degree of rise in temperature above 98.3°. But there
are important exceptions. In typhoid fever the pulse is slower in pro-
portion to the temperature and the gravity of the disease than in most
of the other acute febrile diseases. It may not beat above 85 in mild
cases, and in severe cases frequently does not rise above 100. Conse-
quently a pulse of 120 is of much graver import than it would be in
other diseases. It may be more frequent during convalescence than
during the febrile stage. This pulse-rate helps to differentiate it from
tuberculosis, malignant endocarditis, and septicaemia.
2. The pulse of scarlet fever often aids materially in diagnosis. A
pulse of 120 to 160 is the rule from the development of the sore-throat
to the completion of the eruption. In measles, rubella, diphtheria,
and follicular tonsillitis it is much slower during the early stages.
3. In Graves' disease great frequency of the pulse is the essential
and most constant symptom of the disease. The pulse may be con-
stantly considerably over 100, and in attacks of palpitation 200 or
more. In these attacks there may or may not be precordial distress
and mental anxiety. Here belong the cases described as paroxysmal
hurry of the heart, etc., the thyroid and ophthalmic symptoms being
absent.
4. Cases have been reported of extreme frequency of the pulse
(160 to 240) without palpitation, dyspnoea, or any signs of Graves' dis-
ease. Some of the patients have been able to perform much bodily
and mental labor, notwithstanding that the rate mentioned was main-
tained persistently for weeks. To this class of cases the name tachy-
cardia has been provisionally applied until their pathology is under-
stood.
5. In all forms of valvular disease, except aortic stenosis with fail-
ing compensation, the pulse may be increased in frequency. In col-
lapse ; in weakening of the heart ; and in central or peripheral vagus
disease, the pulse is increased. Mitral stenosis may be latent until
great excitement, overexertion, and particularly running or forced
marches bring on palpitation, or simply abnormal and persistent fre-
quency of the heart's action, with or without dyspnoea.
6. Attention has been called, especially by Dr. J. Kent Spender, to
acceleration of the pulse as an early symptom of rheumatoid arthritis.
The pulse increases gradually until it reaches a range of 110 to 120, and
it persists at that rate with little diurnal variation, even after the
arthritic symptoms subside.
7. In locomotor ataxia permanent moderate acceleration of the pulse
(90 to 100) is a frequent symptom.
8. Infections. In the puerperium increased frequency with irregu-
larity of the pulse is a surer indication of intra-uterine mischief than
is the temperature. So, too, in all cases of inflammation so situated
that the products are absorbed into the circulation and not discharged
externally, the pulse shows by its increased frequency that a septic
process is going on.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 609
Diminished Frequency. A slow pulse (bradycardia), under 60, like
a frequent pulse, is sometimes habitual, and sometimes a family char-
acteristic. Pathologically, it is met with in conditions which increase
the resistance in the arteries, such as Bright's disease, especially acute
glomerulo-nephritis ; but it is especially common in jaundice. The
bile-acids have the effect of retarding the action of the heart.
A slow pulse is met with in certain forms of heart disease, as aortic
stenosis, but it is not constant in any of them. It occurs in fatty de-
generation, especially when due to obstruction, by atheroma or other-
wise, of the coronary arteries. W. J. Pettus has reported a case of
bradycardia associated with aneurism of the right sinus of Valsalva,
involving the orifice of the right coronary artery. When it appears
in the late stages of valvular affections or specific diseases with cerebral
symptoms it is usually a sign of danger. It is seen in articular rheu-
matism (Atkinson). According to Riegel, it is most common in con-
valescence from acute disease, particularly pneumonia, typhoid fever,
erysipelas, and rheumatic fever. It is also frequently encountered in
diseases of the digestive organs and of the urinary organs, particularly
acute nephritis. Moreover, it is generally slow in myxoedema, and both
slow and irregular in epilepsy. It is slow, not uncommonly, also, in
melancholia and in the early stages of cerebral meningitis and in tumors
and cerebral hemorrhage.
The Sphygmograph. The sphygmograph, as its name implies, is
an instrument for recording in writing the volume, force, frequency,
Fig. 154.
Dudgeon's sphygniograph.
tension, and general characteristics of the pulse. Many forms of the
instruments have been devised since the first one of Marey. The later
models have the advantage of simplicity and ease of application. One
of the most convenient is Dudgeon's. It lias its faults, particularly
in exaggerating the vibrations when the pulse is large and the heart is
acting violently ; nevertheless, with care, trustworthy tracing can lie
39
610 SPECIAL DIAGNOSIS.
obtained in all ordinary cases. No matter what instrument is used,
the value of the tracing depends very largely upon the personal skill
and experience of the one who takes the tracing ; hence the sphygmo-
graph occupies a position very different from the thermometer and
other instruments of precision. While it is true that a person can
learn to detect nearly all the variations of the pulse by palpation alone,
yet the tracing has the great advantage of permanency, and many per-
sons are led to palpate the pulse more carefully by seeing in a sphyg-
mographic tracing a dicrotism or irregularity which had escaped their
attention.
The expansile pulsation of the artery is communicated by a system
of levers to a needle, which graphically records the qualities of the
pulse upon smoked paper.
Directions for Using Dudgeon's Sphygmograph. 1. Wind up, by
the button, the clockwork contained in the box. The clockwork
carries the smoked paper under the writing-needle.
2. See that the patient is in a comfortable position, and have him
hold toward you either hand with wrist exposed, fingers gently flexed,
and muscles relaxed.
3. Apply the instrument by slipping the band over the hand, the
free end of the band being passed through the retaining clamp. The
metal box is placed toward the elbow.
4. Now adjust the instrument by placing the bulging button which
connects the levers directly over the radial artery at its most accessible
point.
5. Keep the instrument accurately in place with the left hand, and
draw the band through the clamp with the right until the writing-
needle plays freely with each pulsation of the radial artery, then fasten
the band by screwing up the clamp.
6. Introduce the smoked paper between the rollers and under the
writing-needle.
7. Vary the pressure by means of the thumb-screw, which connects
with an eccentric, until the best apparent amplitude of vibration is
obtained.
8. Instruct the patient not to move the fingers or hand, and further
steady them for him with your own right hand.
9. Start the clockwork by pushing the bar at the top of the clock-
work box.
10. Allow the paper to run through, and then stop the clockwork.
The clockwork is so regulated that five inches of smoked paper
pass through in ten seconds, so that six times the number of pulsa-
tions recorded on the paper represent the pulse-rate per minute. Each
instrument, however, should be tested and its time determined. The
clockwork should be wound up for every tracing.
Considerable practice will be required to take a tracing rapidly and
accurately, in spite of the simplicity of the mechanism.
Several tracings should be taken at different pressures and com-
pared, or, what is better, as suggested by Sansom, stop the clockwork
and alter the pressure two or three times, so as to have the effect of
varying pressures on one tracing.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 611
The technique of sphygmography needs a few words. Smoked
paper is generally used for the tracings. A paper glazed upon one
surface and rough upon the other has some advantages. This paper
has to be cut in strips about seven-eighths of an inch wide and six
inches or more long. The cutting should be done with care so that
the edges are smooth and even, otherwise the paper sticks in the in-
strument and the tracing is spoiled. The glazed surface is blackened
by holding it above the flame of a small piece of burning gum cam-
phor. For convenience a strip of tin, bent upon itself at each end, so
as to catch and hold about an inch of the ends of the paper, may be
used to prevent the fingers from becoming blackened and to preserve
the ends of the paper unblackened for memoranda. The blacking
should not be too thick, otherwise the needle will not plough through
it easily, and the white line of the tracing will not be distinct. After
the tracing has been made, the name of the patient, the diagnosis of
his disease, the date of the tracing, and the amount of pressure em-
ployed should at once be scratched with a fine-pointed pen upon the
blackened surface beneath the tracing, or written in ink upon the un-
blackened end of the paper. The tracing is then ready for preserva-
tion. This is done by dipping it into a solution of shellac or in tinc-
ture of benzoin (gum benzoin oj, alcohol f-5vj) ; the alcohol evaporates
and leaves a smooth, glazed surface. Dr. Dudgeon recommends as a
varnish a solution of gum damar §j, rectified benzoline f§vj. When
the tracing is likely to be subjected to friction, a second or third coat
should be applied subsequently.
Explanation of the Normal Pulse-tracing. With each contraction of
the left ventricle a volume of blood is forced into the aorta, which dis-
tends it, the distended impulse being transmitted by a wave-like
motion to remote arteries. This distending impulse lifts the button of
the lever sharply upward, forming the so-called percussion up-stroke,
Fig. 155.
a, b, percussion up-stroke; a, b, c, percussion wave; c, d, e, tidal wave; e,f,g, dicrotic wave ;
d, e,f, aortic notch ; /, g, diastolic period.
a b ; but the distending impulse is exaggerated by the system of
levers, and having been thrown up too high, the lever falls by its
own weight too low, so that it is again caught and lifted by the tidal
blood, forming the tidal- wave, c d e. The gradual descent of the lever
is again interrupted at efg, forming a wave, called the dicrotic wave,
due to the recoil of the blood from the closure of the aortic valves.
(Fig. 155.)
Roy and Adami believe that the apex (h, b, d) of the percussion-
wave is due to the sudden pulling down of the auriculo-ventricular
612 SPECIAL DIAGNOSIS.
valves by the papillary muscles during the first rapid part of their
contraction. Hence they call the wave the " papillary wave."
The second wave (c, d, e) corresponds in time, they say, with the
outflow from the ventricle due to the continued contraction of the
heart-wall and papillary muscles after the flaps have been pulled down.
Hence, they prefer to call this wave the " outflow remainder," instead
of " tidal " wave.
Interpretation of Pulse-tracings. Sphygniographic tracings
must be interpreted in accordance with the known peculiarities of the
patient, his history, and the associated physical signs.
1. The Amplitude. The height of the percussion-stroke varies con-
siderably in health. It is increased in conditions which bring about
low tension and rapid systolic contraction of the heart. Hence the
febrile pulse is usually one of considerable amplitude. It is increased
also very markedly hi aortic regurgitation. Suddenness of systole
rather than force determines the height of the up-stroke. (See Fig.
156).
Fig. 156.
Tracing from a case of aortic regurgitation.
2. Obliquity of the Percussion-stroke. Normally the percussion-
stroke ascends vertically from the base-line. A tendency to incline
forward indicates a weak and laboring heart or an aneurism inter-
posed between the radial artery and the heart. In the latter case
there is also a tendency to rounding of the summit of the percussion-
wave, and the up-stroke is generally short. There is usually also
irregularity in successive pulsations, some showing the gradual ascent
and rounded summit much better than others. Sometimes, however,
when aneurism exists, there is no evidence of it in the tracing, and
differences upon the two sides are not always significant. (See Fig.
157.)
Fig. 157.
Tracing from a case of aneurism of the aorta.
Disease at the aortic orifice and the intervention of a considerable
quantity of subcutaneous fat or of any growth superficial to the vessel
may cause a marked obliquity of the percussion-stroke. Sansom
asserts that, such causes excluded, as well as aneurism and organic
disease of the aorta and its valves, a sloping line of ascent, observed
under various gradations of pressure, indicates feebleness of the left
ventricle. He considers it of higher diagnostic value than irregularity,
which he says is often neurotic.
3. Increased Breadth of the Apex of the Percussion-icave. The
breadth of the apex of .the percussion-wave indicates the time during
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 613
which the artery is kept full by the systole of the left ventricle.
When the left ventricle acts slowly and forcibly the arteries will be
kept distended for a longer time, and this distention will be manifest
in broadening of the apex of the tracing. (See Fig. 158.) The degree
Fig. 15S.
From a case of aortic stenosis, showing increased tension and the pulsus bisferiens.
of distention of the artery is called tension, hence a broadening of the
apex is an evidence of high tension. As the word " high " does not
indicate the duration of the tension, Sansom has very properly sug-
gested that we should speak of persistent high tension as " prolonged "
tension. This, then, is the significance of the broad top of the tracing.
(See Fig. 159.)
Fig. 159.
From a case of mitral stenosis, showing increased tension and some irregularity.
Prolonged arterial tension occurs when there is a strong heart acting
slowly, a large volume of blood, or obstruction in the capillary circu-
lation. (For specific causes, see under Tension.)
The amount of pressure required to develop the characteristics of a
pulse, and. still more, the amount required to obliterate it, are good
indexes of the degree of tension present. Some pulses, however,
appear to the touch to be of prolonged tension, but a sphygmogram
does not show it. Such cases are often explained by the fact that the
heart has begun to fail under the strain put upon it by prolonged
obstruction in the capillaries. There may be regurgitation also from
the mitral or aortic orifice.
4. Acute Angle of the Percussion-wave. When the heart's action is
feeble or sudden, the volume of blood small, or the resistance in the
Fig. 160.
Low tension with irregularity, from cases of mitral regurgitation.
capillaries much diminished, the up-stroke of the tracing is vertical,
and the down-stroke forms an acute ancde with it. The dicrotic wave
•
is pronounced, and often descends unduly low, sometimes to the base-
line. These are the characteristics of low tension. (See Fig. 160.)
When the dicrotic wave springs from a lower level than the base-line
614
SPECIAL DIAGNOSIS.
of the tracing it is hyper 'dicrotic. When the dicrotic wave is wholly
effaced in the succeeding up-stroke it is monocrotic.
While dicrotism is commonly associated with low-tension pulses, it
is occasionally met with also in high-tension pulses. Sansom says,
however, that he has scarcely ever observed the conjunction of broad
summit and marked dicrotism without the patient's manifesting the
sign of failing heart.
5. Irregularity of the Base-line. This occurs normally in some
persons as the result of respiration, especially deep breathing. It
occurs in respiratory diseases also, and in affections causing dyspnoea.
Decided undulation of the base-line, the curves being irregular, occurs
in tubercular meningitis.
6. Differences in the Height of Successive Percussion-waves or in their
Distance from Each Other. These are written evidences of disturb-
ance in the rhythm of the heart. The first expresses irregularity in
volume of successive beats, and the second irregularity in time. When
this latter amounts to the omission of a beat it is called intermission.
All these changes are shown in Fig. 161.
From a case of advanced mitral stenosis, showing extreme irregularity and intermission.
The Veins. Thrombosis. This is usually detected by palpation,
and occurs most frequently in the femoral vein. The vein is trans-
formed into a firm, round cord, and is distinguished from the artery
by the absence of pulsation. Thrombosis in these veins and in the iliac
veins higher up occurs in acute infectious diseases and in the debility
of the aged. Dropsy in the area of distribution of the veins is per-
ceived.
Percussion By means of percussion the shape and size of the heart
and changes in the area of cardiac dulness are determined. (See the
Lungs for discussion on percussion.) To determine the size of the
heart, both superficial or light, and deep, or strong, percussion must be
employed. By the former we determine the area of superficial or
absolute cardiac dulness ; by the latter, the area of deep cardiac dulness.
1. The Area of Superficial or Absolute Cardiac Dulness.
(See Plate XVI.) It is the area not covered by the lung at the time
of inspiration. The lungs overlap the heart, and, in inspiration, allow
a small area to be in contact with the chest-wall. The percussion-force
employed must be light, so as not to elicit the resonance of the extreme
thin edge of the lung. The area extends from the fourth to the sixth
costal cartilages. The right border may be roughly defined by a line
drawn along the left edge of the sternum from the upper border of the
fourth rib downward ; the left border by a line extending from the upper
border of the fourth rib at the left edge of the sternum to a point
DISEASES OF HEAR T, WtoOD VESSELS AND MEDIASTIN UM. 615
midway between the parasternal and the mammillary line in the fifth
interspace. The lower border is continuous with liver dulness.
Method. The right border is determined by percussing from right
to left toward the median line. Always begin to percuss far enough
from the heart to get the clear pulmonary note. To insure uniformity,
select a definite area from which to start in all cases. Apply the
finger vertically at first. The right border may correspond with a
line outside of or along the right edge of the sternum, with the median
line or the left edge of the sternum, or even beyond the latter. After
the edge of modified resonance is reached, percuss with the finger par-
allel to the ribs, to control the result previously secured, and as each
interspace is percussed the upper limit of liver-dulness and the tri-
angle (Ebstein's) between the liver and heart may be determined.
The left edge is determined by percussing in vertical lines from a
point near the axilla toAvard the heart. Opposite the second and third
interspaces the aorta on the right side, and the pulmonary artery on
the left, will cause impairment of the normal pulmonary resonance.
The student should acquire the habit of proceeding from definite fixed
positions toward the heart, and to observe the changes during inspira-
tion and expiration. The lower border and rounded apex of an en-
larged heart cannot be defined if the stomach contains food or fluid.
It is triangular in shape, with the apex pointing downward.
The cardio-hepatic triangle is the more or less resonant area in the
right fifth interspace which separates the right heart and the liver.
The apex of the triangle points to the sternal edge, the base to the
axilla. The upper side corresponds to the right border of the heart ;
the lower is the upper limit of the liver.
Changes in Size. The superficial area of dulness or absolute dulness
is increased in pericardial effusion in enlargement of the heart and
when the heart is pushed against the chest-wall. It is replaced by
resonance in emphysema, and hence absent entirely, as the lung over-
laps or completely covers the heart. It is absent when the heart is
drawn under the lungs by adhesions and when there is air in the
pleural or pericardial sac.
Absolute Dulness Increased. The increase in the area of abso-
lute dulness in all directions occurs in hypertrophy of the heart and in
pericardial effusions. The increase in width at the base of the heart
occurs in dilatation, pericardial effusion, and aneurism of the aorta.
Change in the position of the heart, a general idea of which is obtained
by inspection and palpation, always changes the shape and extent of
the dulness. The heart should be accurately delimited when displace-
ments have taken place.
Increase of Dulness Upward. In addition to general increase
in cardiac dulness, one of the boundaries or a portion of the boundary
may be increased or extended beyond the normal line. Thus the area
of dulness may extend upward. It may be followed by extension of
the right and left boundaries. The relative area of dulness is abol-
ished. The change from pulmonary resonance to dulness is abrupt and
decided. The area of dulness becomes pyramidal or pyrifonn in shape.
It is due to effusion in the pericardium. Upward increase of dulness
61 (J SPECIAL DIAGNOWS.
may be due to disease of the vessels. Increase in the area of dulness
over the bloodvessels is usually due to aneurism. It may be general,
as in dilatation of the aorta, or local, as in aneurism. Extension of
the dulness outward or upward from the normal line may be found at
the right of the sternum (aneurism of the ascending aorta), or over the
first bone of the sternum (aneurism of the transverse aorta), or to the
left just above the cardiac area. In the last case the dulness is an
extension upward of the normal area of cardiac dulness with rounding
of the area affected ; the aneurism is situated at the beginning of the
aorta.
Increase to the Left. Increase in dulness to the left occurs in
enlargement of the heart from hypertrophy or dilatation. If the dul-
ness extends outward to the left and retains the triangular shape, with
the apex pointed, it is due to hypertrophy of the left ventricle. If, on
the other hand, it becomes quadrilateral in shape, with the apex
rounded, it is due to dilatation of the left ventricle. The results of
palpation and inspection aid in detecting the presence of one or the
other of the two conditions.
Increase to the Right. The area of dulness extends to the
right. It is due to hypertrophy and dilatation of the right auricle and
ventricle. If the auricle is dilated, the right edge is extended beyond
the normal in the third and fourth, or as high as the second interspace.
With this increase in dulness there are also seen an epigastric impulse,
venous turgescence, and pulsation of the veins of the neck or of the
liver.
Deep Cardiac Dulness. Many authorities consider the deep or
relative area of cardiac dulness of importance in diagnosis. The percus-
sion must be strong. The best method is that advised by Gibson and
Russell. Their directions are as follows : " Begin in the upper left
interspaces sufficiently far out from the sternum to secure pulmonary
resonance. For instance, in the second interspace begin in the mid-
clavicular line and percuss strongly. As soon as a slight alteration in
that sound is noted, the point is indicated by a mark. The second or
third and succeeding interspaces are percussed in like manner, bearing
in mind that the percussion must begin further out in each interspace,
in order to get pure resonance. As dulness is secured in each space a
mark is made. This is continued to the apex if that is visible, or to
the base of the chest. By joining the marks in each interspace with
the line at the base of the heart, the left border of the cardiac dulness
can be fixed." The authors correctly point out that in this way the
true apex of the heart is found, enabling auscultation to be conducted
more accurately.
The right edge of the vessels and of the heart is defined in the same
way. The difference in the sound, in passing from the lung to the
heart, is not so distinct along the right border as along the left. The
authors include the dulness which is due to the vessels at the base of
the heart, and hence begin percussion in the higher interspaces. This
they deem is proper, because it is impossible to delimit the two. The
dulness of the vessels is not so marked, however, and may be indicated
by simple change in pitch in the percussion-note. The lower border
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 617
of cardiac dulness is ascertained with difficulty, because of its close
apposition with the liver. At times there is a difference in the char-
acter of the dulness between the two organs. It can be well made out
by stethoscopic percussion. This may not be so pronounced as we pass
from the heart to the liver in the median and parasternal lines.
Toward the apex the difference is more apparent.
Pleximeteic Peecussion. For more accurate cardiac percussion,
Sansom recommends the use of a pleximeter designed by himself, by
which delicate shades in dulness can be readily heard. The pleximeter
is a thin, flat, oblong plate one inch by half an inch, which has on its
upper surface a column rising from the middle, one and a half inches
in height, which is surmounted by a second plate three-eighths to
three-fourths of an inch, set parallel with the lower plate. The instru-
ment is held between the forefinger and middle finger of the left hand,
the sensitive tips of the fingers resting on the upper surface of the
larger horizontal plate. The lower surface of this latter is held close
to the wall of the chest, and percussion with one or two fingers of the
right hand with an even and not too forcible stroke from the wrist is
made upon the upper plate. The resulting vibrations are transmitted
to the ear and are also appreciated by the digital sense of touch, so
that both senses aid in the determination of the nature of the sound
produced.
Method. The pleximeter is placed with its long diameter parallel
with the sternum, about midway between the axilla and the right ster-
nal border. Percussion is made upon the summit of the column by
one or two fingers, and the pleximeter is moved, always in parallel
lines, nearer and nearer to the sternum. A line is reached where the
vibrations are modified. Incline the pleximeter so that the vibrations
come from its left edge. This edge, or line, is practically the line of
demarcation of the dulness, and should be indicated with an aniline
pencil. It corresponds to the outline of the right border of the heart.
The process must be repeated at higher and lower levels until the entire
right border of cardiac or aortic dulness is ascertained. In passing, it
may be stated that percussing from above dowirward with the long
diameter of the pleximeter horizontal instead of vertical leads to the
upper limit of the liver as indicated by modified vibrations. At
about the fifth right intercostal space a short curved line is thus
made out along the right edge of the sternum, which indicates the
outline of the right auricle at the point where it joins the liver-
dulness. Above this, as far as the second rib, the line indicates the
outline of the right border of the auricle and the aorta. The outline
of the auricle may be in the mid-sternum ; of the aorta, at the right
edge. In percussing the left side of the chest the same method is
adopted. Begin at the level of the second rib, two or three inches
beyond the left edge of the sternum, and move to the right. Join the
lines of modified vibrations, and in this manner the left border of car-
diac and aortic dulness is secured. The outline of the apex of the
heart is readily mapped out. Over the tympanitic stomach light per-
cussion is necessary. To narrow the area of percussion about the apex,
the percussion may be performed on the larger plate, while the smaller
618 SPECIAL DIAGNOSIS.
is applied to the chest. The vibrations over the liver and over the
right ventricle are difficult to distinguish, although sometimes so differ-
ent that demarcation of the border of the ventricle presents no difficulty.
Between the apex of the left ventricle and the left lobe of the liver the
space is easily marked out.
A correct outline of the heart and of the vessels is thus obtained.
The upper limit of dulness is formed by the right auricle, the aorta,
and the pulmonary artery. Any bulging or undue expansion is due
to aneurism or aneurismal dilatation of the aorta. The space be-
tween the apex and the left lobe of the liver defines the lower border.
Sansom points out that by this method of percussion the following
absolute data can be obtained : " A projection to the right of the area
of the upper part over the second and third interspaces points to aneu-
rism of the aorta or of the innominate artery. It may be traced to the
left side of the sternum, on account of saccular dilatation of the aorta.
If the dulness at the upper part extend greatly to the left, an increase
in size of the pulmonary artery may be suspected. Along the mid-
sternal region, extension beyond the right side joining the line indi-
cating the upper border of the liver indicates distended inferior cava.
This distention occurs in right-sided dilatation of the heart, and the
dulness may also be due to dilatation of the adjoining auricle. The
outline of dulness obtained over the apex of the heart, if pointed, indi-
cates hypertrophy ; a more rounded outline shows dilatation. In un-
complicated hypertrophy the line of the right ventricle forms a much
less obtuse angle with the liver-dnlness than in dilatation. Of great
diagnostic value is the diminution of the area of dulness from atrophy
of the heart as observed in wasting, as in cancer, and in tuberculosis ;
it may also be observed in typhoid fever. In the above-mentioned
conditions it is a bad prognostic sign."
Adjacent Dulness. Care must be taken not to confound the
dulness of pleural effusion or consolidated lung with the cardiac
dulness.
Repercussion. Modification of the vibrations felt by the fingers
on the pleximeter, as pointed out by Sansom, may indicate an abnormal
change in physical condition impossible to detect in any other way.
It is to be remembered that over the lungs the vibrations are exces-
sive ; over solid structures they are modified or lessened. Xow, the
change from vibrations to absence of vibrations may be gradual or
abrupt. Sansom determines this by percussion, after the heart has
been outlined in the above-mentioned manner. In percussing from
the lung to the heart area, if the modified vibrations occur abruptly,
it is very probable that there is pericarditis with effusion or thickened
pericardium ; or if, on percussing from above downward, there is
pericardial effusion, no vibrations are to be elicited over the area de-
limited — that is, the absence of vibrations is noted over the whole
area — whereas, in ordinary conditions, when the pericardium is unaf-
fected, in percussing from above downward over the area which had
been delimited on the right and left sides respectively, a line will
be reached where the vibrations become modified. This line com-
mences a little above the ensiform cartilage and inclines toward the
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 619
left border of the cardiac dullness at the level of the fourth rib and
third interspace. Vibrations are more marked above than below the
line. The line at which the lessened vibrations begin points out the
commencement of the thick wall of the ventricles ; the portion above
(more vibratory) indicates the position of the right auricle and vessels.
If the pleximetric percussion is employed, areas of superficial and deep
dulness need not be estimated.
The Apex Impulse. Whichever method of percussion is em-
ployed, it will be often observed that the spot marked by inspection
and palpation as the apex impulse is far outside of the left border of
cardiac dulness. In hypertrophy of the left ventricle it may be a con-
siderable distance to the left. In dilatation the difference is not so
marked. The percussion-lines are made when the heart is away from
the chest, and hence are within the systolic apex -beat.
Method of Graphic Record. (See also page 536.) We are indebted
to Sansom and Ewart for a method of recording the outlines of the
areas of dulness and the position of the apex-beat and other pulsations,
which is of great value for class-demonstration, and for permanent
records to compare with other records taken from time to time. The
points of pulsation and border-lines of dulness are marked by a derma-
tographic pencil. Various colors may be used in order to indicate the
different data. The landmarks, etc., are outlined by a camel's-hair
pencil dipped in olive oil. The episternal notch, the clavicles, the
intercostal spaces, the ensiform cartilage and nipples, etc., the percus-
sion-outlines, and other recorded marks are passed over with the oiled
pencil. A sheet of tissue-paper, or of copying-paper, is then gently
placed over the whole, so that the oil-marks are imprinted. After the
paper is removed the oil-outline is colored with the dermatographic
pencil, and a permanent record is preserved. By this plan of record-
ing a maximum of precision is attained. Outlines can be measured
and positions defined by mathematical data. The name of the patient,
the date of observation, with a brief history of the case, should be
attached to the chart. If the colored pencil-marks on the patient's
chest are objectionable, the outline may be made with the colorless
oil-pencil at the various steps of the examination. After they are trans-
mitted to the paper they may be made more distinct with the colored
pencils. Packard fits to the chest a square of coarsely woven muslin
and outlines the ribs and sternum, etc., which are seen through the
meshes. With colored pencils, dull areas, etc., the site of organs, the
position of murmurs, are then designated.
Ewart has shown that after long intervals the size of the chest and
abdomen is apt to alter from various circumstances— growth, muscu-
lar development, habit of sitting, etc. He therefore points out the
advisability of using the sternum, which is immovable, for the sake of
future comparison.
Sense op Resistance. Ebstein delimits the heart by the sense of
resistance, change in size being noted by increase or diminution of the
area, which in health gives a sense of resistance to the percussing finger.
Auscultation. Method. Either method of auscultation may be
employed. By the immediate method we may form a general notion
620
SPECIAL DIAGNOSIS.
as to the condition of the heart-sounds. The mediate, however, is pref-
erable, because it is essential to localize the sounds that are heard, and
because, if the double stethoscope is used, we can percuss the cardiac
area. The patient should be in a comfortable position. The muscles
should not be strained. The general directions for performing auscul-
tation must be followed. Before he begins the observer has, if pos-
sible, determined the presence of the impulse, or found the radial or
carotid pulse. By this means the time of the heart is taken and the
relation of the events of the cardiac cycle to each other is ascertained.
With each normal impulse or carotid pulse a systole takes place ; hence
they are synchronous. The systole occurs just before the radial pulse.
By auscultation we determine (1) the normal sounds of the heart,
including their rhythm, their character and the seat of maximum in-
tensity ; (2) modifications of the normal sounds as regards (a) loudness
and (6) rhythm ; (3) the presence of abnormal sounds or murmurs.
I. The Normal Sounds. The stethoscope is placed over the heart
and the finger on the impulse or the radial pulse ; a sound will be noted
at the time of the impulse or the systole, followed almost immediately
by another sound and then a period of silence. The sounds that attend
the systole are known as the systolic, or first sounds. The sounds that
follow are known as the diastolic, or second sounds. The sounds and
Fig. 162.
Diagrammatic representation of the movements and sounds of the heart. (After Sharpey.) This
diagram shows merely the general relations of the several events, and does not represent exact
measurements.
In a heart beating seventy-two times a minute, Foster estimates each entire cardiac cycle as
occupying about 0.8 sec, of which 0.3 sec. represents the duration of the systole of the ventricle,
0.4 sec. the diastole of both auricle and ventricle, or the " passive interval," and 0.1 sec the systole
of the auricle.
Only one '• pause " is marked here— sometimes called the " long pause " ; some writers describe
a "short pause" also— indicated in the diagram by the small space between the first and the
second sound.
silence mark the completion of a cardiac cycle as far as the ear is con-
cerned. (Fig. 162.) A definite relationship in time exists in the car-
diac cycle. Cause. Four sounds are created during a cycle, one at
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 621
each valve. The sounds created with the systole (systolic sounds) are
due to contraction of the right ventricle and closure of the tricuspid
valve ; and on the opposite side, of the left ventricle and the mitral
valve. The rash of blood along the course of the vessels and the
shock of the heart may contribute somewhat to the systolic sound.
The sounds heard in the beginning of the diastole (diastolic sounds)
are due to closure of the aortic and pulmonary valves. They are due
to the tension produced on the valves as the respective arteries con-
tract upon the columns of blood. The closures of the valves make
up most, if not all, of the sounds. To review : two sounds occur with
the systole, one from closure of the mitral, another from closure of
the tricusjrid valve ; two with the diastole from closure of the aortic
and pulmonary valves, respectively. In health the sounds of the sys-
tole blend because synchronous, giving the impression at a common
point of one sound. Analysis of the sound in the respective valve
areas will show that the systolic sound is made of two sounds. The
sounds of the diastole may or may not blend. Often there is an appre-
ciable difference between the two.
Recognition of the Respective Sounds. To distinguish the sounds we
study their rhythm or time, their character, their position of maximum
intensity, and their direction of transmission. We distinguish the first
from the second sounds by their rhythm and character, and then differ-
entiate the sounds respectively of the systole and of the diastole by
their point of maximum intensity.
(a) The Rhythm or Time. The sounds that are heard at the time of
the normal impulse or just before the radial pulse are the systolic or
first sounds ; the sounds that follow the impulse are the second sounds.
The sounds that follow the long silence are the systolic or first sounds ;
those that precede the long silence are diastolic or second sounds.
(b) Character of the Sounds. The systolic sounds are pro-
longed, somewhat dull in character, low in pitch, and resemble the
sound produced by the pronunciation of the syllable " ubb." The
diastolic sounds are short, sharp, and quick, and resemble the sound
produced by the pronunciation of the syllable " dupp." The syllables
ubb, dupp indicate the character of the sounds in health. Modifica-
tions in the intensity of the sound are due to changes in the tension of
the valve-curtains, and are dependent upon the force of muscular con-
traction, which, if strong, renders the valves more tense. Experiment
and the results of disease have aided in proving these points.
(c) Position op Maximum Intensity. In general the first sounds
are loudest at the lower part of the prsecordia, the second at the upper.
But we especially distinguish the independent valve elements which
make up the systolic and the diastolic sounds in the following manner.
The sounds produced by the closure of the valves are created, as the
topography of the heart shows, quite near to each other, but by con-
duction of the sound they are transmitted away from the respective
valves in particular directions, and heard loudest in definite areas on
the chest.
The Systolic or First Sounds. Two sounds are created. The
valves which cause the sound are near to each other. Because of their
622
SPECIAL DIAGNOSIS.
anatomical relations the sounds are conducted into different areas, by
virtue of which they are differentiated. The Mitral Valve Sound.
The sound produced by the closure of the mitral valve is created oppo-
site the fourth interspace near the sternum. It is transmitted to the
surface of the chest by the thickened left ventricle, and hence is heard
Fig. 163.
Areas of cardiac murmurs (Gairdner for the areas; and Luschka for the anatomy). The out-
lines of organs, which are partially invisihle in the dissection, are indicated by very fine dotted
lines ; while the areas of propagation of valvular murmurs, as described in the text, have been
roughly marked by additional much coarser and more visible dotted lines— the character of the
dots being different in each of the four areas A capital letter marks each area — viz., A, the circle
of mitral murmurs corresponding with the left apex ; B, the irregular space indicating the ordi-
nary limits of diffusion of aortic murmurs, corresponding mainly with the whole sternum, and
extending into the neck along the course of the arteries ; C, the broad and somewhat diffused
area occupied by tricuspid murmurs, and corresponding generally with the right ventricle ; D, the
circumscribed circular area over which pulmonic murmurs are commonly heard loudest.
Reference letters : r. au. = right auricle : a. o. = arch of aorta ; v. i. = the two innominate veins ;
v. c. = vena cava descendens ; p. = pulmonary artery ; 1. au. = left auricle ; 1. v. = left ventricle ;
r. v. = right ventricle. (Finlayson.)
loudest where that is nearest the chest, namely, at the apex — the mitral
area. The Tricuspid Valve Sound. The sound produced by the
closure of the tricuspid valve is transmitted by the right ventricle, and
is heard loudest over the lower portion of the sternum — the tricuspid
area.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 623
The Diastolic or Second Sounds. Two sounds are created.
The valves at which they are produced are also in close proximity.
To distinguish the two sounds it is necessary to auscult over areas into
which they are transmitted. They may often be distinguished by
Fig. 164.
The valve areas.
1. Mitral area. 2. Tricuspid area. 3. Aortic area. 4. Pulmonary area.
their slight difference in time, the aortic preceding the pulmonic by a
fraction of a second. The Aortic Valve Sound. The sound produced
by the closure of the aortic valve is heard loudest at the second costal
cartilage on the right, because the aorta which conducts the sound is
nearest the surface of the chest at this point — the aortic area. This
cartilage is known as the aortic cartilage. The Pulmonary Valve
Sound. The sound produced by the closure of the pulmonary valve is
conducted to the left and heard loudest in the second interspace near
the left edge of the sternum — the pulmonary area.
(d) The Direction of Transmission. The first sounds are trans-
mitted toward the axillae. They may be heard all over the cardiac
area, but the position of maximum intensity is in the lower portion and
toward the left. The second sounds are loudest at the base of the heart.
They may be propagated beyond the prsecordia toward the neck, and
be heard loudest in the vessels of the neck.
Precise Location and Differentiation of Each Sound.
This may be determined by listening with the bell of the stethoscope
over each area. Then move the bell of the stethoscope gradually from
one area into the other. As the sound of the original area lessens the
sound of the approached area is observed. The change from one to
the other is often very marked. 1. Mitral first or systolic sound, heard
loudest at the apex, inward to the parasternal line, upward to the third
interspace. 2. Tricuspid first or systolic sound, heard loudest at the
lower part of the sternum and toward the left to the parasternal line as
high as the third rib. 3. Aortic second or diastolic sound, heard loudest
at the aortic cartilage, propagated into the vessels of the neck, and also
624 SPECIAL DIAGNOSIS.
heard at and outside of the apex-beat. It is louder than the pulmo-
narv second sound in health. 4. Pulmonary second or diastolic sound,
localized to the second interspace and the third rib.
II. Modifications of the Sounds. The sounds, singly or com-
bined, may be increased or diminished in intensity or accentuation.
They may be altered in rhythm.
Sounds Increased, a. Games outside of the pericardium. 1. Any-
thing which brings the heart closer to the ear of the observer. Thus,
in patients with thin chest-walls, when the heart is pushed to the sur-
face of the chest (mediastinal tumor) or the lung removed (pleural
contraction). 2. Anything which conducts the sounds, as consolidated
lung in the vicinity, or a pneumothorax, or pulmonary cavities. 6.
Affections of the pericardium, as pericardial adhesions, c. Conditions of
the heart. 1. Hypertrophy. 2. Overaction, as in palpitation, fevers,
anaemia, exophthalmic goitre.
Sounds AYeakened. a. Causes outside of the pericardium. 1. Gen-
eral exhaustion. 2. Thick chest-walls, large ma mm ary gland. 3.
Emphvsema of the lungs overlapping the heart, b. Affections of the
pericardium, as fluid or air in the pericardial sac. c. Conditions of
the heart. Atrophy ; myocarditis ; some cases of dilatation.
In short, loudness of all the sounds occurs from (a) conditions out-
side of the heart ; heart nearer chest-wall, consolidation of lungs, cavi-
ties ; (b) conditions of the heart itself ; hypertrophy ; overaction.
Weakness of the sound occurs from : (a) Conditions outside of the
heart : thick chest- walls, emphysema, general exhaustion ; (6) affec-
tions of the pericardium : effusions ; (c) affections of the heart : atro-
phy ; dilatation ; myocarditis.
Modifications of Individual Sounds. The above applies to all
the sounds. Increase or diminution of the systolic or of the diastolic
sounds, or of any one of the four sounds, may be present.
Increase in Loudness of the Systolic Sound. Increased loud-
ness of the first sound is noted when the muscle is hypertrophied, and
the tension on the valves thereby increased. In hypertrophy of the
left ventricle the increase is most marked. The sound is duller and
has a prolongation which is very characteristic. In hypertrophy of
the right ventricle the sound is dull and prolonged over the sternum,
but not to the same degree as when the left is hypertrophied.
Increase in Loudness of the Diastolic Sound. Either of the
second or diastolic sounds may be increased in loudness or accentuated.
Fig. 165.
A
Normal first Accentuated
and second sounds. first sound.
1. Tin 1 Aort'u- Diastolic Sound. Anything which causes increased
tension in the aortic circulation, and hence increased contractile force
of the aorta, will increase the intensity or accentuation of the second
sound. In hypertrophy of the heart the aortic sound is accentuated
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 625
because there is corresponding increased contraction of the aorta, fol-
lowing the forcible expulsion of the blood from the ventricle. Increase
in arterial tension is also due to increased contraction of the aorta when
there is peripheral resistance to the outflow of blood. It is associated
with the following conditions which cause accentuation of the second
sound : Atheroma of the aorta, or of the arteries in general ; aneurism
of the aorta ; disease of the kidneys, and particularly in that form in
which there are also general arterial changes — namely, chronic inter-
stitial nephritis. It is true that the accentuation may be partly due
to the hypertrophy of the heart which coexists.
Accentuation of the aortic second sound occurs independently of per-
manent change in the arteries. If for any reason there is spasm of the
peripheral capillaries, as from a chill, from epilepsy, from nervousness
due to hysteria, tension in the arteries is heightened, and hence the
second sound accentuated. It is seen that accentuation of the second
sound is, therefore, a marked index of the state of the vascular system
in general ; it is not an evidence of disease of the heart alone. In
certain fevers and in states of the blood in which the vasomotor nerves
are irritated, causing peripheral contraction, as in scarlatina, accentu-
FlG. 166.
A
n n r
Normal first and Accentuated
second sounds. second sound.
ation of the second sound is observed, often before the development of
local inflammatory diseases due to the same cause, as nephritis in scar-
latina. The occurrence of this complication may be suspected when
accentuation of the aortic second sound is heard.
2. The Pulmonary Diastolic Sound. This is due to the same phys-
ical condition which causes accentuation of the aortic second sound.
Anything which heightens the tension in the pulmonary artery will
cause increased loudness. In health the pulmonary second is not so
loud as the corresponding aortic sound. If, therefore, we find in the
second or third left interspace the sound as loud as an aortic sound, or
louder, it can be said that the pulmonary second sound is accentuated.
It is due : 1. To any condition which causes congestion within the
lungs, the right ventricle being at the same time of normal or increased
strength. It is heard in the early stages of pneumonia, and, if the
course of the disease continues favorable, may remain accentuated to
the end. If, on the other hand, the circulation is embarrassed, and
the right heart is failing, it will become fainter, and may be scarcely
recognizable. Such change in the sound accompanies increase of respi-
ratory distress, and indicates that the right heart is becoming ex-
hausted. It is, therefore, an ominous sign in acute pulmonary disease.
If the case is unfavorable, the signs of right-sided dilatation will sub-
sequently occur. 2. It occurs in emphysema of the lungs. Notwith-
standing the covering of the heart by the lung, the sound can be heard,
40
626 SPECIAL DIAGNOSIS.
and may be the only one of the four sounds which can be distin-
guished. 3. In valvular disease of the heart seated at the mitral orifice
accentuation of the pulmonary second sound is heard, due to increased
tension in the pulmonary artery. In mitral obstruction the blood is
retained in the auricle and pulmonary veins, causing a resistance to
the force of the right ventricle. Increased tension in the pulmonary
artery is the result, with exaggerated strain upon the valves. In
mitral regurgitation, with the systole the blood is thrown back into
the auricle, and consequently meets with blood coming from the lungs.
This in time increases the amount of blood and of blood-pressure in
the pulmonary artery. A heightened tension results. Skoda pointed
out the significance of this association. Sometimes in doubtful cases,
either in the presence or absence of a murmur at the mitral orifice, the
occurrence of this sign makes it more than probable that there is mitral
valvulitis.
Diminished Accentuation of Feebleness of the Sounds. 1.
Feebleness of the Mitral Sound. Feebleness of the mitral sound ob-
served at the apex of the heart may be an indication of weakness of
the muscle from dilatation, atrophy, or myocarditis. It must be remem-
bered, however, that weakness of the ventricle is not attended by en-
feeblement of sound alone, but that when the right or left ventricle is
weakened the duration of the sound is lessened. The loudness remains
the same, or may be increased. Note, then, that a short systolic sound,
a
n
Normal first and Diminished
second sounds. first sound.
loud, sharp, flapping, sometimes reverberating, heard at the apex, indi-
cates dilatation or feebleness. The tension of the ventricles and valves
creating the sound is increased by internal pressure. The systolic
sounds become like the diastolic, and may be distinguished by the ear
with difficulty ; but if the time is taken with the finger on the apex-
beat or carotid artery, if the heart's action is slow the distinction can
readily be made.
Diminished Accentuation of the Aortic Sound. This is an indication
of cardiac weakness, and is apt to ensue in the course of fevers when
exhaustion takes place. It is a sign of myocarditis and of degenera-
tion of the muscular walls of the heart. Under these circumstances
the systole of the ventricle is also weakened.
Feebleness of the aortic second sound, with hypertrophy and hence
strong contraction of the ventricle, occurs when the aortic leaflets are
swollen or enlarged and thickened. This condition of the valves is due
to atheroma, and is in all probability associated with atheroma of adja-
cent vessels, as the coronary arteries. It is, therefore, a sign of serious
importance.
diminished Accentuation of the Pulmonary Sound. This is of impor-
tance in the course of valvular disease of the heart, providing previous
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 627
accentuation has been observed. If the marked loudness gives way to
feebleness, there is strong probability that the right heart is under-
going dilatation with regurgitation at the tricuspid orifice. While
accentuation of the pulmonary second sound in valvular disease is of*
good omen, enfeeblement of the sound is of bad prognostic omen, indi-
cating weakness of the right ventricle.
Alterations in the Rhythm. Foetal rhythm of the heart :
Embryocardia — a term first used by Huchard to designate a condition
in which the pauses between the heart-sounds are of equal length. The
first and second sounds are exactly alike, resembling the beat of the
foetal heart. The sign is of importance in prognosis. In acute dis-
ease and in fever it indicates enfeeblement of the heart and reduction
of arterial tension. In the later stages of Graves' disease it is a fore-
runner of death. It is distinguished from the rapid beat of the heart
in tachycardia by the fact that in the latter condition the normal
rhythm is preserved.
Cantering Rhythm of the Heart. The ear recognizes three sounds.
The usual sounds may or may not be attended by murmur, and the
interpolated sound may be dull, or short and sudden. It may occur at
various periods in the cardiac cycle, either just before the systolic sound,
just after the diastolic sound, or during the diastolic pause. The rhythm
recalls the sound of a horse cantering. It was termed by Bouillaud
the bruit de galop. When the interpolated sound resembles the first
or second it is similar to reduplication of the sounds. It has been
observed in hypertrophy of the heart, especially of the left ventricle ;
dilatation of the heart ; in adherent pericardium with dilated hyper-
trophy ; in myocarditis, in the course of fevers ; and in excessive
ansemia. It is heard loudest over the right and left ventricles.
Potain thinks it is due to tension communicated to the wall of the
ventricle by the entrance of blood into its cavity, and is more marked
when the wall is least extensible, as in hypertrophy on the one hand
or exhaustion of the muscle ; in either of the two the walls vibrate
more readily. The triple rhythm is of bad prognostic omen in chronic
Blight's disease.
Reduplication of the Sounds. Reduplication, or apparent
doubling of the heart-sounds, occurs in various forms. In health the
systolic sounds are created synchronously ; a fraction of a second, not
appreciated by the ear, separates the diastolic sounds. In so-called
reduplication one systolic sound may follow the other, or the aortic and
pulmonary diastolic sounds may be created at distinct intervals. As
has been stated, in galloping rhythm the idea of reduplication is some-
times transmitted to the ear. Reduplication may take place in health
under the influence of respiratory movements. The systolic sounds
may be doubled at the end of expiration and the commencement of
inspiration, while the diastolic sounds are doubled at the end of inspi-
ration and the commencement of expiration. In mitral disease redu-
plication, or want of synchronous closure of the two valves, is of frer-
quent occurrence. The heart-sounds are doubled and heard over the
base of the heart. Reduplication of the systolic sounds occurs in
chronic Bright' s disease.
628 SPECIAL DIAGNOSIS.
Reduplication, or Doubling of the Systolic Sounds, is heard over the
apex or the right ventricle. Several explanations have been given
for the cause of the reduplication. At first it was thought to be due
to want of synchronism in the action of the ventricles — that one ven-
tricle contracted before the other, due to the fact, of course, that the
presence of blood stimulates one but not the other. By Hayden it
was thought that reduplication of the first sound was due to the two
major elements of the sound acting asynchronously, the muscular sound
n
Fig. 168.
n
a. b
Normal first and Reduplicated
second sounds. first sound.
taking place before the sound produced by the tension of the valves.
Dr. George Johnson took the view that the reduplication was due to
the contraction of the auricle and ventricle ; that the sound produced
by the former was heard on account of hypertrophy of the auricle, and
heard first because of the natural order of precedence. Thus far the
reasons for each view have not been fully established.
Sansom believes that reduplication of the first sound is due to the
shock communicated to the contents of the ventricle just before systole
— that is, during the auricular-systolic period — in other words, it is
due to the indirect effect of the auricular systole. The contraction of
the auricle makes tense the auriculo-ventricular valve of the left side.
If it occurs late in the diastole, or just before the systole, reduplication
of the first sound is caused ; if early in the diastole, reduplication of
the second sound is created.
Reduplication of the Diastolic Sounds. While held by some authori-
ties to occur in a large proportion of healthy individuals at the end of
inspiration and the commencement of expiration, other observers,
equally careful, think that it is extremely rare. It is of frequent
occurrence in the patients of the Philadelphia Hospital. This is no
doubt due to the fact that so many of the inmates are the subjects
of all forms of lung disease, or disease of the vascular system, with
muscular degeneration of the heart, that the equability of the pul-
monic circulation is disturbed. There is no doubt that it can be
modified or induced by inspiration. It is usually heard at the end of
inspiration and commencement of expiration. Actual reduplication of
the second sound occurs when the normal asynchronism of the closure
of the aortic and pulmonary valves is exaggerated. It has been found
that the valve of the pulmonary artery closes a fraction of a second
after the aortic valve. The ear usually fails to appreciate the differ-
ence unless there are differences of blood-pressure ; when doubled, and
therefore appreciated, it is indicative of a difference in blood-pressure
between the two sides of the circulation. Increased resistance in
either will lead to increased tension, quickened recoil, and hence quick-
ened closure of the valve. The conditions that are associated with the
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 629
doubling of the second sound are (1) and most frequently, mitral sten-
osis ; (2) obstruction of the circulation in the lung — tuberculosis, em-
physema, and bronchopneumonia ; (3) dilatation of the right ventricle ;
(4) myocarditis. The sound is heard at the second and third costal
cartilages along the left edge of the sternum. It is frequently heard
at the fourth and fifth cartilages on the left side. In cases of mitral
stenosis it is heard near the apex.
Fig. 169.
A
a. b.
Normal first and Reduplicated and
second sounds. accentuated second sound.
Illustrating diagrammatically modifications of the heart-sounds. (Gibson and Russell.)
Simulated doubling, or false reduplication, is a sound produced at
the mitral orifice. It is difficult to tell it from true doubling or redu-
plication. It is most distinct at the base of the heart along the left
edge of the sternum. Occasionally it is more distinct near the apex
than elsewhere. It occurs with the conditions found in true doubling
and in mitral obstruction. Cause. Sansom, Cheadle, and others dis-
tinctly point out that this double second sound is of frequent occur-
rence, and that it is heard most frequently at the apex. Sansom
thinks that the cause for simulated doubling of the second sound is
the same as for doubling of the first. There is, first, the normal second
sound ; second, a tension of the mitral curtain producing the second
simulated sound. This tension is due to the shock of the blood coming
from the auricle to the ventricle.
III. Abnormal Sounds or Murmurs. Abnormal sounds may be
heard over the heart in addition to or replacing the normal sounds.
These sounds are produced in the pericardium, in the heart, or in the
bloodvessels. They are divided into friction-sounds and murmurs.
They are recognized because they are a departure from the normal
sounds or because they are superadded sounds.
Abnormal Sounds in the Pericardium. They are known as
friction-sounds and splashing or bubbling sounds. The former occur in
the first stage of pericarditis, and are due to the rubbing together of
the inflamed surfaces, either the congested, vascular pericardium, or
the membrane bathed in exudation, or covered by lymph. The fric-
tion-sound is recognized by (1) its character, (2) time, (3) position, (4)
transmission, (5) movability, (6) modification by position of patient,
pressure, course of disease, etc. 1. The pericardial friction is usually
of a to-and-fro character, and can be recognized as distinct from the
heart-sounds. It resembles the rubbing or scraping together of two
roughened surfaces. 2. It is not necessarily synchronous with each
sound. It is a to-and-fro sound, systolic and diastolic in time. It
may, however, be only systolic or only diastolic. 3. It is heard over
the body of the heart, usually in the third and fourth interspaces, or
even over the right ventricle. 4. It is not transmitted away from the
630 SPECIAL DIAGNOSIS.
heart. Its location may shift from day to day in the precordial area.
5. It may be modified by pressure or by respiratory movement, or be
influenced by the position of the patient. It may disappear entirely
in the upright posture. An impression of nearness to the ear is given
by the sound observed in the first stage of pericarditis. It may be in-
creased or lessened in loudness by a deep inspiration. It disappears
during the period of effusion, to return after that is absorbed.
Diagnosis. It must be distinguished from the pleural friction, which
disappears if the patient is asked to hold his breath. The pericardial
friction is of cardiac rhythm, the pleural friction of respiratory rhythm.
It must also be distinguished from the so-called exocardial _ friction-
sounds. The pleura adjacent to the pericardium may be inflamed.
With each beat of the heart the rough surfaces of the pleura are agi-
tated and generate a friction. It is seated along the edges of the right
auricle or left ventricle. It is systolic in rhythm, but has the special
characteristic that it is modified by respiration. It may be arrested if
the patient holds his breath. It is increased by inspiration, or dimin-
ished in expiration when the lungs recede from the heart in expiration.
The pericardial friction must be distinguished from the crepitations
and rales of cardiac rhythm produced by the impact of the heart
against the lung. They disappear when the breath is held. The dis-
tinctions between pericardial frictions and cardiac murmurs will be
considered later.
Splashing sounds are heard when there are air and fluid in the peri-
cardium. They may be bubbling or gurgling or resemble the sound
of a water-wheel. They continue when the breath is held.
■ Abnormal Sounds in the Heart and Vessels. Murmurs.
If the student listens with the stethoscope over a large superficial
vessel, and does not employ pressure, he will not detect any sound.
If, however, pressure is employed, a sound or murmur is produced.
The passage of the blood through the vessel produces no sound because
the vessel or tube is of equal calibre. The pressure of the stethoscope
alters the calibre and compels the fluid to pass through a narrow orifice
into a wider space. In this manner a fluid vein is produced. The
vibration of the molecules of the agitated fluid vein produces a sound
or murmur. The loudness of the sound depends upon the swiftness
of the flow. The sound in this instance is carried in the direction of
the blood-current, hence the murmur is known as an onward murmur.
The reverse may take place. The fluid may flow backward from a
wider into a narrower space without the production of sound ; if, how-
ever, the fluid breaks on bevelled edges, as the leaflets of heart-valves
projecting into the current, the fluid is again thrown into vibration and
produces noise. If there is considerable constriction by the bevelled
edge, the sound is carried farthest against the natural flow of the fluid
— hence the term backward murmur. Some authors hold that mur-
murs are also due to lateral vibrations of the walls of the heart or of
the vessels. Some murmurs may resemble tones, and are called musi-
cal murmurs. Such murmurs are due either to the vibrations of the
solids set up by the vibrating fluid vein, or to the vibrations of the
fluid vein alone.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 631
Murmurs are divided into two classes, in accordance with their seat
of development. Murmurs originating in the heart are known as car-
diac murmurs. Murmurs originating in the bloodvessels are vascular
murmurs. (See The Arteries.) Cardiac and vascular murmurs are
divided into (1) organic murmurs, if due to physical changes of the
heart or vessels ; (2) inorganic, functional, or hcemic, if due to changes
in the quality of the blood. (See Functional Murmurs.) Cardiac
murmurs are always generated at the orifices from disease or from
incompetency of the valves, or from patulous non-valve opening. The
orifices are valvular and non-valvular.
Murmurs at. Valvular Orifices. The valvular orifices and
their anatomical relations have been described. Murmurs are produced
at these orifices when they are open or when normally they should be
closed. If the murmur is produced when the orifice is open it is
because there is narrowing of the orifice or dilatation of the cavity
(relative narrowing). The murmur, then, is always produced ivith the
natural current of blood, and hence is known as an onward or obstructive
murmur. It always or nearly always implies organic disease at the
valve-orifice, hsemic murmurs excluded. If the murmur is produced
when the orifice should be closed, and hence when the valve leaks, it is
because the valves are diseased and cannot shut the orifice, or because
they are too small — incompetent — to shut it. Such murmurs are pro-
duced against the natural current of blood, and are known as backward
or regurgitant murmurs.
Murmurs at Non-valvular Orifices. The orifices of the vena
cavse and of the pulmonary veins, and of the perforations of the septa
in congenital heart disease, are non-valvular. They are at times the
seat of murmurs — as in open foramen ovale or perforated ventricular
septum.
Diagnosis of Murmurs. The student has learned that an abnor-
mal sound or a murmur is present. It is necessary then to determine,
first, at which orifice the murmur is produced (the seat of the murmur)
and, second, the kind of murmur — obstructive or regurgitant. Mur-
murs are therefore studied as heart-sounds are studied, as to their
position of maximum intensity, their time, and the direction of their
transmission. The position of the murmur indicates which valve-
orifice is affected, the time and the direction of transmission, and the
kind of murmur.
The Position of Maximum Intensity of the Murmur. The
Orifice Affected. We are enabled accurately to determine the orifice
at which the murmur is generated by noting the position of maximum
intensity of the murmur. This corresponds to the area at which the
normal sound of the respective valve is heard loudest. It may be re-
membered that the cardiac orifices are closely situated, and that, there-
fore, the murmurs must be generated within a small area, so small that
it would be impossible to ascertain at which valve-orifice the murmur
is created, were it not for the fact that under the laws of conduction of
sound the murmurs are conducted away from their point of origin to
certain definite stations, where in health the respective valve-sound is
also heard loudest.
632
SPECIAL DIAGNOSIS.
1. Murmurs at the Apex — the Mitral Area. A murmur heard
loudest, or with the greatest intensity, at the apex is known as a mitral
murmur. It is created at the mitral orifice, but is conducted to the
apex by the left ventricle, which is nearest the chest-wall at this point.
(See 1, Fig. 164.)
2. Murmurs at the Xijjhoid Cartilage — the Tricuspid Area. The
murmur is heard loudest at the xiphoid cartilage or the head of the
fourth or fifth rib. It is created at the tricuspid orifice, and is heard
most distinctly over the lower portion of the sternum, and along the
left edge, because the right ventricle is in apposition with the chest-
wall at this spot. (See 2, Fig. 164.)
3. Murmurs at the Second Costal Cartilage or Second Interspace on
the Right — the Aortic Area. When a murmur is heard with great-
est intensity at this point it is usually generated at the aortic orifice,
and is conducted to this region by the aorta, which comes nearest to
the surface of the chest at this point. (See 3, Fig. 164.)
4. Murmurs in the Second Left Interspace — the Pulmonic Area. A
murmur heard loudest at the second interspace along the left edge of
the sternum is generated at the pulmonary orifice ; it is heard loudest
in this area because the pulmonary artery is nearest the chest at this
point. (See 4, Fig. 164.)
The Rhythm or Time of the Murmur. The Kind of Murmur.
Having determined the point of maximum intensity of the murmur,
hence the valve at which it has its origin, we next wish to determine
the kind of murmur. A murmur which is produced at orifices when
they should be closed is known as the murmur of regurgitation, as the
valve permits the blood to flow backward. A murmur that occurs
Fig. 170.
Maximum intensity of murmur of mitra 1 regurgitation ; systolic ; transmitted to the left.
when the blood should in health be passing through an orifice is known
as a murmur of obstruction, as the flow of blood is obstructed. We
have to determine whether the murmur at an orifice is due to regurgi-
tation or to obstruction. This is ascertained by the time of the murmur.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 633
The time of the murmur is determined by the heart-sounds, by the
impulse, and by the pulse.
Murmurs with the Systole.
1. In the Mitral Area. In health, during this time, the auriculo-
ventricular valve is closed. The murmur indicates there is such dis-
ease as to permit of a backward flow of blood, or of regurgitation, into
the auricle. It is the murmur of mitral regurgitation. It may be due
to disease of the valves or to incompetency. (See Fig. 170.)
Maximum intensity of murmur of tricuspid regurgitation ; systolic.
2. In the Tricuspid Area. As on the left side, the murmur in this
area is due to valvular disease or valvular incompetency, which per-
mits of regurgitation, tricuspid regurgitation. (See Fig. 171.)
Fig. 172.
Position of maximum intensity and directions of transmission of murmur of aortic obstruction.
3. In the Aortic Area. During this time the blood is flowing from
the ventricle into the aorta. If there is disease which causes obstruc-
tion at the orifice the murmur of aortic obstruction is produced. The
634 SPECIAL DIAGNOSIS.
murmur may be due to ansemia ; to disease of the aorta, or to its mal-
position. (See Fig. 172.)
4. In the Pulmonary Area. The pulmonary orifice is affected in
the same way as the aortic orifice under the same circumstances. The
murmur is due to pulmonary obstruction. It is exceedingly rare. It
is more frequently hsemic. (See Fig. 175.)
Murmurs with the Diastole.
1. In the Mitral Area. The blood is flowing from the left auricle
to the left ventricle. Disease of the valves obstructs the flow. The
murmur occurs in the beginning, in the middle, or at the end of the
long silence. Mid-diastolic and late diastolic, or because it occurs
before the systole, presystolic, are the terms applied to this murmur.
It is the murmur of mitral obstruction. (See Fig. 173.)
Fig. 173.
Maximum intensity of murmur of mitral obstruction ; presystolic, localized or transmitted as
area shows.
1. Normal impulse. O. Area of reduplication of second sound.
2. In the Tricuspid Area. It occurs for the same reason and at the
same time as the diastolic murmurs generated at the mitral orifice.
It is rare, although more common than usually supposed, to find tri-
cuspid obstruction.
3. In the Aortic Area. The aortic valve closes in the diastole. A
murmur indicates it is so diseased that it cannot prevent blood flowing
backward or regurgitating into the ventricle. It is the murmur of
aortic regurgitation. A murmur of the same time and in the same
situation may be due to dilatation or aneurism of the aorta. (See Fig.
174.)
4. In the Pulmonary Area. A diastolic murmur in this area is due
to regurgitation at the pulmonary orifice. (See Fig. 175.)
Murmurs are divided as to time into systolic and diastolic murmurs.
The above shows that we may have practically only three systolic and
two diastolic murmurs. The systolic murmurs are aortic obstruction
and mitral and tricuspid regurgitation. The diastolic murmurs are
aortic regurgitation and mitral obstruction.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 635
The Direction of Transmission. It depends upon the situation
of the murmur and the time at which it is produced. Some murmurs
are not transmitted. The transmission is usually in the direction of
the currents which produce them.
Fig. 174.
Positions of maximum intensity and directions of transmission of murmur of aortic regurgitation.
Murmurs in the Mitral Area. To the axilla. A murmur which is
produced at the apex with the systole, caused by regurgitation at the
mitral orifice, is transmitted into the axilla, and may be heard at the
angle of the scapula. The murmur which is produced in the same
area before the systole — obstruction — is usually not transmitted. It is
heard at the apex, or a little inside of the apexj or may rarely have its
point of maximum intensity in the third interspace. Sometimes it is
transmitted to the axilla and to the angle of the scapula. (See Figs.
170 and 173.)
Murmurs in the Tricuspid Area. The murmur of tricuspid regurgi-
tation is not transmitted. It is heard over a relatively large area, de-
pending upon the intensity of the sounds.
Murmurs in the Aortic Area. Upward and Along the Vessels. The
murmur, systolic in time, heard at the second costal cartilage on the
right, due to aortic obstruction, is transmitted in the direction of the
blood-current. The sound is conducted by the vessels and by the
fluid ; it is, therefore, heard along the course of the aorta and in the
carotid arteries. Downivard to the Apex. The murmur of aortic re-
gurgitation, heard in the same area, is transmitted downward along the
course of the sternum. It may be transmitted to the apex, or may
be heard along the sternum only. The left ventricle conducts this
murmur. (See Figs. 172 and 174.)
Character of the Murmurs. Murmurs are further distinguished
by their character and the degree of loudness. By the character of the
murmurs we are aided (1) in distinguishing them from heart-sounds ;
(2) in estimating the nature of the lesion that produces the murmur ;
(3) in judging, in the case of murmur of mitral obstruction, of the
presence or absence of that disease.
636
SPECIAL DIAGNOSIS.
Distinction feom Normal Sounds. Normal sounds are sounds
of tension ; murmurs are sounds of rhythmical vibration. The normal
sounds of the heart have been described by the syllable " ubb," " dupp,"
" od," and abnormal sounds of endocardial origin by " uf" " uv"
Maximum intensity of pulmonary systolic murmur.
O . Area of murmur of anaemia.
us" " ush," or by full vowel sounds as " oo,
» u „, }} a
ah," and "aw,
by musical tones, or by interrupted tones, or by general sounds, as
" urr " or " orr."
The Nature of the Lesion. The murmurs may be rough or rasping,
musical or whistling in character. They may be high or low in pitch.
Murmurs that are rough and high in pitch are usually due to disease
of the valves, causing thickening or stiffening of the leaflets, or to the
projection of an atheromatous plate into the lumen of the orifice. Such
conditions occur in chronic endarteritis and chronic endocarditis or
valvulitis. On the other hand, murmurs that are soft and low in pitch
are usually due to a physical condition which causes swelling of the
valve or occlusion by soft exudations ; they are heard in endocarditis
of rheumatic origin, or the malignant form of endocarditis. The only
murmur which has special characteristics is the murmur of mitral
obstruction. It is a prolonged murmur of a churning or grinding char-
acter, sometimes rippling, and as if fluid were being forced through a
narrow channel. It is usually presystolic, but may occur in the middle
of the diastole.
Loudness. The loudness of the murmur is not of special signifi-
cance, although, in general, it may be said that it indicates good com-
pensation, and that the heart muscle is sufficiently strong to meet the
demands of the circulation. Murmurs are louder in the recumbent
than in the erect posture in some instances, especially mitral and tricus-
pid murmurs. Murmurs are often more distinct after exertion. Loud
murmurs may become weak, and this change in character of the sound
is of serious omen. They may disappear in the course of fevers and
in the dying state.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 637
Disappearance of Murmur. The student will often find that
after a patient has been under treatment for a short time the murmurs
disappear. This is probably due to the fact that there is complete
compensation. In the terminal stages of cardiac disease they disap-
pear because of weakness of the heart muscle. Rarely they disappear
because the roughened valve causing them has been repaired. (See
" Disappearance of Murmurs/' by the author. British Medical Journal,
1897.) In other cases it may be necessary to bring out a faint mur-
mur or increase its intensity by having the patient move about ; this
renders it more distinct by inducing more rapid action of the heart.
The Significance of Murmurs. Murmurs heard at the various
orifices indicate either (1) disease of the valves • (2) incompetency of
the valves ; (3) disease of the blood ; or (4) disease of the vessels in
intimate relation with the heart. The systolic murmur at the second
costal cartilage on the right may be heard when there is disease at the
aortic orifice, causing obstruction ; in atheroma of the aorta ; in cases
of aneurism just above the valves ; in anaemia, and chlorosis, and in
some vasomotor neuroses, as Graves' disease. Before concluding that
the murmur is due to disease of the valves we must be able to exclude
the other conditions. Atheroma of the aorta, is most difficult to distin-
guish from obstruction, because the character of the murmur is the
same and the associated conditions are similar. In both there may be
a previous history of gout, rheumatism, syphilis, or alcoholism. The
latter are associated with atheroma in other arteries of the body, and
with degenerative changes that accompany atheroma. In young sub-
jects, in whom there has been a direct history of rheumatism, or when
the process has followed septicaemia, the probabilities are, in nearly
all the cases, that the murmur is due to aortic obstruction. To dis-
tinguish the murmur of anaemia, chlorosis, or Graves' diseases is often
difficult. The associate symptoms in each case are different, however,
and with the changes in the blood indicate the nature of the murmur.
In other valve areas the chief task is to decide whether the murmur
is organic, due to valvulitis, or whether it is functional, due to incompe-
tency or to anaemia.
Murmurs due to Incompetency. The valves are sometimes
unable to close properly. The cavity of the ventricles may increase
in size, so that the valves do not coaptate to close the widened orifice.
The tricuspid and mitral valve leaflets often become thus incompetent.
Mitral and tricuspid regurgitation ensue. The murmurs are soft and
low in pitch and not widely transmitted ; the heart is dilated.
Murmurs of Anjemia. The murmurs of anaemia have some char-
acteristics which aid in distinguishing them from true organic mur-
murs. The most important of these are : (1) The situation of the mur-
mur ; (2) its character ; (3) the direction in which it is transmitted ; (4)
the time ; (5) the associate signs ; (6) the secondary heart-muscle changes.
1. The murmurs of anaemia may be heard at any orifice, but are usually
heard at the second costal cartilage, or the third interspace, on the left
side. They are generated at the pulmonary orifice, or in the cone of
the right ventricle. The murmur at the pulmonary orifice may be
heard as high as the second interspace, but otherwise is not transmitted.
638
SPECIAL DIAGNOSIS.
Murmurs of anaemia are also heard at the apex, at the aortic cartilage?
and over the tricuspid area. They are comparatively infrequent in
these situations, but partake of the same nature as the murmur heard
at the pulmonary orifice. 2. They are soft in character and low in
pitch. They are louder in the recumbent than in the upright posi-
tion. Their loudness is increased by violent cardiac action. They
are loudest just at the end of expiration or beginning of inspiration.
3. They are not transmitted away from the heart. 4. They are systolic
in time. 5. They are associated with murmurs in other parts of the
vascular system, as the murmur in the jugular veins. Its characteris-
tics and mode of recognition will be described elsewhere. 6. Mural
changes, as general dilatation, fatty degeneration, or hypertrophy may
be present ; but single chambers do not undergo change. The murmur
of anaemia may usually be considered to be temporary.
Fig. 176.
Maximum intensity of murmurs of aneemia, systolic. iSansom.)
1 Pulmonary artery, 59 per cent. 2. Apes, 7 per cent. 3. Right v. and conus, 11 per cent.
4. Aortic area, 11 per cent. 1 and 2. Pulmonary and apex coexisting, 9 per cent.
^Functional Murmurs not Anaemic. Drummond divides func-
tional murmurs into three classes : cardio-heemic or anaemic ; cardio-
muscular or neuro-typtic, and cardio-respiratory. The first has been
considered above. The cardio-muscular murmur attends excited action
of the heart. It is heard loudest at the fourth left interspace close to
the sternum ; loudest in the upright posture ; loudest at the end of
expiration, It disappears at the end of inspiration, or when the patient
lies on the side. Of course, it is increased by exertion and excitement.
It is rough or whizzing in character. The cardio-respiratory murmur
is fairly common. It is most marked in inspiration, but may be heard
in both acts. It is systolic in time, and is heard loudest at the apex,
but I have often heard it along the left border of the heart, as high as
the second rib and in the axilla, and at the angle of the scapula. It is
short and whiffing, and the sound gives one the impression that the
heart is striking the lung.
Influence of Pressure. Pressure exerted, Sewall says, while using
the flexible stethoscope over the second costal interspace annuls in part,
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 639
or wholly, the second sound of the heart ; but if the ascending aorta
be dilated or the site of an aneurism, the second sound persists strongly
notwithstanding firm pressure.
Further, firm pressure removes —
(A) 1. Hsemic murmurs over the base of the heart (save Jenner's
pulmonary murmurs).
2. An aortic obstructive murmur of the apex.
3. When mitral and aortic regurgitant murmurs coexist, the
aortic murmur is diminished in the greater degree.
4. Aortic regurgitant murmurs over the second right intercostal
space.
While it does not markedly affect —
(JB) 1 . Mitral regurgitant murmurs heard over the apex ; or
2. Mitral obstructive murmurs over the same spot.
3. Tricuspid regurgitant murmurs over the area of greatest in-
tensity.
4. Aortic regurgitant murmurs over the apex (see (A), No. 3).
Secondary Effect of Valve-lesions on the Heart and Pulse.
The secondary effect of valve-lesions on the heart and pulse aid in the
diagnosis. While we are enabled by the time of the murmur, the posi-
tion, and the direction of transmission to affirm the nature of the dis-
ease at the respective valve-orifices, other physical signs further aid
us in determining more precisely the lesion and its seat. They are
derived from the heart and the pulse. They depend upon the second-
ary effect of the lesion upon the heart and upon the circulation. In
aortic obstruction, on account of obstruction to the flow of blood, the
left ventricle hypertrophies ; moreover, the blood stream is lessened in
volume, and hence the pulse is small and of high tension. The physi-
cal signs of hypertrophy and small pulse are corroborative evidence of
this lesion at the left orifice. In aortic regurgitation the blood flows
back into the ventricle. On this account, therefore, some dilatation
takes place, a dilatation which, if compensation is perfect, is overcome
by hypertrophy. The signs, however, of enlarged left heart are pres-
ent, as shown by inspection, palpation, and percussion. But the pulse
of aortic regurgitation is of the greatest diagnostic significance. With
the finger on the radial, the impression is at once received of recedence
of the pulse- wave as soon as it strikes the finger. This is more marked
if the hand is elevated. It is the water-hammer, or Corrigan's, pulse.
In mitral regurgitation the left auricle does not change, but the stress
is thrown upon the right side of the heart, and we have the signs of
right-sided hypertrophy and dilatation ; but more marked than this is
the evidence of high tension of the pulmonary artery, shown by accen-
tuation of the second sound. (See p. 625.) In mitral regurgitation,
the blood flows back into the auricle, and when the right heart weak-
ens engorges the venous system. The arterial system is in consequence
devoid of blood, and hence the arteries are empty. The pulse is small
and feeble. The depleted coronary arteries do not nourish the ven-
tricles, hence dilatation or failure in nutrition soon ensues, and the
6 40 SPECIAL DIAGNOSIS.
heart is further weakened. In addition to being small and feeble, the
pulse, on account of inefficient and hurried contractions of the ventricle,
is irregular and intermittent.
In mitral obstruction, in addition to the characteristic murmur, the
thrill is of great significance. Moreover, the left auricle hypertrophies,
and shortly afterward the right heart. It is accompanied by an ac-
centuated pulmonary second sound, and frequently by doubling of that
sound. The pulse is small and feeble.
Multiple Cardiac Murmurs. More than one murmur may be
heard over the heart. The number depends upon the number of
valves that are the seat of disease and the lesions at the orifices. We
may have valvulitis of the aortic, mitral, and tricuspid valves conjoined.
More commonly one valve is diseased, giving rise to a murmur, while
another valve is incompetent, on account of dilatation, and a murmur
thus generated at its orifice It is common to see aortic obstruction
from valvulitis and mitral regurgitation from incompetency ; mitral
obstruction or regurgitation from valvulitis, and tricuspid regurgita-
tion from incompetency. I have seen double aortic disease (combined
obstruction and regurgitation), double mitral disease, and tricuspid
regurgitation. The diagnosis of the various murmurs will be dis-
cussed in the chapter on Valvulitis.
The Arteries. The stethoscope should always be used in examining
the arteries. The double stethoscope is preferable, as strong pressure
must be avoided upon the vessels. When the single stethoscope is used
some diagnostic value attaches to the character of the shock that is trans-
mitted to the head. The arteries open to auscultation are the carotids
when the neck is slightly extended ; the subclavian ; the innominate
above the sterno-clavicular articulation ; the brachial artery in the
bend of the elbow, with the arm slightly extended ; and the crural
artery just below Poupart's ligament. The normal systolic and dias-
tolic heart-sounds are often heard in the carotid and subclavian arte-
ries. The systolic sounds may be heard over the abdominal aorta,
due to tension of the vessels. The diastolic sound is rarely heard in
this situation. In the other vessels no sounds are heard.
Induced or pressure-murmur. By pressure with the stethoscope over
one of the vessels its calibre is modified and a murmur created. This
murmur corresponds in time with the pulse, hence it is systolic, and
increases or diminishes in intensity, depending upon the amount of
pressure placed upon it. Just here may be mentioned the systolic
humming which is heard in children between the third month and the
sixth year over the fontanelles and sometimes over the rest of the
head. ' (See The Head.)
Abnormal Sounds. Abnormal sounds or murmurs are due to
alterations of the blood, disease outside of the vessels causing pressure,
and disease of the vessels. Murmurs from disease of the vessels, as
the aorta, are discussed under the head of arterio-sclerosis or aneurism.
Conduction Murmurs. Murmurs may be propagated into the
arteries. A systolic murmur created at the aortic orifice may be heard
in the vessels of the neck and along the aorta. On the other hand,
in aortic regurgitation, the diastolic sound normal in the carotid and
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 641
subclavian disappears, and the diastolic murmur is not heard. Double
Sounds of the Vessels. Double sounds are sometimes heard in the
crural artery under the following circumstances : (1) In aortic insuffi-
ciency ; (2) in mitral stenosis ; (3) in lead-poisoning ; (4) in pregnancy.
Duroziez's double murmur, heard when greater pressure is used by the
stethoscope, occurs in aortic regurgitation when there is good compen-
sation. Many authorities refer to this as a valuable diagnostic sign
in this affection. The double sound in all instances occurs with large
and quick pulse. It is probably caused by sudden collapse of the
artery, and the reflux blood-current which is possibly an aortic regur-
gitation.
Murmurs due to Alteratioxs of the Blood. They are gen-
erated in anaemia and chlorosis. They are called functional murmurs,
to distinguish them from murmurs due to disease of the vessels. They
are systolic in time. They are soft and low in pitch, often of a musical
character. The degree of loudness may vary with the position of the
patient. They are increased by excitement. The intensity of the mur-
mur increases in the course of fevers.
Murmurs in Relaxed Vessels. Murmurs in the vessels, appar-
ently of functional origin, are sometimes heard. The vessels are
dilated from actual disease. The increased calibre favors the develop-
ment of a murmur by the creation of a fluid vein. Dilatation of the
innominate artery sometimes takes place, giving rise to a murmur, which
in loudness and character simulates the murmur of aneurism. A
functional murmur is sometimes heard in the vessels, independently of
disease, in cases of aortic regurgitation. The murmur is systolic in
time.
Pressure-murmurs. Pressure of the stethoscope, or that caused
by diseases outside of the bloodvessels. When heard over the subclavian
artery, the pressure-murmur may be due to adhesions or consolidation
at the apex of the lung. It is more frequently heard at the left, and
may only be present during full expansion of the lung. It is due to
temporary pulling or bending of the artery during deep breathing.
When it occurs on both sides it is not of much significance. Murmurs
in the axillary artery, or in any arteries surrounded by enlarged lym-
phatic glands, are created by their pressure. Murmurs in the thyroid
gland have been referred to. (See Goitre.)
Murmurs due to Disease of the Arteries. In the aorta the
murmurs are due to aneurism or atheroma, or both. They may be
systolic or diastolic. In the smaller vessels both conditions may be
present, although atheroma is the usual one. The murmur is systolic
in time, rough in character, strong or weak. It is associated with
other signs of atheroma.
The Veins. In health no sounds are heard. Two conditions
contribute to the creation of a murmur in the veins : (1) Change in the
character of the blood ; (2) dilatation with the occurrence of positive
venous pulse.
The Venous Hum. In aneemia and chlorosis, and sometimes in
healthy patients, a hum or murmur, or buzzing sound is heard over
the jugular veins. It is louder on the right side than on the left. It is
41
642 SPECIAL DIAGNOSIS.
soft and low in pitch, and may be musical ; it has been described as
humming or whizzing. It is continuous. For its detection a double
stethoscope should be used, as pressure increases it, and the patient
should not turn the head to one side, as it is increased when this posi-
tion is taken. The murmur is modified by the respiration and by the
cardiac action. It is louder in deep inspiration when the blood is
going more rapidly to the thorax. It is also louder in the upright
position. It is frequently louder during the diastole. The increased
loudness at these periods occurs because, from the sucking action
daring inspiration and during the diastole, the blood is more rapidly
drawn toward the heart. The murmur is caused by the flow of blood
from the narrow jugular into its wider bulb, producing a fluid vein.
Later authorities believe it to be due to lateral vibration of the Avails
of the veins. Similar murmurs are heard in other veins, as in those
of the extremities when the anaemia is profound. They are stronger
during the diastole of the heart. The venous hum is sometimes heard
at the lower border of the liver, to the right of the median line, in
cirrhosis of the liver. It is created in the enlarged collateral veins.
It may be modified by pressure of the stethoscope. It may be heard
in this situation in emaciated and cachectic subjects not the subject of
cirrhosis. The venous hum may be heard in the innominate veins
(first and second interspaces and right costo-clavicular articulation), in
the subclavian and axillary veins.
Pericarditis.
Inflammation of the Pericardium. The inflammation may be
acute or chronic. It is also divided according to the nature of the in-
flammation into simple fibrinous inflammation and inflammation with
effusion. The effusion may be serous, bloody, or purulent, depending
upon the nature of the inflammation. Pericarditis, either acute or
chronic, is also divided into primary or secondary pericarditis. The
primary form is of extremely rare occurrence. Indeed, it may well
be doubted whether, in common with the inflammations of serous
membranes in general, pericarditis is ever primary, or so-called idio-
pathic, in origin.
Causes. 1. Extension from Neighboring Structures. Extension of
the inflammation from infected tissues in the vicinity is a common
cause of pericarditis. It may follow a pleurisy and partake of the
nature of the primary pleural inflammation. It often attends em-
pyema, either from extension of the infection to the pericardium or
from rupture into the pericardial sac. It may follow all forms of in-
flammation of the mediastinum. Disease of the ribs adjacent to the
pericardium may set up pericarditis, acute and chronic. It attends
on the course of aortic aneurism, at times, but more frequently in-
fectious endocarditis and myocarditis. Inflammations below the
diaphragm frequently give rise to pericarditis. Peritonitis, when
general or local ; sub-diaphragmatic abscess ; suppurative gastritis,
with perforation of the stomach ; abscess of the liver ; suppurating
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 643
hydatid, and other forms of suppuration below the diaphragm, belong
to the latter.
2. General Infections. The general diseases causing inflammation of
the pericardium are those which affect serous membranes. They are :
Infectious diseases, particularly scarlet fever, measles, erysipelas, and
typhoid fever. All forms of septicaemia may be attended by inflamma-
tion of the pericardium. Tuberculosis is a frequent cause of pericar-
ditis. Inflammation of this membrane frequently arises in the course
of rheumatism. It may occur in the course of the disease, or attend
some of the affections which are themselves manifestations of rheuma-
tism, such as acute tonsillitis. In the course of certain dyscrasise the
pericardium is frequently the seat of inflammation because more vulner-
able. This is particularly the case in scurvy. It occurs also in Bright's
disease, and may be the first manifestation to the patient of this disease,
particularly in the chronic form of nephritis. It occurs in the course
of gout.
The various forms of pericarditis may occur at any age. although
that which attends scarlatina and rheumatism occurs in early life, while
late in life it is an attendant upon chronic Bright's disease and gout.
Acute Fibrinous or Plastic Pericarditis.
This is probably the most common form that is seen. It is the
variety that attends Bright's disease, rheumatism, and tuberculosis.
It may be wanting entirely in symptoms. An examination of the
heart in the routine of duty may reveal its presence by physical signs.
In the course of one of the primary causal diseases, if the tempera-
ture rises a little higher than it should, or convalescence is delayed,
pericarditis should be suspected. Again, if the pulse is more rapid
and quicker than customary at the period of disease the examina-
tion is made, or out of proportion to the temperature, the disease
should be suspected. There may be altered rhythm or tumultuous
action. In other instances the patient may complain of pain in the
region of the heart. It is usually localized in the fourth or fifth inter-
space. It is not very severe and not influenced by pressure. Some-
times the pain is complained of at the xiphoid cartilage. In rare
instances it may resemble angina. The pain and the occurrence of
fever further call attention to the heart.
Physical Signs. Inspection. Nothing unusual is observed, although
the heart may be seen to beat more violently against the chest-wall.
The impulse is diffused.
Palpation. A friction-fremitus may be detected, due to the rub-
bing together of the roughened pericardial surfaces. It is not always
present. It may be felt when the whole hand is laid over the praecor-
dia, or by palpation with the tips of the fingers. It is most marked
over the right ventricle, particularly in the fourth interspace, and is
increased when the patient leans forward.
Auscultation. A friction-sound is usually present. It may be present
while the fremitus is absent ; but, on the other hand, if the fremitus
644 SPECIAL DIAGNOSIS.
is present, we can always hear the friction. It is heard over the region
where the fremitus is felt.
Point of Maximum Intensity. It may be heard along the course of
the sternum It is usually heard in the third or fourth interspace,
but may be heard as high as the second, adjacent to the sternum in
either interspace. Sometimes it is heard at the second costal cartilage
on the right, rarely at the apex. The point of maximum intensity
may vary with the position of the patient.
Time. It is both systolic and diastolic. In some cases it may be
only systolic in time, or it may be of a galloping nature, representing
three sounds during the cardiac cycle. Again, the to-and-fro sound is
not synchronous with the systolic and diastolic sound, although it
occurs but once in the cardiac cycle. It may begin after systole, and
be completed before the end of the diastole. The impression that it
is a superadded sound is most positive.
Direction of Transmission. It is localized, and not transmitted.
Character. It is a to-and-fro rubbing, scratching, or grating sound ;
it gives the impression of being near the ear. It may be modified by
the pressure of the stethoscope and by the position of the patient. It
may be heard in the erect and disappear in the recumbent posture.
Diagnosis. Acute pericarditis without effusion is not recognized
generally, because it is not sought for. In the larger number of
cases, as previously intimated, there have been no indications of dis-
ease of the pericardium during life. If sought for, however, the diag-
nosis is usually easy. The pericardial friction may be mistaken for
an organic heart-murmur or for -pleural or pleuro-pericardial friction.
It is often difficult to distinguish the to-and-fro friction from the mur-
murs of double aortic disease. If attention is paid to the general and
local phenomena, the mistake is not likely to be made. The location
of the murmurs in organic heart disease, the direction of the transmis-
sion, the character of the murmur, the peculiar character of the pulse,
and the secondary effects upon the muscles of the heart, point to the
diagnosis of valvular lesion. The pleuro-pericardial friction which
simulates pericardial friction usually occurs in the course of phthisis
or pleuropneumonia. It is modified by respiratory movement : (1) It
may disappear, or at least diminish, if the breath is held ; (2) a full expi-
ration may cause its disappearance. While it is of cardiac rhythm it
is modified by the respiratory rhythm, so that on inspiration it is
usually more marked. The pleuro-pericardial friction is not so
strikingly- modified by position. Pleural Friction. Tins is of respira-
tory rhythm and ceases with cessation of breathing. The pericardial
friction persists even if the breath is held.
Pericarditis with Effusion.
I knov of no affection which is more frequently overlooked during
life than pericardial effusion This is because it develops without
symptoms. In plastic pericarditis we have referred to the occurrence
of pain. This may occur before the effusion in the latter form, but is
PLATE XXVIII.
Pericarditis With Effusion.
FIO. 2.
Syst. retr.
Adherent Pericardium. Chronic Left-Sided Pleurisy.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 645
usually moderate. As with dry pericarditis, however, it may, in rare
instances, be very severe, anginous in character, and be increased by
pressure over the heart or on the pit of the stomach.
The symptoms are usually due to the special character of the inflam-
mation and the presence of fluid in the pericardium.
1. General Symptoms. In non-suppurative cases the symptoms
are usually cerebral. Delirium may be moderate or maniacal. It
must not be confounded with the delirium which occurs in the course
of acute rheumatism with hyperpyrexia. In addition, choreiform
movements have been described. They may, however, be of rheu-
matic origin. Other cerebral symptoms, as hemiplegia and convulsive
attacks, occur in the course of pericarditis, probably due to an associ-
ated endocarditis, causing embolism. In some cases albuminuria is
found.
The general symptoms of pericardial effusion depend upon the
nature of the primary disease and the character of the fluid. In
tuberculous pericarditis, emaciation, irregular fever, sweats and prostra-
tion ensue. In purulent pericarditis there may be recurring chills with
a temperature-range decidedly intermitting, along with other phenom-
ena of purulent accumulation. In a case recently seen (1895) the
patient was extremely debilitated and prostrated on account of pneumo-
nia following influenza. He was extremely anaemic, and the blood-
count showed diminution of red cells to one-half without other change.
Every fourth day after a chill the temperature would rise to 103° or
104°. A friction-sound was detected after the second chill. It disap-
peared, but the physical signs of effusion were not positive. From
the first the heart's action was so weak that the sounds were scarcely
discernible. At the autopsy four or five ounces of pus were found in
the pericardial sac. The purulent accumulation was the only lesion
to account for the symptoms, and, we would say now, was no doubt
a pneumococcus infection.
2. Local Symptoms The local symptoms are due to the accumu-
lation of fluid within the pericardium. Dyspnoea is the most common.
The degree depends upon the amount of effusion. If the latter is
large, there may be extreme orthopnoea ; if the effusion is present for
a considerable time, it may give rise to no symptoms. Dysphagia.
In large effusions this may occur, on account of pressure upon the
oesophagus. Altered Cardiac Rhythm. The effect of the effusion upon
the heart is to interfere with its action. Although usually regular,
on the slightest exertion or the least excitement it palpates violently or
becomes irregular. The heart's action is increased in frequency ; when
the effusion is very large it may be not only irregular, but also inter-
mittent. Aphonia may occur from pressure upon the recurrent laryn-
geal nerve. Cough of an irritative character is sometimes noted. The
pulsus paradoxus may be present.
3. Physical Signs. (Plate XXVIII., Fig. 1.) Inspection.
There is bulging of the prsecordia, particularly in children. The ribs
and interspaces are prominent. In adults the interspaces are even with
or distended beyond the surface of the ribs, and are sometimes widened.
646 SPECIAL DIAGNOSIS.
The enlargement may extend to the anterolateral region of the left
chest. The large effusion interferes with expansion of the lung on the
left side, and hence movement is diminished. The epigastrium may
be prominent, on account of displacement downward of the diaphragm
and liver. The apex-beat is absent or faintly seen, displaced upward
and to the left. It does not extend as near the left border of d illness
as in dilatation. It may be seen in the fourth interspace, or a faint
impulse may be observed in the second and third interspaces beyond
the mid-clavicular line.
Palpation. The impulse is feeble and diminishes in force as the
effusion increases. The position of the apex as determined by inspec-
tion is confirmed. Ewart points out that the first rib is palpable at
its sternal attachment in pericardial effusion. The pericardial fric-
tion which may have been present at first disappears with the effusion.
Fluctuation may be detected in large effusions. The liver in large
effusions is depressed and readily palpable.
Percussion. The area of precordial dulness is increased. There
is increase of the lateral boundaries and great increase of absolute dul-
ness. The increase of area is usually in all directions, although in-
crease of the dulness upward and to the left only is very common. It
may extend as high as the second rib. As pointed out by Rotch,
dulness in the fifth right interspace in the angle formed by the right
border of the heart and the right lobe of the liver is common in effu-
sion. It may be an early sign of effusion. Ebstein calls this region
the cardio-hepatic triangle, and points out that the dulness is absolute
in effusion, although impaired in normal states because of proximity to
the liver.
Pulmonary resonance is modified posteriorly in large effusions. The
dulness in large effusion includes the axillary region, so that it may
simulate a pleural effusion. The dulness, however, does not extend
below the eighth rib in this region, whereas, in pleural effusion, dul-
ness always extends to the bottom of the pleural sac. In a large peri-
cardial effusion the semilunar space of Traube is obliterated.
Auscultation. The sounds are feeble and distant. They may be
scarcely heard at all over the precordial region. The sounds at the
base of the heart are diminished in intensity. If a friction-sound was
heard at the beginning, it disappears entirely as the effusion is poured
out. In moderate effusions the friction may be heard when the erect
posture is assumed.
It must not be forgotten that the physical signs, and especially the
change in impulse and the area of precordial dulness, are modified by
the position of the effusion. Accumulations occur behind the heart or
above it, and in these situations interfere least with the displacement
or the enfeeblement of the apex-beat. The area of dulness, however,
is increased upward.
In cases of large effusion the compression of the lung may cause
bronchial breathing to be heard posteriorly or in the axillary region.
In a case under my care the diagnosis of pericardial effusion was
readily made, but the enormous effusion so markedly simulated an
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 647
effusion into the pleural cavity that both serous cavities were believed
to contain fluid. Aspiration was performed in the sixth interspace in
the anterior axillary line. The fluid was removed from the peri-
cardium, as was afterward determined. During life pressure-signs —
laryngeal stridor, difficulty of deglutition, and extreme dyspnoea — were
present. Early vomiting, epigastric pain and tenderness, slight de-
lirium, albuminuria, and an excessively weak, rapid pulse occurred in
the course of the disease. The patient was a male, twenty years of
age. The effusion was due to tuberculous pericarditis, secondary to
tuberculosis of the bronchial glands. The physical signs were prom-
inence of the praecordia ; bulging of the interspaces on the left side ;
diminished expansion of the left side — anteriorly, laterally, and poste-
riorly ; increased expansion at the extreme apex of the lung. The
vocal fremitus was absent below the second interspace in front, below
the third in the axilla, and diminished below the spine of the scapula
behind. There was dulness from the second left rib in front to
the margin of the thorax ; from the fourth to the eighth rib in the
axilla ; below the eighth rib, tympany. The dulness extended be-
yond the margin of the sternum on the right side, almost to the
right nipple-line, in the fourth and fifth interspaces. Posteriorly, dul-
ness from the middle of the scapula to the base of the thorax, except
along the vertebrae, where, from the seventh to the ninth rib, there
was tympany. The physical signs of pericardial effusion on auscul-
tation were marked. In the axilla the breath-sounds were absent.
There were bronchial breathing and bronchophony behind from the
spine of the scapula to the base along the vertebrae. They were most
marked opposite the angle of the scapula, where the above-noted tym-
pany was observed. In the mid-scapular line the breath-sounds dimin-
ished from above downward, and Avere absent at the base. It is seen
that the physical signs of pleural effusion were present posteriorly and
laterally, due to the enormous effusion. At the autopsy the pericar-
dium was found to contain sixty-four ounces of fluid.
Pleural effusions may be excluded in similar cases by the absence
of dulness in the axillary region below the eighth rib ; by increase in
dulness beyond the right edge of the sternum ; and, at the same time,
by the absence of signs indicating dislocation of the heart to the right.
Diagnosis. Pericardial effusion must be distinguished from dilata-
tion of the heart. Although feeble and diffuse, the expansile shock of
the impulse is more distinct than in dilatation. This distinction is not
generally difficult if the patient has been under observation during the
development of the disease. The impulse is not always absent in dila-
tation. Fluctuation may be detected. The area of dulness in dilata-
tion does not extend upward except in cases in which the right auricle is
enlarged. The dulness does not extend downward in dilatation with-
out a similar displacement of the apex impulse. The shape of the
dulness differs. In dilatation the dulness is square in shape ; in
effusion it is triangular or pear-shaped, with the base downward. In
dilatation the sounds are accentuated, and are of a valvular character ;
in effusion they are muffled. Dilatation does not cause the pressure-
648 SPECIAL DIAGNOSIS.
symptoms that occur in effusion. In pericardial effusion Bamberger's
sign is of importance. When the patient is sitting upright an area of
dulness about the size of a silver dollar can be marked out at the
angle of the scapula. Over it, dulness, increased fremitus, and bron-
chial breathing are made out. If the patient leans forward, the dulness
and the other signs of consolidation disappear, to return when he sits
upright. In children pseudo-pleuritic signs are often present poste-
riorly — dulness, pleuritic friction, broncho-oegophony — but will disap-
pear if the patient is put in the knee-chest posture. It is of diag-
nostic significance to have change of the rhythm and the character of
the sound from day to day, or of its degree of loudness on movement
of the patient.
In pericarditis with effusion, after its absorption, the friction-sound
may return. Often it may disappear entirely and all signs of pericar-
dial inflammation subside. In plastic pericarditis and pericarditis with
effusion adhesion of the two layers of the pericardium may take place.
Effusions into the. pericardial sac of serum, of blood, or of air, may
take place without previous inflammation.
Hydro-pericardium. This may occur in the course of general
dropsy from kidney or heart disease. It may not prove fatal of itself,
but when associated with effusion in the pleural sac it contributes to
the orthopnoea, which may cause death. Rarely after scarlet fever,
effusion into the pericardial sac may be the only dropsical symptom.
The physical signs are those of effusion. It is not attended by fever.
It is frequently overlooked, because investigation beyond the pleura
is not made after an effusion into that cavity has been found.
Haemo-pericardium. This occurs on account of rupture of an
aneurism of the first part of the aorta, of the heart itself, or of the
coronary arteries. Wounds of the pericardium and heart cause hsemo-
pericardimn. The extension of the ulceration of malignant endocar-
ditis to the surface may cause gradual effusion of blood. (See Keat-
ing, Transactions of the Philadelphia Pathological Society.) The physical
signs are those of effusion. Death usually takes place before there has
been time to make a sufficiently accurate examination to determine its
presence. Rapid heart-failure due to compression is the cause of death.
In the case referred to above, and in cases of rupture of the heart, the
patient may live for many hours with dyspnoea and progressive weak-
ening of the heart. In tuberculosis and cancer the effusion is fre-
quently blood-stained.
Pneumo-pericardium. This occurs very rarely, and is due to per-
foration from without by a stab-wound, or perforation from the lung,
oesophagus, or stomach. A purulent exudation may undergo decom-
position, causing an accumulation of gas. If it arises from perforation,
acute pericarditis is set up. The accumulation of gas causes tympany
over the movable area of percussion-dulness. The most striking sign
is noted on auscultation. Churning, splashing, or metallic sounds are
heard, drowning the feeble heart-sounds. Death usually occurs quickly.
Adherent Pericardium. (Plate XXVIIL, Fig. 2.) Chronic adhe-
sive pericarditis may follow the acute form or, particularly if tubercu-
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 649
lous, develop independently and progress slowly. Inspection and Palpa-
tion. Indrawing of the interspaces may be seen at the time of the systole
of the ventricles ; even the ribs are said to be drawn in. This indrawing
is most marked at the apex, and must not be confounded with the retrac-
tion that occurs in the third and fourth interspaces with the ventricular
systole. The recession is synchronous with the systolic shock. In some
cases the systolic movement over the prsecordia is of an undulatory
character. Walter Broadbent calls attention to systolic retraction of the
back in the region of the eleventh or twelfth rib as a valuable sign.
The apex is displaced outward and the area of impulse is increased. The
increase in area of impulse is due to the hypertrophy which always
attends universal adhesion of the pericardium. After the systole there
is frequently felt a quick rebound, known as the diastolic shock, which
is said to be characteristic of pericardial adhesions.
In pericardial adhesions Friedreich's sign, collapse of the cervical
veins, during the diastole of the heart, is seen. We may also see in-
spiratory swelling (Kussmaul). In addition, the pulsus paradoxus
is significant of the presence of pericardial adhesions, or rather of the
dilatation that succeeds the adhesions. The pulse is small and feeble
during inspiration, assuming greater strength during the period of ex-
piration.
Percussion. The area of cardiac dulness is increased usually up-
ward, extending as high as the first interspace. The area of dulness
is frequently not modified by respiration — that is, it is not lessened
when the patient takes a full breath, when the lungs should expand
over the precordial region. This is particularly the case when there
is pleuritis associated with pericarditis, a common association in the
lar ^e majority of cases.
Auscultation. On auscultation the signs vary. The sounds are due
to hypertrophy or to dilatation ; and it must not be forgotten that
they frequently arise on account of pericardial adhesions. In the
former condition the first and second sounds are accentuated ; in the
latter, a murmur may be heard at the apex, loud and systolic in time.
In pericardial adhesions the physical signs depend upon the condi-
tion of the heart muscle at the time of the examination. At first we
have the physical signs of hypertrophy, with retraction of the inter-
spaces, particularly at the apex, or the space at the xiphoid cartilage.
This is particularly the case in young subjects. In the later period of
the disease the physical signs of dilatation arise, indicated by increase
in transverse dulness, enfeeblement of impulse and of sounds, with the
development of a murmur at the apex, undulation of the veins in the
neck, and the pulsus paradoxus. The physical signs of associate pleu-
risy aid in the recognition of adherent pericardium. Diminution of
the breath-sounds, increase in the area of cardiac dulnessj lessened
fremitus in the neighborhood of the heart pointing to pleural thickening,
are associate evidence. Sansom considers the presence of pulmonary
tuberculosis of value, as pointing to the occurrence of pericardial adhe-
sions, for the associate pleural adhesions are likely to be attended by
tuberculous pericarditis.
650 SPECIAL DIAGNOSIS.
I have learned to suspect adhesive pericarditis in a young subject
the victim of valvulitis, when the symptoms do not yield to treatment —
in short, when the heart is not affected by digitalis. Unfortunately,
the physical signs are often not conclusive.
The subjective symptoms of adherent pericardium are those of dilata-
tion or hypertrophy of the heart, whichever one of the two is in excess.
Indurative mediastino-periearditis with adhesion may occur with or
without fibrous inflammation and adhesion of the structures in the
anterior mediastinum. The pericardium is adherent and thickened.
Rarely the anterior mediastinum alone is a mass of fibrous inflamma-
tion. Peritonitis and perihepatitis may be found. The entire process
may be tuberculous. The symptoms are dyspnoea, venous engorgement,
cyanosis, enlargement of the liver, ascites, and dropsy. The physical
signs are those of extreme cardiac dilatation ; the pulsus paradoxus ;
collapsing jugular veins during diastole, due to the dragging upon the
innominate veins and cava by the fibrous adhesions, or to stretching
and narrowing of the aortic arch by these adhesions ; or inspiratory
swelling of the veins of the neck. A friction-sound, systolic in time,
heard over the sternum, increased when the arm is held up — mediasti-
nal friction, so called, has been described in this affection.
It usually follows an acute chest-affection, occurs most frequently in
young adults, and in males. It should also always be suspected in
cases of dilatation and valvulitis in which compensation does not take
place, notwithstanding the best treatment.
Endocarditis.
Endocarditis may be acute or chronic. In either form it is usually
secondary. The acute form is divided into simple and so-called malig-
nant, infectious, or mycotic endocarditis.
Simple Endocarditis. Acute endocarditis rarely occurs primarily.
It usually occurs secondarily to general morbid processes. The patho-
logical antecedents are acute rheumatism, tonsillitis, whooping-cough,
scarlet fever, gonorrhoea, rarely smallpox and typhoid fever. It is of
common occurrence in pneumonia and tuberculosis. It is frequent in
chorea. In the simple form it occurs in septic inflammations and in
debilitating diseases, as cancer. It may occur in gout and develop in
the course of Bright' s disease.
Symptoms. The symptoms of simple endocarditis are scarcely ob-
served during the early course of the disease. The process is latent,
and there are no indications of cardiac disease. The physical signs
alone betray its presence. Unless these are sought for the disease is
overlooked. The subjective symptoms are negative. In the course
of rheumatism or chorea, or during convalescence from the former, the
patient may complain of palpitation, and increased frequency and
irregularity of the heart. At the same time there may be a rise in
temperature, not attended by any increase of the rheumatic symptoms,
which should call attention to the cardiac complication. The rise is
not marked, and may not assert itself during the severity of the disease.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 651
Physical Signs. On examination a murmur is detected in one of
the cardiac areas. The murmur is soft, low in pitch, and follows the
laws of transmission, according to its situation. Instead of a distinct
murmur a roughening of the first sound alone may be heard. Pre-
ceding the murmur the heart's action may be quickened and arhythmi-
cal ; the first sound may change in character from day to day or be
accentuated ; the second reduplicated at the apex and accentuated.
The new sounds may disappear at first when the patient sits up ; later
they persist. The murmur must not be mistaken for the murmur at
the apex in cardiac dilatation ; or the murmur which may be heard in
the course of fevers ; or the murmur of anaemia, which may rapidly
develop in rheumatism and other affections.
Malignant Endocarditis. Unlike simple endocarditis, the malig-
nant form very rarely develops in the course of rheumatism and
chorea. (See the Infections.) It occurs more frequently in pneumonia
than in any other disease. It arises in the course of erysipelas, septi-
caemia, puerperal fever, and gonorrhoea. It may occur in dysentery.
It is usually a streptococcus infection.
Symptoms. The symptoms are (1) those due to the morbid process
— the infection ; (2) the physical signs ; (3) those due to emboli. The
general symptoms due to the specific morbid process are septic in nature.
The febrile phenomena may be one of four groups : (1) The fever is
paroxysmal. Chills and fever occur daily or at intervals of two or
three days, resembling types of malarial fever. Each paroxysm is
attended by profuse sweats. Rapid exhaustion ensues. The fever,
instead of being distinctly intermittent, may be irregularly intermit-
tent. (2) The fever is excessive and continued, and a typhoid state
frequently sets in. The temperature is irregular ; extreme prostration,
low delirium, sordes, subsultus, and other symptoms of that state arise.
(3) The fever is moderate and continued. Physical examination, how-
ever, reveals the presence of marked endocarditis. In this group
chronic heart disease has usually preceded the affection. The duration
may be prolonged. (4) The fever may be remittent. Petechial rashes
and erythema are common, so that, as pointed out by Osier, the disease
may resemble the eruptive fevers. The sweating is profuse, contrib-
uting to the profound exhaustion which usually ensues. A septic
diarrhoea occurs. In a few rapidly fatal cases jaundice has occurred.
Again, the symptoms may be almost exclusively cerebral, resembling
cerebro-spinal or basilar meningitis.
The embolic phenomena are due to escape into the blood-current of soft
vegetations from the valves of the left heart (for the right heart is
rarely affected), which are carried by the blood-stream into distant
points of the circulation. Emboli occur in the brain, producing
aphasia or hemiplegia ; they occur in the retina, causing some com-
plaint as to vision, but are accurately recognized by ophthalmoscopic
examination. They occur in the kidneys, producing bloody urine and
renal pain. In nearly all cases the spleen is the seat of embolism, and
in some instances infarctions may take place in this organ alone. The
spleen is always enlarged, and the infarct may cause pain and increased
652 SPECIAL DIAGNOSIS.
tenderness on pressure. Emboli in the skin and mucous membranes
present the most striking phenomena. The hemorrhages underneath
the skin are minute. They are seen in the extremities, but may also be
found on the trunk. They occur in the mucous membranes, as those of
the mouth and tongue. They are seen in the bulbar conjunctiva?, and
in the conjunctivae of the lids.
Physical Signs. Repeated examinations are necessary in some cases,
to determine the presence of a murmur, or to decide whether a previ-
ously existing organic lesion is the seat of an acute process. Varia-
tions in the character of the murmur from day to day are characteristic
of malignant endocarditis. In organic heart disease with dilatation and
failure of compensation, irregular fever followed by embolic phenom-
ena points to the occurrence of an infectious process on the antecedent
valvulitis.
Diagnosis. This form of endocarditis is of infectious origin. The
diagnosis rests upon proof that an infection is present, and is made by
the methods described in Chapter XIX., Part I., which should be
reviewed by the reader. The history of an infection in some part of the
body is most important in the diagnosis. The presence of the infection,
as well as its nature, may be disclosed by an examination of the blood.
When embolic phenomena are present the diagnosis is made without
much difficulty. The more pronounced general symptoms distinguish
it from simple endocarditis. The temperature-range, the septic and
typhoid symptoms, belong to the malignant form. The more pro-
longed cases with moderately continuous fever, without apparent
primary cause, are frequently confounded with typhoid fever. This is
readily appreciated when the symptoms of the two are compared. In
both there is fever of a continued type, with the symptoms of the
typhoid state, including delirium. In both there are enlargement of
the spleen, diarrhoea, and abdominal tenderness. In both there may
be infarctions, although they are extremely rare in typhoid fever, and
only occur late in the disease. In both there is progressive exhaus-
tion. But in endocarditis the onset may be more abrupt. The fever
does not present the. regularity of type that is seen in the development
of typhoid. In endocarditis there is more chest oppression and
dyspnoea early in the disease than in typhoid fever. In endocarditis
the source of the infection may be discovered in the genito-urinary
organs, the lungs, the bones, etc. The diazo-reaction is found in
typhoid fever after the fifth day, but rarely, if ever, in endocarditis.
The results of bacteriological examination, and especially of serum,
diagnosis, distinguish the two affections. This ought to be of value in
endocarditis, because the process is usually due to a staphylococcus or
streptococcus infection. Either micro-organism may be found in any
suppurations which may possibly be present or in the blood. In a child
recently seen by me in the relapse of an attack of typhoid fever, malig-
nant endocarditis was thought to be present, because of a loud and rough
murmur at the pulmonary orifice. Fortunately the murmur was present
in the apyretic period, and as the child was anaemic its exaggeration
was ascribed to the fever.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 653
Malignant endocarditis must be distinguished from cerebrospinal
fever, and from smallpox of the hemorrhagic type. We must rely on the
local cardiac symptoms and physical signs, and the preponderance of
these over the other symptoms. Of course, the prevalence of an
epidemic and a history of exposure are of service in the distinction
between the diseases. Examination of the blood excludes the forms
of malaria which formerly were mistaken for endocarditis.
Chronic Endocarditis. Chronic endocarditis may follow the acute
form or develop in the course of atheroma or of endarteritis due to
alcoholism, the poison of syphilis or of gout. If associated with endar-
teritis, the endocardial change may be part of the general degenerative
changes which occur in the aging process. It may be of dynamic
origin, often following prolonged heavy muscular exertion, by which
the valves, particularly at the aortic orifice, have been subjected to
strain. The process is slow and insidious, and leads to the changes in
the valve-segments which constitute chronic valvular disease.
Symptoms. The symptoms of chronic, or sclerotic, endocarditis are
the symptoms of chronic valvular disease. Insufficiency or obstruc-
tion, or both combined, take place at the affected valve-orifice. The
outflow of blood is retarded in obstruction. Backward flow, or regur-
gitation, takes place in insufficiency in the opposite direction from
the normal blood-current. When there is obstruction hypertrophy
usually develops to meet it. If the obstruction is moderate, and the
person remains in good health, the hypertrophy is sufficient to over-
come the obstruction. In this manner the effect of the valve lesion is
compensated. On the other hand, when blood is permitted to flow
by regurgitation backward into the cavity — that is, in the opposite
direction to its usual course — it meets a blood-current flowing to this
cavity in the normal direction, and the result is overdistention, or over-
filling, of the cavity. Dilatation ensues, and may persist. If the re-
gurgitation takes place suddenly, the dilatation continues ; if gradually,
as in chronic endocarditis, the dilatation is attended with hypertrophy.
Thus, when there is regurgitation from the left ventricle into the left
auricle, on account of incompetency at the mitral orifice, the auricle
becomes overdistended with blood, for it is filling with blood from the
pulmonary veins at the same time. This overdistention can only be
overcome by some hypertrophy. When this is not sufficient the blood
is obstructed in the pulmonary circulation, with the consequences here-
after to be mentioned.
The symptoms of chronic endocarditis are latent if the lesions are
compensated ; if not, symptoms of failure in compensation occur or
dilatation of the heart arises. The physical signs are those of chronic
valvulitis. The character of the signs depends upon the lesion of the
affected valve.
Disease of the Coronary Arteries.
Atheroma, associated with the process in other vessels, or distinctly
localized to the coronary arteries, affects these vessels. Its causal
factors are those of endarteritis elsewhere. Its influence on the nutri-
654 SPECIAL DIAGNOSIS.
tion of the heart, either by sudden obstruction of the vessels by an
embolus or by their gradual closure, is apparent.
Symptoms. If an atheromatous coronary artery is suddenly ob-
structed by an embolus, death may be immediate. This is a common
cause of sudden death. In other instances thrombosis may take place,
followed by anaemic infarction, myocarditis, and mural aneurism. In
this class of cases the onset of the symptoms may be sudden. Precor-
dial oppression or angina pectoris may be the first indication. Succeed-
ing this, dyspnoea, dilatation of the heart, and venous stasis occur. The
presence of an aneurism may be made out. The heart's action is per-
sistently rapid and may be arhythmical. If there has not been pre-
vious valvulitis, no murmurs are heard until dilatation ensues. The
patient may live three or four weeks, or as many months.
In a third group of cases occlusion, either from the endarteritis or
from a slowly forming thrombus, is so gradual as to lead to myocar-
ditis only with the attending symptoms.
Diagnosis. Unfortunately, too often the diagnosis can only be pro-
visional. Sudden death may be attributed to coronary artery disease
if there has been a history of previous attacks of angina, if there is
evidence of arterial disease elsewhere, and if dyspnoea or anginoid
symptoms preceded the fatal termination. Thrombosis, secondary to
atheroma, may be suspected if a patient, in whom there is no valvular
disease, no pulmonary or renal disease, is seized with angina pectoris
or dyspnoea ; providing tachycardia and arhythmia follow, and in a
short time cardiac dilatation, venous stasis, etc. In a male, aged forty-
three years, without syphilis, but with a history of antecedent rheuma-
tism, an attack of angina pectoris followed some unusual exertion.
Prior to this he had been in the most perfect health. The attack was
followed by dyspnoea and remarkably rapid heart-action without appar-
ent cause. The physical signs of acute congestion of the lower lobe of
the right lung followed within twenty-four hours of the attack of angina.
The patient was ill three months. He improved somewhat, but rapidity
of the heart's action and some stasis in the lung persisted. Gradually
cardiac dilatation ensued, with a murmur in the tricuspid area. Death
took place from pulmonary congestion. At the autopsy the coronary
arteries were atheromatous ; the left was filled with an old thrombus ;
there was extensive myocarditis and an aneurism of the left ventricle.
In another case, male, aged seventy-two years, with general atheroma
but no valvulitis, sudden precordial distress, tachycardia, and persist-
ent dyspnoea were followed by cardiac dilatation, mitral incompetency,
general anasarca.
I have said elsewhere, a persistently rapid pulse, uninfluenced by
digitalis, indicates pericardial adhesion in the young ; the same pulse
uninfluenced by treatment points to coronary artery disease in the
middle-aged and senile.
Myocarditis.
Myocarditis may be acute or chronic. The entire muscle or only
a portion may be affected. General myocarditis is always acute. The
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 655
local form may be acute or chronic, depending upon the degree of
the primary cause. The local variety is usually due to a thrombus
in the terminal endings of the coronary artery, which cuts off the
blood-supply. The changes are those of myocarditis, to which may be
added necrosis of small areas and the development of aneurism.
Etiology. Pathological antecedents of acute general myocarditis are
the fevers, particularly typhoid and typhus fever, pneumonia, diphthe-
ria, and septic fevers generally. Chronic myocarditis is usually asso-
ciated with atheroma, one of the causes of which occurs in the later
stages of Bright' s disease. (See Atheroma.) The result of myocar-
ditis, when acute, is dilatation of the heart, fatty heart, or aneurism of
the heart. Chronic myocarditis is followed by fatty heart, by dilata-
tion, by the so-called fibroid heart or fibrous myocarditis, and by aneu-
rism. The above facts in etiology are important in diagnosis.
Symptoms. The symptoms of acute myocarditis are vague. In
the course of, or in the convalescence from, an infection the patient may
complain of some oppression in the prsecordia and suffer from dyspnoea ;
attacks of syncope may occur, and sighing may be frequent. The
pulse becomes more rapid and weak, but is usually not irregular. The
circulation is much depressed, the hands may be cold, the face pallid.
These symptoms may be accounted for by the extreme exhaustion alone
that follows fever. No doubt some myocarditis accounting for the
symptoms exists in all cases, particularly if there is prolonged high
temperature. Often the patient does not complain of any cardiac symp-
toms. Death takes place suddenly, either in the course of the dis-
ease or after it has spent its force, from acute dilatation or cardiac
paralysis. This is particularly true in pneumonia and diphtheria. In
the latter affection the sudden appearance of cardiac symptoms, dysp-
noea, cyanosis, and cold extremities may be due to paralysis of the
heart.
Physical Signs. Enfeeblement of the heart-sounds, sometimes with
accentuation of the mitral first sound, is observed. The impulse and
apex-beat are scarcely perceptible, or absent altogether. If acute dila-
tation supervenes the area of dulness may be ii: creased.
The symptoms of chronic myocarditis are obscure and indefinite, and
in the majority of cases depend upon the secondary changes that have
taken place in the heart muscle. If there is atrophy of the fibroid
heart, the pulse is feeble, slow, and irregular. It may be as slow as
thirty or forty beats to the minute. Irregularity is not neoessarily
present, but intermittency is of frequent occurrence. The patient com-
plains of dyspnoea aggravated by exertion. Attacks of angina pectoris
are likely to occur. The symptoms of dilatation of the heart may
ensue later, with oedema, cyanosis, and congestions. A symptom-com-
plex, known as the Stokes-Adams syndrome, is often seen, character-
ized by dyspnoea, coma, and slow pulse — a pseudo-apoplexy. In fatty
degeneration of the heart the pulse is increased in frequency ; there are
cardiac irregularity, palpitation, and dyspnoea. These, however, are also
the symptoms of dilatation, which usually succeeds the degeneration.
The heart-sounds are weak. If dilatation has set in, a murmur is heard
656 SPECIAL DIAGNOSIS.
at the apex, with gallop-rhythm of the heart. In fatty degeneration
attacks of collapse with slow pulse are common. Shortness of breath
on exertion may occur. Cardiac asthma occurs at night, and sighing
and yawning are of frequent occurrence during the day. The patient
usually sleeps badly. The cerebral functions are more or less in abey-
ance, the action of the mind is sluggish ; the patient may have delu-
sions or become maniacal. Cheyne-Stokes breathing was formerly
thought to be of diagnostic significance.
Chronic myocarditis must be distinguished from fatty overgrowth of
the heart. This cardiac change is frequently seen in brewers and
saloon-keepers, and is usually associated with obesity. The pulse may
be feeble, the heart-sounds weak and muffled. The patients are sub-
ject to attacks of asthma, and frequently have bronchitis and emphy-
sema. Vertigo is of common occurrence. Death may occur during
syncope.
Aneurism of the Heart.
Aneurism of the valves, following endocarditis, cannot be recognized
during life. Aneurism of the walls usually results from chronic myo-
carditis. The aneurism develops in the left ventricle at the apex.
The symptoms are indefinite. In rare cases a marked bulging has
been noted in the region of the apex, and the tumor may perforate the
chest-wall. A projection beyond the normal line of cardiac dulness
may be detected by stethoscopic or plessimetric percussion. The
symptoms are those of myocarditis and of dilatation of the heart.
Rupture of the heart is one of the causes of sudden death, often
without previous symptoms. The accideut takes place during exer-
tion. Quain collected one hundred cases, in seventy-one of which
death took place without previous warning. In other instances there
was a sense of anguish, and suffocation in the cardiac region. The
physical signs of slowly developing pericardial effusion may be ascer-
tained if the leakage from rupture is slow in progress.
Chronic Valvular Disease.
Valvular disease includes valvulitis and valvular incompetency ;
there is either obstruction or regurgitation at the orifices affected.
Valvulitis may exist with or without symptoms ; valvular incompe-
tency is always accompanied by symptoms. Valvulitis implies organic
disease of the valves ; valvular incompetency, regurgitation through
orifices, the valves of which cannot close it, but they may or may not
be diseased. Valvulitis may be recognized by physical signs of (1)
the lesion, (2) the secondary effects of the lesion on the heart and cir-
culalion — hypertrophy or dilatation. Valvular incompetency occurs
usually in dilatation, and may be secondary to valvulitis. It is recog-
nized by both signs and symptoms. Valvular disease is without symp-
toms as long as the heart-muscle enlarges sufficiently to keep in balance
the impaired circulation ; compensation is then said to be complete.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 657
When compensation is broken we then have the subjective symptoms
enumerated above, all in consequence of dilatation of the heart. It
may be said that valvulitis is of no significance as long as compensation
is perfect. To review — valvulitis may be attended by physical signs
in the heart and vessels only, or by its own physical signs, the physical
signs of dilatation, and the symptoms of the latter. In the considera-
tion of valvular disease it is more profitable to take up the symptoms
of each valve-lesion, bearing in mind that two or more of the valves
may be diseased at the same time, or that both obstruction and regur-
gitation may be present at the same time at the same valve-orifice.
Aortic Regurgitation, Insufficiency or Incompetency. This may
exist for a long time without presenting any symptoms. It occurs
more frequently in men than in women, and is more common in the
later periods of life. It may be due to congenital malformation, to
acute endocarditis, or, as is most frequently the case, to chronic endo-
carditis, particularly when it follows strain or undue exertion ; alco-
holism and syphilis are also frequent antecedents. In rare cases it
follows rupture of the valves. Relative insufficiency or incompetency
is of very rare occurrence. Insufficiency is frequently combined with
obstruction.
On account of regurgitation, or insufficiency, at the aortic orifice the
blood falls directly into the left ventricle during the diastole. There
is, first, a relative diminution in the amount of blood in the artery ;
and, second, an increased amount of blood in the ventricle, because the
regurgitated column of blood meets the blood from the auricle which
is filling the chamber at the same time. Dilatation of the left ventri-
cle ensues, and is followed by hypertrophy. Dilated hypertrophy thus
arises. The heart becomes enormously enlarged. This is one of the
conditions in which enormous cardiac enlargement takes place — so-
called got bovinum. If this valve-lesion occurs at the period of life
and from the causes above mentioned, it is attended by more or less
sclerosis of the arteries.
Symptoms. They may be entirely absent as long as perfect com-
pensation exists. This is particularly the case if there is but little
general arterial sclerosis. Coincident lesions of other valves tend to
break the compensation. The earlier symptoms are those due to
arterial anaemia, particularly anaemia of the brain. They are head-
ache, dizziness, and flashes of light before the eyes. The patient has
an anaemic appearance, and soon begins to suffer from shortness of
breath. This at first develops upon slight exertion. Palpitation and
oppression about the chest are complained of, readily excited by undue
exertion. Pain is a common symptom. It may be in the region of
the prsecordia, of a dull, aching character, and radiate to the neck and
down the arms, particularly on the left side. The anginoid pains may
be followed by attacks of true angina pectoris. The latter are more
common in aortic regurgitation than in any other valve-lesion.
As compensation fails venous stasis occurs and the dyspnoea in-
creases. The latter is worse at night and compels the patient to sleep
in a semi-erect posture. Congestion of the lungs takes place, giving
rise to cough. Hemorrhage occurs, but not so frequently as in mitral
42
g58 SPECIAL DIAGNOSIS.
disease. (Edenia of the feet sets in, but general anasarca is not com-
mon. CEderoa of the feet ma}' be due to the attendant anaemia.
In aortic insufficiency sudden death is of common occurrence. This
may take place at night during an attack of dyspnoea, or occur sud-
denly upon the slightest exertion, such as straining at stool, or ascend-
ing a height, or walking more quickly than usual.
The Physical Signs of Aortic Regurgitation. (Plate XXIX., Fig. 1.)
Inspection. The apex beat is downward, outward, and to the left. It
may be as low as the seventh interspace, and as far out as the anterior
axillary line. The area of cardiac impulse is increased. It occupies
the whole prrecordia, and heaving of the lower half of the chest may
be seen. In young subjects there is precordial bulging.
Palpation. The impulse is strong and heaving. After compensa-
tion fails it is indefinite and wavy. A thrill, diastolic in time, may
be felt if the hand is placed about the middle of the sternum.
Percussion. The area of dulness is increased. The extent is greater
than that in any other valve-lesion, and the enlargement is more par-
ticularly downward and to the left.
Auscultation. At the second costal cartilage on the right a murmur
is heard, diastolic in time. This may be its seat of maximum inten-
sity. (See Fig. 175.) It is transmitted along the course of the ster-
num toward the apex. In some instances the seat of maximum intensity
is at the fourth left costal cartilage, or even at the apex. The second
sound is absent in the large majority of cases. In some instances,
however, both murmur and second sound may be heard at the same
time. Other murmurs also may be associated with aortic regurgita-
tion, not always due to disease of the aortic valves :
1. A systolic murmur at the second costal cartilage on the right,
transmitted into the vessels of the neck, short, rough, and high in
pitch. It is due to roughening of the valve-segments, or to atheroma
of the aorta.
2. A murmur at the apex, rumbling in character, localized to this
area, usually presystolic in time. It is the murmur described by
Flint, who attributes it to flapping of the mitral segments, which
during diastole are not forced back against the heart-wall, on account
of the dilatation of the ventricle. They remain in the blood-current
and produce relative narrowing.
3. A systolic murmur in the mitral area, low in pitch, due to dila-
tation. This occurs when failure in compensation takes place.
Examination of the Arteries. Pulsation of the peripheral vessels is
more common in aortic regurgitation than in any other valve-lesion.
The carotids throb, the temporals pulsate, the brachial and radial arte-
ries are conspicuous. Pulsation of the retinal arteries is seen with the
ophthalmoscope, and has often led to the recognition of the disease by
the ophthalmologist who had been consulted for other conditions. The
pulsation is of a jerking character ; in the neck it may simulate the
pulsation of an aneurism. The aorta can be seen and felt at the supra-
sternal notch. The abdominal aorta pulsates vigorously in the epigas-
trium. The pulse is significant in aortic regurgitation. The so-called
water-hammer, or Corrigan's, pulse is observed. The pulse is quick
PLATE XXIX.
FIO. 1.
Aortic Regurgitation.
FIO. 2.
Aortic Obstruction.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 659
and jerking, and after striking the finger immediately recedes. It is
most marked when the arm is held up. On auscultation of the arteries
double murmurs may be heard in the carotids and subclavians, and in
rare instances they are present in the femorals. (See Pulse.)
The Capillary Pulse. This is seen beneath the finger-nails, or on the
surface of the skin, as the forehead, when a line is drawn across it. The
hypersemia produced on either side of the line becomes alternately red
and pale. Capillary pulse also occurs in anaemia, and at times in
neurasthenia.
Aortic Obstruction. Aortic obstruction occurs in the aged, and
with atheroma of the arteries. It causes some diminution in the
amount of blood in the peripheral circulation, resulting in poor nutri-
tion and the development of ansemia.
Symptoms. Ansemia develops first, and embolic phenomena may
occur later. The symptoms may be latent until the occurrence of em-
bolism. This accident is not uncommon, on account of the position of
the aortic valve. The emboli are distributed throughout the arterial
circuit, and may lodge in the brain, kidneys, or spleen. When the
obstruction is pronounced the blood-supply in the arteries is dimin-
ished. Cerebral ansemia takes place, causing dizziness and fainting.
Sleep is more disturbed than in other valve affections, because of the
cerebral anseruia. Palpitation and cardiac pain occur, but are not so
common as in aortic regurgitation. When compensation fails, dilata-
tion of the left Ventricle ensues, followed by pulmonary congestion
and stasis in the systemic circulation.
The Physical Signs. (Plate XXIX., Fig. 2.) There is hyper-
trophy of the left ventricle. Inspection. The apex-beat is displaced
downward and outward. The impulse is strong during the period of
hypertrophy. When compensation fails the physical signs of dilatation
ensue. In many cases, from the very first, there may be considerable
hypertrophy without the visible impulse, because of associate emphy-
sema, which is common to old men with this lesion.
Palpation. At the base of the heart, and in the aortic area, a thrill,
systolic in time, may be felt. When present, it is usually very distinct,
and is transmitted along the course of the vessels. The impulse is slow
and heaving, if hypertrophy is present ; if dilatation, feeble and indis-
tinct.
Percussion. The area of dulness is increased, in the earlier stages,
to the left and downward. After compensation is broken, dilatation
with increased area of dulness ensues.
Auscultation. A murmur is heard of maximum intensity at the
second costal cartilage to the right, systolic in time, and transmitted in
the course of the bloodvessels. (See Fig. 174.) It is usually harsh
and loud, but may be musical. As the heart weakens, the intensity
of the murmur lessens and its roughening disappears. It becomes soft
and low in pitch. The second sound, if there is no regurgitation, is
muffled or may be absent. The pulse is small and regular. The ten-
sion is usually increased.
Diagnosis. A systolic murmur at the aortic orifice may be due to
aortic obstruction, atheroma or dilatation of the aorta, ulcerative aor-
660 SPECIAL DIAGNOSIS.
titis, or anaemia. Huchard describes a murmur iu this situation, with
vibratory thrill, due to aberrant chorda? tendineae. The murmur of
aortic stenosis is distinguished from the others by its character, by
the presence of thrill, by the character of the pulse, and by its associa-
tion with hypertrophy of the left ventricle. A murmur due to athe-
roma of the aorta, particularly iu the course of renal disease, is also
associated with hypertrophy of the left, ventricle. The diagnosis from
aortic obstruction is often difficult or impossible. Slowness of the pulse
is more characteristic of aortic obstruction. The murmur of anaemia is
softer and low in pitch. There is no thrill, and the left ventricle is not
hvpertrophied. Anaemic murmurs may be heard elsewhere. In athe-
roma the second sound is usually accentuated, and in anaemia also it is
intensified.
Mitral Incompetency or Regurgitation. The regurgitation may
be due to disease of the valves (organic) from previous endocarditis,
or to inability of the segments to close the orifice (incompetency), which
has become enlarged as part of the dilatation of the cavities. The latter
occurs in dilatation of the left ventricle. It takes place when the
muscle is weak in fevers and in anaemia. It is thus seen that the mur-
mur of mitral insufficiency is one of the most commonly observed of all
valve-murmurs. Its ready production and often equally ready removal
with treatment make it the least serious. It must not be forgotten
that insufficiency from disease of the valves and from disease of the
muscles must, if possible, be distinguished from each other. The
historv of the case is essential in determining the diagnosis.
Disease at the mitral orifice producing insufficiency has more serious
effect upon the pulmonic and arterial circulation than disease at any of
the other orifices. These effects must be understood in order to appre-
ciate the symptoms of mitral incompetency. They are as follows : 1.
With each systolic contraction the blood flows back, on account of the
insufficiency, to the auricle, where it soon meets a volume of blood
coming from the lungs. The combined volumes of blood overdistend
the auricle. Dilatation ensues, and because of increased work to get
rid of the increased contents, hypertrophy follows. Dilated hypertro-
phy of the left auricle is the first effect. 2. As a result of the above,
a larger amount of blood is forced from the left auricle into the left
ventricle ; dilatation and subsequent hypertrophy of this chamber also
follow, to remove the fluid. 3. On account of the overdist ended auri-
cle the pulmonary veins are not fully emptied during the diastole of
that chamber. The veins are therefore engorged and interfere with
the flow of blood through the pulmonary circuit. In consequence of
the impeded flow of blood the vessels in the pulmonary circuit are
dilated and overdistended. The right ventricle is compelled to act
more vigorously, and even then cannot empty itself freely. Dila-
tation and hypertrophy of the right ventricle ensue. 4. This causes
obstruction of the flow of blood from the right auricle to the right
ventricle ; dilatation and hypertrophy of its chambers follow. If
perfect compensation ensues through hypertrophy of both ventricles,
engorgement in the lungs may not be observed. Moreover, the left
ventricle is allowed to send out sufficient blood to supply the wants of
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 661
the system. This compensation may continue for years. If it fails,
either from increase in the valve-lesion, or valvular incompetency, or
from weakening of the muscle, a normal amount of blood is not dis-
tributed throughout the aortic area, but is thrown back upon (1) the
left auricle ; (2) the pulmonary circulation ; (3) the right heart ; and,
finally, the systemic veins. For a time the pulmonary circuit will
alone be engorged, subsequently the systemic veins become congested
because of dilatation of the right auricle and incompetency of the tri-
cuspid valves. We then have the secondary effects of stasis upon the
various organs of the body, with cyanotic induration and the develop-
ment of dropsies. Mitral incompetency without disease of the valves is
of frequent occurrence in emphysema of the lungs and in Bright' s dis-
ease, and is a condition which always attends hypertrophy and dilata-
tion, or may take place from various causes. (See Hypertrophy and
Dilatation.)
Symptoms. As to the general symptoms : In a large number of
cases perfect compensation may continue for a long time. Xo subjec-
tive symptoms arise nor are there symptoms due to dilatation. If
compensation is not perfectly effected from the first, or is broken sud-
denly or gradually, the symptoms of dilatation arise.
In patients in whom compensation remains only fairly good we have
the characteristic appearances of heart disease. It is to this class of
patients that the general descriptions of heart disease apply. The face is
pale and pinched, the lips and ears dusky, the capillaries of the cheeks
enlarged, the finger-nails clubbed, particularly in children ; shortness of
breath on exertion may be the only symptom complained of, and this
may exist for years. The patients are, however, liable to attacks of
bronchitis and of pulmonary hemorrhage. Palpitation may occur in
this as in other forms of heart disease, and from the same cause.
When the compensation is broken, symptoms referable to the heart
and to engorgement of systemic and pulmonary veins occur. Of the
former palpitation with a sense of oppression is the most common ;
pain is rare.
Venous engorgement leads to congestions, cyanosis, and dropsies.
We now have the symptoms of dilated right heart superadded. The
lungs are the first to be congested. Dyspnoea becomes constant and
is aggravated by exertion. Cough is present, excited by exertion or
speaking. With the cough there is bloody expectoration. Cyanosis
occurs. Congestion of other organs follows. The liver is enlarged ;
obstruction in the portal area is prominent ; chronic gastritis or gastro-
intestinal catarrh ensues. The spleen is enlarged ; ascites develops,
and hemorrhoids and congestion in the rest of the portal area are seen.
The kidneys are congested ; the urine is scanty, albuminous, and con-
tains casts and blood-corpuscles. At the same time that the internal
viscera are congested dropsies take place, beginning in the feet and
extending to the rest of the body. Dropsy may have been present in
the feet before symptoms of portal congestion ensued.
The patient may be relieved and compensation continue for a long
time. Frequent attacks of dilatation of this character may take place,
their recurrence being due to lack of care in hygienic matters, or
662 SPECIAL DIAGNOSIS.
failure in health from other causes. Finally, however, the compen-
sation cannot be restored ; the stases persist ; the dropsies become
more marked, and the symptoms of cyanotic induration and secondary
scleroses of the internal organs follow. It must not be forgotten that
this is the chief form of organic heart disease seen in children.
Physical Signs. (Plate XXX., Fig. 1.) On inspection the pre-
cordial area appears prominent ; the apex-beat is displaced to the left
and downward, rarefy below the sixth interspace. It may extend to
the anterior axillary line. The cervical veins pulsate and are dis-
tended. The area of impulse is increased.
Palpation. The character of the impulse depends upon the stage
of the disease at which the case is examined. At the time of full com-
pensation it is strong and even. When this is broken, it is feeble and
diffuse. A thrill is extremely rare.
The Bloodvessels. The amount of blood in the arteries is dimin-
ished. There is notable absence of visible pulsation in the arteries.
The pulse at first is full and regular. It is notably small in volume
and soft. As soon as failure of compensation takes place the pulse
becomes irregular. The irregularity may be that of time as well as of
volume.
Percussion. The area of dulness is increased to the left. The trans-
verse diameter of the heart is much increased because of dilatation
of both chambers. The area extends beyond the right margin of the
sternum to the extent of an inch or more and to the left as far as the
mid-clavicular line, sometimes to the anterior axillary line. The
cardio-hepatic triangle is preserved.
Auscultation At the apex, the mitral area, a murmur is heard.
The point of maximum intensity is in this region. It is systolic in
time ; it may replace the first sound entirely. It may be soft and low
in pitch, or rough, high in pitch, even musical in character. It is
transmitted to the axilla and the angle of the scapula. (See Fig. 171.)
In some instances it may be heard loudest along the left border of the
sternum. The pulmonary second sound is accentuated ; the accentu-
ation is loudest in the pulmonary area at the second left interspace.
It may be very loud over the right ventricle, between the paraster-
nal line and the left edge of the sternum. The murmur of mitral
insufficiency is modified by the position of the patient and intensified
after exertion. It may be present when the patient is lying down,
and disappear in an erect posture. It may disappear when the patient
is cpiiet and return after exertion. Other murmurs are sometimes heard :
1. A presystolic murmur, soft or rumbling. 2. When dilatation
ensues a low-pitched systolic murmur is heard at the ensiform carti-
lage and at the lower left border of the sternum. It is due to tricus-
pid regurgitation.
Of special diagnostic significance are : the position of the murmur
and the direction of its transmission ; accentuation of the pulmonary
second sound ; enlargement of the transverse diameter of the heart,
due to dilatation of both ventricles.
Diagnosis. This is usually easy if the physical signs are sought
for. Very often examination of the heart is neglected, and the patient
PLATE XXX.
Ci J
Mf
Mitral Regurgitation.
FIO. 2.
Mitral Stenosis.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 663
is treated for the symptoms that arise from congestion of the viscera.
We have often seen chronic gastritis or gastro-intestinal catarrh, due
to mitral insufficiency, not relieved because the primary lesions had
not been ascertained. In the same way cardiac cough or dyspnoea may
be overlooked. It is important in the diagnosis to determine, if possi-
ble, the nature of the insufficiency, whether it is due to disease or
incompetency of the valves. As previously mentioned, the history is
possibly the only means by which a diagnosis can be made. If a
mitral murmur ensues in old people, in whom there has been physical
cause for the development of dilatation and hypertrophy, as in emphy-
sema or arterio-sclerosis, it is usually due to relative incompetency of
the valve. It must not be forgotten that the mitral area is the seat of
a number of murmurs due to various causes. (See Auscultation.)
Mitral Stenosis. Obstruction to the flow of blood from the auricle
to the ventricle is due to valvulitis, or endocarditis, and particularly
the endocarditis of early life. It is of much more frequent occurrence
in women than aortic disease. It is much more often seen in young
adults and children, because its etiological factors, rheumatism and
chorea, are then more prevalent.
On account of the obstruction at the orifice changes ensue in the
auricle. These changes depend in a measure upon the nature of the
lesion. In the so-called buttonhole contraction they are very marked.
The orifice may be so obliterated in rare cases as to admit only a small
probe. Dilatation and hypertrophy of the left auricle ensue if the
valve-changes take place gradually. The walls of the auricle are
thickened to three or four times their natural size. On account of the
dilatation of this auricle the outflow from the pulmonary veins is im-
peded, which in turn obstructs the circulation of blood through the
lungs. As a consequence, dilatation and hypertrophy of the right ven-
tricle occur. As a result of this we have, later on, the occurrence of
relative incompetency at the tricuspid orifice, with engorgement of the
systemic veins. The left ventricle does not take part in any changes.
It retains its normal size, but it may look small in comparison with
the right ventricle.
Symptoms. If hypertrophy of the right ventricle ensues, the com-
pensation may be sufficient to prevent the occurrence of symptoms for
many years. The disease may exist for a number of years without
discomfort to the patient. Because of its rheumatic origin a fresh
endocarditis may develop, particularly as most of the subjects are
young. The old valve lesion invites infection, and so a recurrent form
of endocarditis is induced. If fresh endocarditis occurs, embolic symp-
toms are likely to follow. Embolism takes place particularly in the
brain, causing hemiplegia or aphasia. When failure of compensation
takes place the symptoms described in mitral incompetency arise.
They are the symptoms of dilatation of the heart, and may recur
frequently during a long period of years.
Dropsy, however, is not so common as in mitral regurgitation.
Visceral stases are common when compensation fails, and in many
cases we find enlargement of the liver continuing for a long period.
Ascites may in rare cases be the only manifestation of mitral obstruction.
664 SPECIAL DIAGNOSIS.
Physical Sigxs. (Plate XXX., Fig. 2.) The physical signs of
mitral obstruction are more striking and more diagnostic of the lesion
than the physical signs of any other form of organic heart disease.
Inspection. As the disease develops in children with soft ribs the
local deformities are very marked. For the same reason precordial
bulging is more prominent. Because the right ventricle is hypertro-
phied, the sternum and the fourth, fifth, and sixth costal cartilages pro-
trude. The apex impulse is not usually displaced, certainly not beyond
the mid-clavicular line. The impulse is not marked at the apex. In
the third and fourth interspaces a visible impulse is seen along the
margin of the sternum. After dilatation the extent of impulse dimin-
ishes and the veins of the neck become engorged, the blood regurgi-
tating into them during the systole.
Palpation. In the "large majority of cases a distinct fremitus or
thrill is felt — more marked in the fourth or fifth interspace, inside of
the nipple. It is usually localized to a small area, is increased during
expiration, and is of a twisting, grating, or grinding character. It is
made up of a series of small shocks increasing in intensity, culminating
in a sudden, sharp shock, which occurs at the time of the impulse.
The thrill and systolic shock are pathognomonic, and may be present
when other signs, as the murmur, are absent or indistinct. The car-
diac impulse is felt strongest at the lower margin of the sternum and
in the third and fourth interspaces, in some cases even in the second.
It is due to an enlarged and dilated right ventricle.
The Pulse. With perfect compensation the pulse is slow, regular,
and firm, although small. If the orifice is much narrowed, small,
weak, and irregular in force and rhythm. When compensation fails
and the right heart is dilated the pulse becomes rapid, quick, weak,
small in size, and irregular in force and rhythm. The dilatation
may be so great that the right auricle and overdistended veins may
press upon the aorta or the innominate and subclavian arteries. The
pulse on that side will be lessened in volume. 1
Percussion. The area of cardiac dulness is increased upward and
to the right and left of the margin of the sternum. Sometimes it ex-
tends upward as high as the second rib ; this increase is quite charac-
teristic.
Auscultation. At the apex, or just inside of the position of the
apex-beat, a murmur is heard, its point of maximum intensity dis-
tinctly localized to this spot. It is usually not transmitted. (See Fig.
172.) It is of a churning and grinding character, or vibratory and
purring. It is usually high in pitch and rough. It occurs synchro-
nously with the thrill, and terminates with a loud shock that is heard
simultaneously with the first sound. It is, therefore, presystolic in
time. As has been said of the thrill, so it may be said of this murmur,
that it is the only murmur that is pathognomonic of a special lesion.
It indicates narrowing of the mitral orifice. The only exception, in
which the lesion is absent, although the murmur is present, is found
in the class of cases described by Flint, referred to in the section on
1 PopofT: British Medical Journal, 1893.
PLATE XXXI.
Tricuspid Regurgitation.
FIO. 2.
¥ X ^
Tricuspid Stenosis.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 665
aortic regurgitation. The first sound is loud, clear, and abrupt ; it
may be thumping.
The presystolic murmur may occupy the entire period of the dias-
tole, but in the large majority of cases it occurs in the latter half only,
during which the auricular systole occurs. In some instances it is
heard in the middle of the diastole.
Associate Murmurs. 1. At the same time a systolic murmur may
be heard at the apex, soft and low in pitch. It may be transmitted
into the axilla. It is usually due to associate mitral regurgitation. 2.
At the lower portion of the sternum a systolic murmur may be heard,
due to dilatation and incompetency at the tricuspid orifice. Murmurs
in the aortic region are not usually heard.
The second sound at the pulmonary orifice is usually accentuated. It
is heard in the second and third interspaces along the left edge of the
sternum ; it may be heard at the apex. Reduplication of the first
sound is often observed. Reduplication of the second sound is very
common. After compensation is broken other murmurs may be heard,
and the presystolic murmur changes hi character. It may disappear
entirely and be replaced by a sharp first sound. The short, high-
pitched systolic shock may continue, although the murmur disappears.
It disappears probably because the left auricle has become weakened.
The tricuspid murmur continues during this period.
The points of distinction of mitral obstruction are (1) the position of
the murmur ; (2) its restricted area ; (3) its peculiar character ; (4) the
systolic shock which takes the place of the first sound ; (5) the thrill ; (6)
the impulse and increased area of dulness upward ; (7) accentuated
pulmonary second sound ; (8) reduplication ; (9) the absence of the pulse
of aortic regurgitation and of hypertrophy of the left ventricle.
Presystolic Murmur not due to Valvulitis. A presystolic
murmur without mitral obstruction may occur in aortic regurgitation
and in adherent pericardium.
Tricuspid Regurgitation or Incompetency. Structural disease at
the tricuspid orifice is of comparatively rare occurrence. Insufficiency
is more frequent, and is due to dilatation, with relative insufficiency of
the valve-orifice. It occurs secondarily to obstructive lung diseases,
as emphysema and cirrhosis, and is secondary to regurgitation at the
mitral orifice, which leads to stasis in the lungs.
Symptoms. The symptoms were detailed in speaking of the mitral
valve affections. They are those of obstruction in the pulmonary cir-
culation and engorgement of the systemic veins.
Physical Signs. (Plate XXXI. , Fig. 1.) Inspection. The physical
signs of dilatation of the right heart are seen. An impulse in the epi-
gastrium is noted. This is seen especially between the xiphoid cartilage
and the left margin of the ribs. Pulsation to the right of the sternum
and in the second and third intercostal spaces may also be observed.
The veins of the neck are also seen to pulsate. In addition to the wavy
pulsation, regurgitation of the blood into the right auricle causes trans-
mission of the pulse-wave into the veins. The pulsation is systolic in
time. It is more marked in the right jugular than in the left, and in
the external than in the internal veins. With the pulsation, regurgi-
QQQ SPECIAL DIAGNOSIS.
tation is readily observed by emptying the external vein. Place the
finger firmly on the vein just above the clavicle, move it along the
course of the vein in the direction of the inferior maxillary bone. The
vein is thus emptied of blood, and with each systole of the heart it will
be seen to fill up from below in rhythmical pulsation. The veins are
increased in size. This is more noticeable during the act of coughing
or when the patient holds his breath in full inspiration. In rare in-
stances the pulsation is transmitted to the subclavian and axillary veins.
Palpation. By palpation the above conditions are also determined.
The impulse over the lower sternum and in the epigastrium is noted
to be forcible.
The regurgitant pulsation is transmitted to the descending vena cava
as well as to the ascending. The hepatic veins also distend during
the systole. So-called pulsation of the liver is produced. With one
hand on the fifth and sixth costal cartilages and the other over the
liver in the axillary region, rhythmical expansile pulsation may be
recognized. It is not of common occurrence, but is absolutely diag-
nostic of regurgitation at the tricuspid orifice.
Percussion. The area of cardiac dulness is increased transversely
and upward, as described in mitral stenosis. It extends often far be-
yond the right edge of the sternum.
Auscultation. At the xiphoid cartilage, the lower end of the ster-
num or the head of the fourth rib, a murmur is heard. It is sys-
tolic in time, usually low in pitch, and is heard loud to the left of the
sternum, within an inch of the apex, and to the right of the sternum
and the outer limits of percussion-dulness. (See Fig. 173.) It is not
further transmitted. Other murmurs are heard, due to the primary
organic disease. If the heart is weak, the lesion may not be produc-
tive of a murmur. The pulmonary second sound is accentuated.
Tricuspid Stenosis. Stenosis at this valve-orifice is generally of
congenital origin. In rare instances it may be secondary to lesions in
the left heart. It is accompanied by dilatation of the right auricle.
The physical signs (Plate XXXI. , Fig. 2) are the same as in stenosis
at the mitral orifice, except for the alteration in their position. In
some instances a presystolic thrill has been observed, and with it a
presystolic murmur at the lower end of the sternum or toward the right
of it. The area of dulness is increased as in right-sided dilatation.
Cyanosis is a prominent symptom and may be intense.
Disease of the Pulmonary Valve. Diseases of the pulmonary
valve are extremely rare and are almost always congenital.
Pulmonary Insufficiency. (Plate XXXII., Fig. 1.) The physical
signs are due to regurgitation into the right ventricle. The maximum
intensity of the murmur is in the second pulmonary interspace, and it
is transmitted down the sternum. It cannot be distinguished from
aortic regurgitation, except by the pulse.
Pulmonary Stenosis. (Plate XXXIL, Fig. 2.) In stenosis of the
pulmonary valve a systolic murmur and thrill are detected to the left of
the sternum in the second interspace. The murmur is not transmitted
to the vessels of the neck. The pulmonary second sound is weak.
The effect on the heart is the production of right-sided hypertrophy.
PLATE XXXII.
***.
Pulmonary Insufficiency.
FIG. 2.
Pulmonary Stenosis.
PLATE XXXIII.
FIG. 1.
Combined Mitral and Aortic Insufficiency and Stenosis.
Combined Mitral and Tricuspid Insufficiency.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 667
Combined Valvular Lesions. (Plate XXXIII.) It must not be
forgotten that there may be disease causing both obstruction and re-
gurgitation at the same time and at the same orifice, or that two or
more valves may be the seat of disease in the same individual. It is
not impossible, for instance, to have aortic obstruction and regurgita-
tion, mitral obstruction and regurgitation, and tricuspid regurgitation.
Aortic obstruction or insufficiency is frequently combined with mitral
insufficiency. Aortic and mitral insufficiency occur together most fre-
quently in children ; aortic obstruction and mitral obstruction in adults.
When more than one valve is diseased the site of the various lesions
is based upon the time, the position of maximum intensity, and the
direction of transmission of the murmurs. Students often experience
difficulty here. A systolic murmur may be heard in the aortic area and
in the mitral area at the same time. If it is observed that each pro-
gressively weakens as the stethoscope is moved toward the middle of
the precordial area, it may be inferred that the murmur, systolic in
time, is due to two lesions. As previously intimated, the direction of
the transmission of the murmur further aids in the diagnosis.
Enlargement of the Heart.
Enlargement of the heart is due to hypertrophy or to dilatation. In
hypertrophy there is increased thickness of the muscular walls. This
may be general or limited to the walls of one chamber. Hypertrophy
is further divided into simple hypertrophy, in which the cavity or
cavities are of normal size, and eccentric hypertrophy, in which, with
increase in the wall, there is enlargement of the cavities. This is
hypertrophy with dilatation. The left ventricle is most frequently the
seat of hypertrophy when one chamber is involved. The cause of
hypertrophy is obstruction to the flow of blood ; increased work is fol-
lowed by increased size of the muscle. General hypertrophy or hyper-
trophy of the left ventricle occurs from diseases of the heart itself, or
from affections of the bloodvessels.
A. Diseases of the heart. 1. Disease of the aortic valves. Hyper-
trophy of the left ventricle always follows. 2. Mitral regurgitation.
3. Pericardial adhesions. 4. Myocarditis of the fibrous variety. 5.
Neuroses with overaction and frequent palpitation, as in exophthal-
mic goitre and from the effects of tea, tobacco, and alcohol. In peri-
cardial adhesions and myocarditis hypertrophy arises because of the
inability of the heart to do the work expected of it. There is no ob-
struction in the course of the vessels or at the orifices. The struggle
to keep up causes the hypertrophy. In neuroses there is absence of
obstruction, but the rapid action causes hypertrophy.
B. Affections of the bloodvessels which cause hypertrophy are : 1.
General arterial sclerosis. 2. Increased arterial tension due to con-
traction of the peripheral arteries, as in Bright's disease, and in tox-
aemias from lead, the poison of gout and of syphilis. 3. Increased
blood-pressure from prolonged muscular exertion. 4. Narrowing of
the aorta from external pressure and from congenital stenosis or the
development of an aneurism.
668 SPECIAL DIAGNOSIS.
Hypertrophy of the Right Ventricle. Obstruction to the flow of blood
in the pulmonary area is the usual cause of hypertrophy of the right
ventricle. This obstruction occurs in lesions of the mitral valve, caus-
ing pulmonary stasis ; and disease of the lungs, causing compression
of the bloodvessels, as in emphysema or cirrhosis. It occurs if there
is disease of the right heart with obstruction of the valves. Thus in
obstruction at the pulmonary orifice the right ventricle undergoes
secondary hypertrophy.
Hypertrophy of the Auricles. Simple hypertrophy of the left auri-
cle with dilatation develops in mitral stenosis. Hypertrophy of the
right auricle occurs in tricuspid obstruction and in right-sided dilata-
tion with tricuspid regurgitation.
Symptoms. The symptoms of hypertrophy of the heart are general
and local. The former are not common. They are due to increased
tension in the cerebral vessels because of increased force of the heart,
usually causing congestive headaches, noises in the ears, flashes of light,
and flushing of the face.
General symptoms arise in hypertrophy of the left ventricle because
the increased force causes reactive spasm of peripheral vessels, and
hence increased tension in the vascular system. In Bright' s disease,
for instance, or heightened arterial tension from other causes, endarter-
itis develops in the large vessels, on account of the strain put upon them.
This is seen particularly in the aorta and its divisions. Whether
atheroma is primary or secondary, its presence, with hypertrophy of
the left ventricle, indicates that rupture of the vessels somewhere in the
periphery may take place. This occurs most frequently in the brain,
causing apoplexy.
Locally, the patient complains of fulness and discomfort, particularly
marked when lying down on the left side. In the hypertrophy that
accompanies the tobacco-heart, or the irritable heart of soldiers, there
may be some pain. On the other hand, the organ may be enormously
enlarged without the patient complaining of discomfort about the heart.
Palpitation is not of common occurrence except in neurasthenic subjects.
Physical Sig-xs. The hypertrophy causes precordial bulging, if
it has developed early in life, when the ribs are soft. The intercostal
spaces are widened and the area of impulse is much increased. The
normal impulse is changed in position. It is downward and to the
left, often extending as far as the axilla in hypertrophy of the left
ventricle.
Palpation. The impulse is forcible and heaving. The head is
visibly raised with each systole when placed upon the chest for auscul-
tation. The impulse is slow. This slow, heaving impulse distin-
guishes it from the forcible impulse of dilated hypertrophy, which is
sudden and abrupt. Inspection is confirmed as to the position of the
apex. In moderate hypertrophy the apex extends to the sixth inter-
space in the mid-clavicular line. In large-sized hypertrophy it may
extend to the seventh interspace. The heart may be apparently
hypertrophied in fibrous and fatty myocarditis. The impulse may be
absent in emphysema, in fatty overgroAvth of the heart, and in persons
with thick chest-walls.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 669
TJie Pulse. The frequency of the pulse is not affected. It is full,
regular, and strong. The tension is increased. In dilated hyper-
trophy the pulse is full but soft, and more rapid than in simple hyper-
trophy. When failure of the heart takes place the pulse increases hi
frequency and becomes intermittent and irregular. When valve-lesions
are present the pulse is modified accordingly.
Percussion. The area of dulness is increased both upward and
transversely. It may begin as high as the second interspace and ex-
tend two inches beyond the left mid-clavicular line, and an inch beyond
the right edge of the sternum transversely. In simple hypertrophy
the area is ovoid.
Auscultation. When the valves are healthy, prolongations of the first
sounds occur. They are also at times duller than in health. The dull,
prolonged first sounds distinguish hypertrophy from dilatation, for in
the latter they are clear and sharp. The second sounds are clear and
loud. The degree of accentuation depends upon the state of the per-
ipheral arteries. If there is heightened tension, the second sound may
be reduplicated. If valvular disease is present, the sounds are modified.
Hypertrophy of the Right Ventricle. Increased pulmonary
tension from resistance in the pulmonary circulation may always be
looked for. If there is complete compensation, no symptoms are ob-
served, or only those of dyspnoea on extra exertion. Hypertrophy of
this ventricle persists for a long period of time without the grave local
changes in the heart, or secondary changes in the peripheral vessels,
which occur in left ventricle hypertrophy. In dilated hypertrophy,
when the dilatation is in excess, tricuspid regurgitation takes place,
with the development of venous stases. Induration of the lungs may
succeed the persistent engorgement of the capillaries. Pulmonary con-
gestions and apoplexy may also occur.
Physical Signs. The physical signs of hypertrophy of the right
ventricle have been partially referred to under the various valve affec-
tions. There is bulging of the lower part of the sternum and carti-
lages. The epigastric impulse in the angle between the ensiform carti-
lage and the ribs has been referred to. The impulse may be in the
sixth interspace. It is diffuse ; it may extend upward as in mitral
stenosis. Cardiac dulness is increased toward the right an inch or
more beyond the border of the sternum. The heart-sounds are not
much changed unless there is dilatation. The tricuspid sound is clear
and sharp when this occurs. The pulmonary second sound is accentu-
ated, and reduplication may take place. The radial pulse is small.
If there is tricuspid regurgitation, the physical signs that attend it
are present.
Hypertrophy of the Left Auricle. This is present in mitral
stenosis, but cannot be determined by physical signs, save possibly by
greater increase of dulness to the left of the sternum in the second
and third interspaces. Barr states that dulness above the " supraster-
nal mammillary line " toward the left clavicle indicates enlargement < >f
the left auricle, as in mitral stenosis. The line above mentioned is
drawn from the middle of the suprasternal notch to the normal site of
the left nipple on the fourth rib.
670 SPECIAL DIAGNOSIS.
Hypertrophy of the right auricle with dilatation occurs
under the same circumstances as hypertrophy of the ventricle. It
usually dilates more than the left auricle in left ventricle hypertrophy.
There is increased area of dulness in the third and fourth right inter-
spaces ; abnormal pulsation is sometimes observed in this situation
before the systole, with the signs of tricuspid regurgitation.
Diagnosis. The forcible impulse in nervous palpitation of the
heart must not be confounded with true hypertrophy, although it
must not be forgotten that hypertrophy frequently follows neurotic
palpitation, as in the smoker's heart, or in exophthalmic goitre.
The enlargement must not be confounded with enlargement of the
area of cardiac dulness in the precordial region from other causes,
such as pericardial effusion ; aneurism and mediastinal tumor, push-
ing the heart against the chest-wall ; disease of the lungs, on ac-
count of which they are withdrawn from the surface of the heart, as
in phthisis or chronic pleurisy ; and displacement of the heart from
pressure, as in effusion on the left side of the chest, or in disease below
the diaphragm. The cause of hypertrophy should be ascertained, for
it is a valuable aid in diagnosis. It must not be forgotten that emphy-
sema of the lung may mask a considerable hypertrophy of the heart
by causing diminution of the area of dulness.
Dilatation of the Heart. Enlargement due to dilatation of the
heart is common. The condition usually succeeds hypertrophy.
Thickening of the muscles attends dilatation of the cavities, as in
dilated or eccentric hypertrophy. The dilatation occurs because of in-
creased pressure within the cavities or because of weakening of the
heart-walls, the pressure within being normal.
1. Increased pressure within the walls is due to an increased amount
of blood within the chamber from regurgitation, or from an obstacle
to the outward flow of blood. Simple hypertrophy occurs first in
many cases ; in others, hypertrophy with dilatation ; in not a few,
dilatation takes place at once. In dilatation the chamber does not
empty itself during the systole. It is seen physiologically after the
exertion of ascending a great height. It may remain within the
bounds of physiological action. Temporarily, as any one can show
by running violently, the dilatation is attended by increased epi-
gastric pulsation and increased cardiac dulness. The tricuspid valves
temporarily become incompetent, owing to their safety-valve action.
The latter may continue after the acute strain, the heart always show-
ing symptoms of the condition, or it may disappear entirely. An
excessive dilatation results in heart-strain, with cardiac distress and
dyspnoea, symptoms due to overdistention and paralysis of the heart.
(See Symptoms.) Dilatation occurs in all forms of heart-lesions pre-
viously described. The most typical is seen in aortic regurgitation,
when the left ventricle becomes the seat of dilatation, and hi mitral
regurgitation when the left auricle becomes the seat of dilatation.
2. Disease of the heart-walls, lessening the resisting power, the nor-
mal pressure Avithin the cavities being maintained, invites dilatation.
In myocarditis, in infections, acute dilatation may ensue. It occurs in
scarlatinal dropsy, typhoid fever, rheumatic fever, and erysipelas.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 671
The heart-muscle changes in acute endocarditis and pericarditis, on
account of which dilatation may ensue. In anaemia and chlorosis the
same process may take place. In chronic myocarditis dilatation takes
place at the apex. When pericardial adhesions are present the fibrous
overgrowth invades the interstices of the myocardium, thereby weaken-
ing the heart-muscle. Dilatation may follow.
Symptoms. The symptoms of dilatation are the reverse of those
of hypertrophy. When the latter fails the blood is not expelled from
the chambers in systole, so that the cavity is overdistended with
blood that accumulates in the diastole. Weakening of the muscles
also favors the development of dilatation. As soon as dilatation be-
comes permanent, incompetency of the valves takes place. In obstruc-
tive heart disease the left side is first affected. It may be compen-
sated for by hypertrophy of the right side. When this fails venous
engorgement and dropsy ensue. The symptoms have been described
under chronic valvular disease. In acute dilatation there is a sudden
occurrence of dyspnoea. Pain, or at least precordial oppression, may
be complained of. The heart's action increases in frequency. The
pulse is rapid, feeble, irregular, and may scarcely be felt at the wrist.
Physical Signs. Inspection. The apex is displaced to the left,
even as far as the axillary line, but rarely downward, unless hypertro-
phy precedes the dilatation. The impulse is diffused and undulatory
in appearance. The apex-beat may be defined with extreme difficulty.
It may be visible when the patient leans forward, yet not felt.
With the diffused area of impulse a quick apex-beat may be felt —
much weakened, however. When the right ventricle is dilated, the
impulse is seen and felt to the right or left of the xiphoid cartilage,
and there is a wavy pulsation along the left edge of the sternum
in the fourth, fifth, and sixth interspaces. If the dilatation is extreme,
involving the right auricle, a pulsation at the third right interspace
close to the sternum may be felt. Tricuspid regurgitation is then
present.
The area of dulness is increased in the same directions as in hyper-
trophy, if the two coexist. In general, it may be said the increase
extends outward to the right or left, the direction corresponding to
the ventricle affected. It is increased upward along the left edge of
the sternum in left auricle dilatation. (See Mitral Valvulitis.) When
the whole heart is dilated the increase of dulness is in a transverse
direction on both sides. The apex is rounded or square, not pointed,
as in hypertrophy ; indeed, it retains the oval shape of the dulness
of a normal heart. As dilatation occurs so frequently in emphysema
of the lungs, the modification of the percussion-sound must be re-
membered.
Auscultation. The systolic sounds are short and sharp. They are
high-pitched and resemble the diastolic. The latter may become
enfeebled when the dilatation becomes excessive. The right and left
first sounds may differ somewhat in intensity, and reduplication may
occur. The sounds may be obscured by murmurs. The murmurs
are due to previous valve disease or to incompetency, on account of
dilatation. The action of the heart is irregular and intermittent. The
g72 SPECIAL DIAGNOSIS.
pulse is correspondingly small. In dilatation the alteration of the
rhythm is extreme. There may be embryoeardia or foetal-heart rhythm,
in which the first and second sounds are alike, and the long pause is
shortened. More frequently we have galloping rhythm of the heart.
It must not be forgotten that, as dilatation ensues, murmurs of various
valve-lesions may disappear, particularly the murmur of mitral steno-
sis. On the other hand, in the earlier stages particularly, murmurs
develop, on account of incompetency at the auriculo- ventricular orifices,
in addition to the primary organic murmur. These murmurs in turn
may disappear, if the dilatation is controlled by careful treatment.
Diseases of the Arteries.
Arterial Sclerosis or Arterio-capillary Fibrosis. This
occurs as the result of wear and tear of life and as the accompaniment
of age. The time of its onset depends upon the quality of the arterial
tissue which the individual inherited, and upon the amount of wear
and tear. It may occur early in life, and entire families may show
this tendency. Very frequently the sclerosis develops from intoxica-
tions of the system, on account of which persistent spasm of the small
vessels is set up — for blood of an impaired quality is passed with greater
difficulty through the capillaries, as was taught by Bright. The blood-
tension is raised thereby. The poison of alcohol, of lead, of gout, and
of syphilis leads to this condition. The poison of syphilis and of gout
may set up directly an inflammation and degeneration of the arteries.
In renal disease arterial sclerosis is of common occurrence. The rela-
tion to the renal lesion differs. It may be primary or secondary.
When primary, the morbid cause operates upon the kidneys as well as
the arteries. When secondary a morbid poison is retained within the
system by the diseased kidneys, the action of which is such as to cause
peripheral spasm and heightened tension.
Overfilling of the bloodvessels from excessive eating and drinking
is thought by some to cause arterial sclerosis through constant overdis-
tention of the vessels. In overwork of the vessels and excessive strain
there is either heightened tension or increased peripheral resistance,
the effect upon the bloodvessels being the same in either case. The
result of the above causes is thickening of the intima, followed by
changes in the media and adventitia, terminating in endarteritis de-
formans of the large arteries.
Symptoms. The symptoms vary. They may be general or local.
The disease may be present and the patients die from other causes.
Local symptoms are due to rupture of the vessels, as in apoplexy from
cerebral hemorrhage, or to their obstruction, as the coronary artery, or
to rupture of an aneurism.
Physical Signs. Arterio-sclerosis is recognized by inspection,
palpation, and auscultation of the bloodvessels, and by observation
of the condition of the heart. The superficial bloodvessels are elon-
gated and tortuous, and pulsate visibly. On palpation the artery feels
very hard to the touch ; it resists compression ; it is corded or rounded
underneath the finger, and readily rolled about. The pulse shows at
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 673
once high tension ; the wave is slow in ascent, continues long under-
neath the finger, and subsides slowly. If in the interval of the beats
the vessel remains full, the pulse, as previously noted, is obliterated
with difficulty. Sphygmographic tracings are characteristic. (See
Pulse.) If, after pressure on the radial artery, it can still be felt be-
yond the point of compression, its walls are sclerosed ; whereas, if
after such compression the artery is obliterated beyond the point of
compression, the hardness and firmness of the pulse previously ob-
served are due to vascular tension and not to thickened walls. The
two conditions should be distinguished. Hypertrophy of the heart
occurs early in the course of the sclerosis, on account of peripheral
resistance. The hypertrophy involves the left ventricle, and is not
attended by dilatation. The apex-beat is out beyond the mid-clavicu-
lar line ; the impulse is heaving and forcible. The second sound at
the aortic cartilage is characteristic. It is clear and ringing ; it is heard
in the course of the bloodvessels, and is most distinct at or just beyond
the apex. Right-sided hypertrophy and dilatation are not generally
present. Auscultation of the larger arteries, as the carotids, the abdom-
inal aorta, and femorals, shows a systolic murmur usually rough and
high in pitch. All the above-mentioned conditions may be present,
and yet the patient remain in good health. The hypertrophy appar-
ently compensates for the arterial occlusion. There may be no renal
disease, or moderate renal cirrhosis may be present, indicated by tran-
sient albuminuria, polyuria, and hyaline tube-casts. The subsequent
symptoms are due largely to closure of one or more vessels in the
peripheral circulation, to the development of an aneurism or dilatation
of the aorta, to failing hypertrophy of the heart, or to the development
of renal cirrhosis.
The blocking of peripheral arteries is due to embolism or throm-
bosis, more frequently the latter, and to rupture of peripheral vessels,
or, in all probability, miliary aneurisms. When occlusion of the
vessels takes place in arteries which supply the extremities gangrene
may occur. Sometimes the occlusion is due to simple narrowing of
the vessels alone. Gangrene of the feet is frequently seen secondary
to bad arteries. If the occlusion takes place in the vessels of the
brain, various secondary lesions are produced. In more or less gen-
eral occlusion from sclerosis of the smaller arteries acute and chronic
softening occur. Hemiplegia, monoplegia, or aphasia may occur tem-
porarily, if relieved by collateral circulation, or permanently, from
embolism, thrombosis, or rupture of the vessels. Hence, apoplexy is
almost always due to primary disease of the arteries, upon which, in
the large majority of cases, miliary aneurisms have existed. If the
coronary arteries are blocked, thrombosis with sudden death takes
place, or chronic myocarditis may develop, with subsequent aneurism
and rupture. Angina pectoris, with or without thrombosis of the
coronary artery, is always associated with arterial sclerosis.
Failure of the hypertrophied heart leads to dilatation with all the
symptoms as previously described, including cyanosis, visceral conges-
tions, and dropsies. The murmur at the apex, due to incompetency
from dilatation, may simulate chronic valvular disease, although the
43
674 SPECIAL DIAGNOSIS.
latter may never have been present, The sclerosis may advance more
rapidly in the kidneys than in the other portions of the circulation ;
later, on account of the contracted kidney, symptoms of interstitial .
nephritis may arise.
Aneurism.
A true aneurism is formed by the distention of one or more of the
arterial coats. It is usually fusiform, but may be cylindrical. It may
be circumscribed or sacculated. The fusiform and saccular are the
forms most commonly seen. False aneurism or dissecting-aneurism
arises from laceration of the internal coat of the artery. The blood
dissects between the layers. It occurs in the aorta. It may begin at
the heart and separate the coats as far down as the iliac arteries.
Arterio-venous aneurism is seen when communication between an artery
and a vein has been set up. If a sac intervenes, it is called a vari-
cose aneurism. Sometimes communication is direct, the vein becoming
dilated, tortuous, and pulsating. It is known as an aneurismal varix.
An aneurism may occur in the course of arterial sclerosis from
diffuse distention of the coats. Its typical form is seen in dilatation of
the aorta with one or more sacculated aneurisms on its surface.
Sacculated aneurism occurs from rupture of the tunica media, indepen-
dently of general disease of the arteries, and in arterial sclerosis. The
most common seat is the ascending portion of the aorta. It occurs
early in the course of arterial sclerosis. Such form of aneurism is
seen in the smaller vessels. Aneurisms also arise after the lodgement
of an embolus, permanently plugging the vessel. The proximal end
of the vessel becomes dilated.
Mycotic aneurism, first described by Osier and exhaustively by
Eppinger, occurs in malignant endocarditis. The aneurisms are small
in size and multiple, and not recognized during life. They arise from
the injury produced by the local infection of bacteria in different por-
tions of the vascular system.
Aneurism of the Thoracic Aorta. The causes which produce
arterial sclerosis are operative in the thoracic portion of the aorta —
chiefly physical overwork, alcohol, syphilis, and gout. It may be
situated just beyond the aortic ring, at the junction of the ascending
and transverse aorta, in the transverse, or at the beginning of the
descending, portion of the thoracic aorta. The larger aneurisms are at
the two bends of the aorta.
Symptoms. The symptoms of aneurism are largely due to press-
ure, and depend upon the position of the aneurism and the direction of
its growth.
Aneurisms, however, may exist without symptoms or appreciable
physical signs. Even in a patient who has been under careful obser-
vation, sudden death may take place from rupture of a concealed
aneurism, the presence of which had not been suspected during life.
On the other hand, cases occur with characteristic pressure-symptoms
and with no physical signs. Pressure -symptoms depend entirely upon
the position of the tumor.
Aneurisms of the ascending portion of the arch cause dislocation of
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 675
the heart outward, or toward the right pleura or forward, appearing
at the second or third interspace, causing erosion of the ribs and ster-
num. The vena cava is compressed, causing enlargement of the veins
of the head and arms ; the subclavian vein may be compressed alone,
causing enlargement and oedema of the right arm. Localized oedema
may result, confined to the thorax. (See (Edema.) If the aneurism
is large, the inferior vena cava may be pressed upon, causing oedema
of the feet. The right laryngeal nerve may be involved, causing
aphonia and dyspnoea. Pain attends the aneurismal process.
Fig. 177.
Aneurism of ascending portion of arch of aorta. Tumor in first and second interspaces,
extending into neck. Portion of sternum atrophied.
Aneurisms of the transverse portion of the aorta project below, for-
ward, or backward. When forward, they produce tumors behind the
manubrium, which from pressure cause destruction of the bone ; if the
aneurism projects backward, marked pressure-symptoms are produced.
When the trachea is pressed upon, it causes dyspnoea and cough, which
67 6 SPECIAL DIAGNOSIS.
is paroxysmal. (See Dyspnoea.) The oesophagus may be pressed
upon, causing dysphagia. The left recurrent laryngeal nerve may be
pressed upon, causing paralysis of the corresponding cord, with aphonia.
(See Larynx.) Pressure on a bronchus may produce bronchorrhoea
and dilatation, which in turn may lead to localized^ abscess. The
growth may extend upward, involving the coats of the innominate and
carotid arteries on the right side, or carotid and subclavian on the left,
markedly interfering with the pulse of the two sides. Pressure on
the sympathetic nerve is likely to take place in this situation, with
contraction of one of the pupils, although at first it is sometimes
dilated. The thoracic duct is sometimes compressed, leading to rapid
wasting.
In the descending portion the pressure-signs of aneurism are often not
so marked. The vertebras are likely to be pressed upon in this situation.
The pain, therefore, is most intense. The oesophagus and left bronchus
are compressed. Dysphagia and bronchiectasis, the latter causing
bronchorrhoea with subsequent gangrene, are likely to occur. The
cough and the fever in bronchorrhoea, together with emaciation, simu-
late phthisis, for Avhich aneurism is often mistaken. The physical
signs of phthisis are usually pronounced in this situation, and, with the
presence of bacilli in the sputum, render the diagnosis easy. In these
cases rupture takes place into the bronchus or into the oesophagus.
In one of my cases, which had been treated for tuberculosis because of
small hemorrhages, with the conditions above-mentioned, death took
place from rupture into the bronchus, causing sudden profuse hemor-
rhage. When the aneurism is adherent to the oesophagus and slowly
ulcerating into it, rupture may take place, followed by instantaneous
death. The vertebrae may be eroded and symptoms of spinal com-
pression arise.
I once saw an autopsy performed by a medico-legal expert on a case of
sudden death from gastric hemorrhage. The source of the hemorrhage
could not be ascertained. There was blood in the stomach. When he
was about to give up the search, the oesophagus and aorta were sug-
gested for examination. A small aneurism was found which had
ulcerated and then ruptured into the gullet. In another the aneurism
had ruptured into the pleural sac, causing internal concealed hemor-
rhage and death.
Special Symptoms. While pressure-symptoms are the most striking
symptoms of this affection, pain, which is usually due to pressure,
must be referred to. It is an important constant symptom. It is
sharp and lancinating, and may occur in paroxysms. It is more
severe and constant when bone is eroded by pressure on the vertebras,
or the thorax in front. The gnawing pain that attends ulceration of
bone is relieved, if it, as the sternum, is perforated. Anginal attacks
may attend the neuralgic pains just described. Pain sometimes fol-
lows the course of the nerves, extending down the arm or to the neck,
or along the course of the intercostal nerves.
Cough. The cough is peculiar. It is paroxysmal in many cases
and of a brazen, ringing character, indicating its laryngeal origin, due
to pressure upon the recurrent laryngeal nerves. It is frequently
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 677
paroxysmal when the pressure is directed upon the windpipe or bron-
chus. In the former instance the cough is dry, in the latter tracheal
and bronchial. It is attended by a thin, watery expectoration which,
if bronchiectasis with fermentation ensues, becomes thick and ropy.
Dyspnoea occurs more frequently in aneurism of the transverse portion,
due (1) to pressure on the recurrent laryngeal nerves ; (2) to compres-
sion of the trachea ; (3) to compression of the left bronchus. Marked
stridor attends the first form. When one of the recurrent laryngeal
nerves, more particularly the left, is pressed upon, there is spasm or
paralysis of the muscles of the vocal cord, causing hoarseness and loss
of voice. Laryngoscopic examination should not be neglected, for
paralysis of the abductor muscles without symptoms may be present.
Hemorrhage. The hemorrhage may be gradual when there is
slight leakage into the trachea at the point of compression. The
amount of blood lost is small. It may take place externally. (See
Fig. 178.) Profuse hemorrhages, causing sudden death, occur from
Fig. 178.
Aneurism of ascending and transverse portions of aorta projecting forward, destroying ribs and
sternum. The skin ulcerated, and gradual external leakage took place. The bleeding continued
in small amounts for a long time.
rupture into the trachea or bronchus, and from perforation into the
lung. With regard to difficulty of deglutition, it may be said that the
sound should never be passed in suspected cases of aneurism, on
account of the danger of rupturing the sac.
Clubbed Fingers. In intrathoracic aneurism clubbing of the fingers
and incurvation of the nails of one hand are sometimes seen, although
comparatively rarely.
Compression and pressure on the sympathetic system of nerves has
been referred to. In addition to pupillary changes there may be pallor
678
SPECIAL DIAGNOSIS.
of one side of the face. When the pupil is dilated this pallor may
accompany it, on account of stimulation of the vaso-dilator fibres.
When the cilio-spinal branches of the sympathetic are pressed upon,
the dilator fibres are paralyzed. If the pupil contracts, there are also
hypersemia of the side of the face and unilateral sweating.
Physical Signs. (Plate XXXIV., Fig. 1.) Inspection. In
health the position of the aorta cannot be recognized. Pulsation may
be seen at the episternal notch in rare instances, particularly in women,
independently of disease of the aorta ; it is due to nervous palpitation.
An aneurism may exist without any external visible signs. On the
Fig. 179.
Aneurism. General endarteritis and valvulitis.
■ TR. = Thrill and impulse. + = Murmur.
other hand, pulsation may be seen at either side of the sternum above
the level of the third rib, most commonly in the second interspace on
the right side. The impulse may be seen alone without visible swell-
ing ; the chest must be viewed from different situations in order to
detect it. An oblique light falling on the surface is sometimes neces-
sary. When the innominate artery is involved the pulsation is observed
in the neck, above the sterno-clavicular junction, or above the sternum.
With the abnormal impulse a swelling or tumor is often present.
It may be large enough to press the upper portion of the sternum and
adjacent ribs forward. In other instances a tumor the size of the half
PLATE XXXIV.
fiq. 1
\
Aneurism of the Arch of the Aorta.
Tumor / t
Tumor of the Anterior Mediastinum.
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 679
of a lemon may be seen along the edge of the sternum. The most fre-
quent site is the first and second right, or the second left interspace.
The skin over the tumor, as in the case of which an illustration is
given, may ulcerate and be the seat of persistent small hemorrhages.
The apex-beat of the heart is displaced downward and outward from
pressure.
If the aneurism is seated in the ascending portion of the aorta, just
beyond the aortic ring, a pulsating tumor may be seen in the third
interspace at the left edge of the sternum. If in the ascending por-
tion, beyond the heart, the tumor is in the first or second interspace
along the right edge of the sternum. If the aneurism is in the trans-
verse portion of the aorta, the upper portion of the sternum is fre-
quently made to protrude, or the tumor projects upward into the fossa?
of the neck. If in the descending portion, it is in the second or third
interspace on the left side. In this portion of the aorta a tumor is
seen in the left scapular region in rare instances.
Palpation. Palpation must be employed by the usual method ;
bimanual palpation must also be used, one hand placed upon the ster-
num and the other upon the vertebrae. Moderate pressure should be
exerted. Palpation should also be employed at different periods of
respiration. At times signs are only yielded at the end of complete
expiration". It must further be said that palpation must be employed
both with the tips of the fingers and with the palm of the hand applied
to the surface.
Fig. 180.
Possible position of impulse in aneurism ; arranged in order of frequency.
By palpation the area and degree of pulsation are determined. If
the aneurism is large or has perforated, the impulse is expansile and
heaving in character. The sac may be soft and fluctuating, but usually
presents considerable resistance. In addition to the systolic impulse
the diastolic shock is also felt. This is a most conclusive physical
sign. A thrill is frequently present, systolic in time, usually due to
dilatation of the arch ; at times, to sacculated aneurism. Without
visible tumor, pulsation and thrill may be felt in the suprasternal
notch, if the head is bent forward, so that the tissues are relaxed, and
680 SPECIAL DIAGNOSIS.
the fingers pushed down toward the aorta. When the aneurism is
filled or filling with clot, the tumor may be seen and felt, but no im-
pulse will be transmitted to the hand or thrill be felt by the fingers.
Percussion. Percussion furnishes the most reliable evidence of the
presence of an aneurism or aneurismal dilatation in cases in which the
tumor is not too deep-seated or small in size. The dulness may be
relative only. (See Cardiac Percussion.) The area of dulness is
increased somewhere in the course of the aorta. It may be observed
projecting outward at the right edge of the sternum when the ascend-
ing portion of the aorta is the seat of disease, or over the entire upper
part of the sternum, extending toward the left, when the transverse
portion is diseased. It may be observed as an extension of cardiac
dulness upward in the second and third interspaces. Sometimes dul-
ness is detected in the scapular regions, particularly of the left side.
The percussion-tone is flat, and there is marked sense of resistance.
Percussion must be employed with the patient in the upright and in
the recmnbent posture.
Respiratory Percussion. The character of the tone and the shape of
the dulness must be noted at the end of full inspiration and of full
expiration.
Fig. 181.
Aneurism of aorta.
Area of absolute dulness, dark line. Area of relative dulness, broken line.
Auscultatory -percussion is of the utmost value, and the method of
percussion taught by Sansom and Ewart must be carefully followed.
An aneurismal tumor may be present without thrill or murmur, but
yields signs of dulness on percussion.
Auscultation. As just stated, murmurs may not always be pres-
ent. They depend upon the amount of fibrin in the sac. When pres-
ent the murmur is systolic in time, heard with maximum intensity
usually over the abnormal area of impulse or tumor, or over the in-
creasing area of dulness. It is transmitted in the direction of the
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 681
vessels, and may be heard louder in the vessels of the neck and along
the course of the aorta. Often a double murmur is heard, the diastolic
sound being- due to associated regurgitation at the aortic orifice. Some-
times the diastolic murmur alone may be heard. Increase in intensity
or accentuation of the aortic second sound is pronounced. The sound
is ringing in character, and is rarely absent in large aneurisms.
The Peripheral Vessels in Aneurism. The pulse in the two radial
arteries may show a marked difference both in volume and in time.
The difference may indicate the position of the aneurism. If the
pulse of the right radial is smaller than the left, the aneurism may
be in or near the innominate artery ; if the opposite, it is near or in-
cludes the orifice of the left subclavian. In the same way the differ-
ence in time may also aid in determining the location. Osier refers
to obliteration of the pulse in the abdominal aorta and its branches.
In one case he could not feel throbbing in the aorta and the femorals,
although the circulation was unimpaired. The aneurism was in the
descending portion of the aorta, and its pulsation was seen in the left
scapular region. The sac was sufficiently large to act as a reservoir,
which filled during the ventricular systole, and from which the blood
poured toward the periphery in a continuous stream instead of being
intermittent.
Tracheal Tugging. Tracheal tugging may be obtained in one of two
ways. By the old method the patient should be sitting or standing,
while the observer sits or stands to one side, and faces him. With the
hand furthest from the patient steadying the head, the observer gently
but firmly grasps the surface of the cricoid cartilage with the thumb
and finger of the other hand, while the head is slightly thrown back.
The head is then flexed, so that the neck is no longer stretched. The
patient is then told to hold his breath completely, and any up-and-down
movement of the trachea is immediately transmitted to the observer's
fingers. One must not mistake the transmitted pulsation in the
cervical vessels for such movement ; and great care should be exer-
cised to see that the breathing is entirely stopped.
In the other method, as proposed and practised by Ewart (British
Medical Journal, March 19, 1892), the observer stands behind the
patient, steadying the latter's head against his body, and the cricoid is
firmly held between the tips of the first or middle fingers. The
writer, after considerable experience, prefers this second method, on
account of delicacy of touch, firmness of grasp, and comfort to the
patient.
Diagnosis. The special points of diagnosis are : the etiological
factors ; the antecedent pathological conditions, as arterial sclerosis ;
the occurrence of pain ; the occurrence of pressure-symptoms ; and
the physical signs. These have been sufficiently dwelt upon, and it is
not necessary to consider them again. It must not be forgotten that
aneurism may be present without diagnostic physical signs, and, on
the other hand, the pressure-symptoms may also be in abeyance. If
one of the two is present in the male subject past forty, with a pre-
vious history of syphilis, gout, alcoholism, or muscular strain, the
probability is that an aneurism exists. The pressure-symptoms
682
SPECIAL DIAGNOSIS.
always point to some form of intrathoracic disease as the cause of this
group of symptoms. Thus, in cancerous disease of the lymphatic
glands, or other tumors within the mediastinum, pressure-symptoms
exactly simulating aneurism may be present and also the physical signs
of a tumor. The tumor, however, rarely projects externally, and still
more rarely pulsates. If pulsation is present, it is not of the expan-
sile character seen in aneurism, nor is there as decided a systolic shock
when the ear is held against the chest. By the same method we ob-
FlG. 182.
X-ray appearance in aneurism. (Pepper and Leonaed.)
serve the shock of the heart-sounds, which are notably lessened or
absent in tumors from other causes than aneurism. In deep-seated
tumors with pressure-symptoms the condition of the arteries, apart
from aneurism, is of diagnostic importance. Accentuation of the
aortic second sound, with hypertrophy of the heart, points to aneu-
rism. The presence of tracheal tugging is also a valuable diagnostic
point in its favor. In tumor, and . especially in cancer, there are
emaciation and development of a cachexia, which is, as is well known,
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 683
most pronounced in cancer of the oesophagus. Cancer of the oesopha-
gus, from its frequent point of election near the left bronchus, often
simulates the pressure-symptoms of aneurism.
Aneurism must be distinguished from the pulsation of the aorta
which is seen in aortic regurgitation. This pulsation is usually asso-
ciated with dilatation, the latter causing increased dulness, which may
add further to the confusion. Exaggerated pulsation without dilata-
tion may, as Bramwell has recorded, be the cause of dulness and pul-
sation over the aorta. The subjects are under forty, neurotic, and
usually ansemic.
It is not, as a rule, difficult to distinguish between pulsating empy-
ema and aneurism. Wilson points out that aneurism bears a definite
relation to the central long axis of the chest. The area of dulness of
aneurism is circumscribed, and is usually the seat of murmurs or other
sounds synchronous with the rhythm of the heart. The signs of pul-
sating empyema are usually upon the left side and at a distance from
the median line. The percussion-dulness is at the base of the chest and
quite extensive. Arterial murmurs are not present. The pulsation
is influenced by pressure and by respiratory movements.
In mediastinal cancer we are aided by the discovery of enlargement
of the glands in the axillary or some other situation, or by a history
of the growth elsewhere.
Aneurism must not be confounded with phthisis. The diseased
vessel may occlude a bronchus and cause collapse and bronchial dila-
tation ; hemorrhage may occur ; bronchorrhcea and cough always
ensue. Fever is not marked, which fact, with tracheal tugging, vas-
cular physical signs, and the absence of tubercle bacilli, points to
aneurism.
X-ray Examination. By virtue of the large amount of blood in an
aneurism, the tumor is not pervious to the X-rays, and in consequence
is readily seen by fluoroscopic examination. Williams and others have
been very successful in recognizing an aneurism even when it could
not be made out by physical signs. Such examination must be resorted
to in all cases. (Fig. 182.)
Diseases of the Mediastinum.
Inflammation of the mediastinum may be limited to the glands or
the connective tissue. Moderate inflammation of the glands, lymph-
adenitis, occurs in bronchitis and pneumonia, particularly if bronchitis
is of specific origin, as in measles or influenza. It is said that such
inflammation is of common occurrence in whooping-cough, and may
be the exciting cause of the paroxysms. DeMussy and Guiteras have
found physical signs of enlargement, characterized by dulness in the
upper part of the interscapular region, in cases of this disease and of
influenza. Other authorities, as Osier, dispute the possibility of this
occurrence, or at least of its recognition by physical signs. Tubercu-
lous inflammation of the lymphatic glands of the mediastinum may
give rise, however, to local physical signs. Abscess of the glands
cannot be distinguished during life.
684 SPECIAL DIAGNOSIS.
Tumors of the Mediastinum.
Cancer and sarcoma are the most frequent forms of tumor in this
locality. Hare found the proportion in 520 cases to be as follows :
134 of cancer, 98 of sarcoma, 21 of lymphoma, 7 of fibroma, 11 of
dermoid cyst, 8 of hydatid cyst, and the remainder of lipoma, gumma,
and enchondroma. With the application of more correct histological
methods we now know that sarcoma is more common than carcinoma.
The tmnor is most frequently found in the anterior mediastinum when
one region alone is affected. The disease may be either primary or
secondary. In sarcoma it is usually primary. Males are chiefly
affected, and most often between thirty and forty. The thymus gland,
the lymphatic glands, the pleura, or the oesophagus is the source of
origin in all cases, the former the most frequent.
The symptoms of mediastinal tumor are chiefly due to pressure.
Dyspnoea is early and constant, and may be laryngeal, or tracheal
from pressure on that tube. In some instances encroachment upon
the heart or the vessels causes dyspncea. Again, the dyspnoea may
be due to a pleural effusion which accompanies the growths. Cough
of a peculiar character occurs. It is laryngeal, and of a dry, brazen
quality. Aphonia may arise from pressure upon the recurrent laryn-
geal nerves. (See Diseases of the Larynx.) If the bloodvessels are
pressed upon symptoms of obstruction occur, depending upon the ves-
sel occluded. GEdema of the upper extremities may occur. If the
oesophagus is pressed upon, there is difficulty in deglutition. In some
instances the sympathetic nerve is presseol upon, causing hyperemias
and pupillary changes.
The physical signs (Plate XXXIV., Fig. 2) are those of a tumor
in the anterior portion of the chest, frequently in the precordial area,
which may or may not pulsate ; dislocation of the heart, not limited
to any position ; great dulness and resistance ; frequently conduction
of lung-sounds and heart-sounds to some distance ; at times a systolic
murmur ; increased size and pulsation of the veins ; and physical signs
from pressure. (See Aneurism.) It must be remembered that pain is
more common in aneurism, fever and emaciation in mediastinal growths.
Tumors of the anterior mediastinum present the phvsical signs, in
front, of a prominence more or less marked, often including projection
of the sternum ; an irregular area of dulness ; rarely transmitted pul-
sation ; more frequently transmitted heart-sounds and lung-sounds.
It is the form in which phenomena from pressure upon the veins are
most marked. Symptoms from arterial pressure (difference in pulse),
pressure on the vagus anol sympathetic are less frequent. Dyspnoea
may occur.
Tumors of the middle and posterior mediastinum are characterized by
pressure upon the bronchi and structures adjacent thereto, hence we
have symptoms from pressure upon the oesophagus, aorta, and the nerves.
Dyspnoea and cough are the most pronounced symptoms, while phe-
nomena from pressure on the vagus, cardiac palpitation, vomiting,
etc., are not uncommon. Emaciation and a cachexia are more marked
DISEASES OF HEART, BLOODVESSELS AND MEDIASTINUM. 685
than in tumors in other regions. Pepper and Stengel consider that
fever attends growths in this region with greater frequency.
Tumors of pleural origin have symptoms of acute or subacute pleu-
ritis, with or without effusion. The fluid secured by puncture is
usually bloody, rarely chylous, and may contain suspicious vacuolated
epithelial cells. A mass may be suspected if there is great resistance
to the trocar. If the tmnor ulcerate into the lung, the sputa may con-
tain characteristic groups of cells, while hemorrhagic oozing mav be
suspicious.
CHAPTEE IV.
DISEASES OF THE MOUTH, FAUCES, PHAEYNX, AND
CESOPHAGUS.
The Mouth.
The mouth is affected by comparatively few diseases, and most of
these are the result of infection or of trauma, or, rarely, are tropho-
neurotic. The cavity forms a good breeding-place for all forms of
organisms, and were it not for the secretions and constant cleansing of
the mouth by the passage of food and its physiological labors, diseases
would be very common. Indeed, it is possible that such diseases do
not take place at all unless there is such perversion of the normal
secretion as destroys its antiseptic or antimicrobic qualities. We know
but little specifically concerning the changes in the secretions. Clini-
cally, we do know, however, that in conditions of poor nutrition, in
wasting diseases generally., and probably in connection with the rheu-
matic diathesis, there is such change in the secretions as permits patho-
genic micro-organisms to exercise their influence upon the mucous
membrane. The result of their action is seen in various forms of in-
flammation.
Symptomatology. The symptomatology of mouth-affections is
the symptomatology of inflammation : pain, heat, redness, and swelling.
The Data Obtained by Inquiry.
The subjective symptoms are not characterized by great gravity,
but they are most annoying.
Pain. This symptom is most aggravating, because it is excited by
the many functional acts connected with the mouth. It occurs in all
inflammations and ulcerations except those due to syphilis. It is
aggravated by food, by movements of the lips, cheeks, or tongue, and
by attempts to discharge saliva. The absence of pain is observed in
gangrene.
Heat. The patient complains of heat of the mouth in inflammations.
Dryness. This symptom is complained of in fevers, and by those
who are compelled to sleep with the mouth open. It may be a condi-
tion of itself, as the following shows :
Dry Mouth. Xerostoma. Hutchinson first described a condition
of the mouth in which dryness was the chief complaint. The secre-
tions are suppressed entirely, the tongue red and dry, the mucous mem-
brane of the cheeks and palate smooth, shining, and dry. Functional
movements are very difficult. The majority of the cases are in women
in whom the general health is always impaired. Hayden thinks that
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 687
the secretion of the salivary and buccal glands is modified as the result
of a central nervous disturbance. In xerostoma there is also dry-
ness of the nostrils and eyes, with intolerable itching. In a case which
Harris reported both parotid glands were enlarged and firm but painless.
There is some dryness of the mouth in fevers. It is also symptom-
atic of chronic gastritis, and may occur in diabetes.
The Data Obtained by Observation.
The objective symptoms are determined by inspection and palpation.
By these means we observe the color of the parts of the mouth,
changes in temperature, as well as in the size and shape (swelling).
The teeth, gums, and tongue are also examined.
Color. The normal redness of the mucous membrane may be in-
creased or diminished in intensity. Pallor is associated with anaemia.
Increased redness attends inflammation, and with it the temperature
is raised. The mucous membrane is yellow in jaundice, bluish in
cyanosis. Both of the latter changes are observed to greater advan-
tage under the tongue. The mucous membrane is the seat of pig-
mentation hi Addison's disease and in argyria. In the former, small
oval purplish spots are seen. They must not be confounded with the
pigmented spots common after stomatitis in negroes. Eruptions occur
in the mouth and may precede external eruptions. This is notably so
in measles. In this affection the eruption is seen on the hard and soft
palate twenty-four hours before the development of the rash. In
smallpox and chickenpox the vesicles are seen.
Shape. Swellings are seen usually as the result of disease of struc-
tures about the mouth. The floor of the mouth is encroached upon by
glands underneath or by swelling of the cellular tissue. Bone diseases
and some teeth affections cause swellings. The dental arch must be
observed. Narrowing of the arch is due to adenoid disease or to the
habit of thumb-sucking in childhood, much more likely the former.
Foetor. The odor imparted to exhaled air is peculiar in mouth-
affections. It may be a simple foetor or of a metallic or gangrenous
odor. Foetor attends all inflammations ; it is more pronounced in
ulcerative and mercurial stomatitis. In the latter it may be metallic.
Hemorrhage. Petechias in jjurpura hemorrhagica ; submucous hemor-
rhages in scorbutus and severe forms of purpura — morbus maculosus
werlhofii — are common on the cheeks and on the gums. In ulcerative
endocarditis hemorrhagic infarcts are seen. In grave anaemias petechias
are also seen.
Capillary oozing of blood takes place from the mucous membranes
in low typhoid states. The accumulated blood collects about the
teeth, on the tongue, etc., and in febrile states becomes dry. Dry
incrustations are known as sordes.
Salivation. Increased flow of saliva occurs in all inflammations
unless attended by high fever. It may be constantly discharged by
the patient or dribble in a continuous stream. (See Saliva.)
Secretions of the Mouth. The Saliva. The saliva is derived from the
parotid, submaxillary, and sublingual glands, and from the mucous
688
SPECIAL DIAGNOSIS.
glands within the mouth. The mouth should be washed with a warm
alkaline solution and afterward with cold water, in order that the saliva
obtained may be perfectly pure for examination. After the washing the
glands may be stimulated by the application of dilute acid on a glass
rod. The normal amount secreted in twenty-four hours varies from
two to three pints. It is of a light bluish color, or colorless. It is
somewhat stringy. On standing, two layers form in a conical glass,
the upper clear, the lower cloudy. The reaction of saliva is alkaline.
Microscopical Examination. The following formed elements are
observed : 1. Salivary corpuscles of the appearance of, but larger and
more granular than, a white corpuscle. 2. Epithelium. The squa-
mous variety derived from the mouth is seen. The cells are large in
size and of polygonal shape. 3. Fungi. In health the mould and
yeast fungi are seldom found. In disease they are present in large
numbers ; fission-fungi are met with in great numbers, both in health
and in disease. In health small and large colonies of micrococci are
found along with abundant bacilli. Miller has studied the micro-
organisms of the mouth carefully and exhaustively (see The Dental
Cosmos), both by microscopical examination and culture-methods.
The following are found to be pathogenetic : (1) The leptothrix buc-
calis ; ( 2) vibrio buccalis ; (3) spirochete dentium ; (4) micrococcus
tetragenus ; (5) the micrococcus de la rage ; (6) the micrococcus of
sputum septicaemia ; (7) the bacillus of decaying teeth, three varieties
of the staphylococcus ; (8) the bacillus crassus sputigenus ; (9) the
bacillus salivarius septicus and bacillus septicus sputigenus.
Fig. 183.
Buccal secretion. (Eye-piece III., obj., Reichert, 1/15, homogeneous immersion ; Abbe illumina-
tion, open condenser.) FriedlSnder's and GUnther's method. (Von Jaksch.)
a, epithelial cells ; 6, salivary corpuscles ; c, fat-drops ; d, leucocytes ; e, spirochete buccalis ;
/, common bacilli of mouth ; g, leptothrix buccalis ; h, i, k, different fungi.
Of course, in the saliva the thrush-fungus, actinomyces, the tubercle
bacillus, and the bacillus of diphtheria are found. It must not be
forgotten that the diplococcus pneumoniae or micrococcus lanceolatus,
which is the specific cause of pneumonia, is found in the saliva of some
persons in health. It is also called the bacillus sputi septicaemici.
Chemical Examination. The chemical characters of the secretion
depend upon the activity of the different glands. The saliva con-
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 689
tains a trace of albumin, found by heating ; a ferment which changes
starch into sugar ; mucin ; and occasionally sulphocyanide of potas-
sium. In disease, as the quantity is diminished rather than increased,
examinations have rarely been made. In ptyalism the saliva should
be collected after rinsing the mouth frequently, especially after eating.
The reaction is found to be alkaline, and the specific gravity low, 1002
to 1006. Albumin is tested for by the usual methods. The sulpho-
cvanides are detected by a solution of chloride of iron. When this is
added to the fluid a bright red color appears which does not disappear
with heat ; a similar color, due to the precipitation of meconic acid,
may be obtained by the same test from the saliva in opium-poisoning.
Sugar is tested for by the methods used in the examination of the
blood. The di astatic ferment is detected by adding 5 c.cm. of saliva
to 50 c.cm. of starch solution and placing the mixture in a warm
chamber or a water-bath heated to 40° C. After an hour's time the
fluid will show the presence of grape-sugar. Xitrites are detected by
adding a little saliva to a mixture of starch paste, iodide of potassium,
and dilute sulphuric acid. If the nitrites are present, a blue color
results.
Saliva in Disease. In catarrhal stomatitis the secretion is in-
creased. It is acid and contains epithelium in excess. In ulcerative
stomatitis it is also increased, is of a dark-brown color, foetid, and alka-
line. It contains degenerated epithelium, leucocytes, blood-corpuscles,
and many forms of fungi. It is increased in pregnancy, in rabies, and
in glosso-labio-laryngeal palsy. I have seen it in excess in the con-
valescence of typhoid fever. It is increased by the internal use of
jaborancli.
Fig. 184.
■ ■■••Cp./a. -.■::'■-.
^3
O'idium albicans, the vegetable parasite of muguet or thrush. (Reduced from Ch. Robin.)
The reaction becomes acid in diabetes, gout, rheumatism, and mer-
curial poisoning. Urea may be found in cases of nephritis, particu-
larly in uraemia. There is no sugar in diabetes. Fenwick has inves-
tigated the changes in the sulphocyanide of potassium in disease. By
a scale of colors he was enabled to compare the saliva in which sulpho-
cyanide of potassium had been detected in health with the saliva in
various diseases. He believes that the amount of this ingredient is
indicative of the degree of functional activity of the organs of nutri-
44
690 SPECIAL DIAGNOSIS.
tion. It is increased in acute inflammation and in the earlier stages of
cancer and phthisis ; in acute congestion of the liver from stimulants
or food excess ; and in rheumatism, gout, and the convalescence of
typhoid fever. Where the power of the nutritive organs is diminished
the sulphocyanide of potassium is lessened, as in late phthisis and
cancer, the later stages of chronic diarrhoea and dysentery, chronic
catarrhal jaundice, hi ascites, and in the passive congestion of the
abdominal viscera. Fenwick believes that tedious recovery and fre-
quent relapses will occur if this element is found in excess in acute
rheumatism.
Thrush. The fungus peculiar to this disease is found. Saliva is
increased ; it is usually acid. The disease is characterized by the
formation of small patches on the mucous membrane, which in a few
days coalesce and form a mass which may cover the entire mouth and
extend to the fauces. Before coalescing they are firmly adherent.
Subsequently they loosen. On microscopical examination, in addition
to epithelial cells, leucocytes, and unorganized elements, the character-
istic parasite is seen. It is of ribbon-shape, varying in length, and
composed of long segments which often contain highly refractive nuclei
at either end. The segments are homogeneous ; they vary in length,
those nearest the extremities being somewhat shorter. When mounted
in glycerin they are readily seen. Spores are also seen.
The Leptothrix Buccalis. The latter is seen in ribbon-like bundles
composed of numerous segments ; it stains a bluish-red in potassic iodide
solution. It is most frequently seen in the tartar of the teeth.
Fig. 185.
f»
///
Leptothrix buccalis from the gums at edges of teeth, x 350.
a, the filaments separated ; b, masses of filameuts.
The Gums. The gums and the mucous membrane of the mouth are
involved in inflammations and ulcerations, and in certain metallic
poisonings. The gums swell and grow spongy in inflammations.
The Gingival Line. In cases of tuberculosis a red line at the
junction of the gums and the teeth is frequently seen. At one time it
was thought to be of diagnostic value. It is seen, however, in other
cachectic conditions, as carcinoma, and at times in diabetes.
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 691
The Gums in Scurvy. In scurvy the gums are swollen and spongy.
They bleed easily, and are usually streaked with blood. Ulcers form
along the margin of the teeth. There is not much fcetor of the breath.
In mild cases the inflammation may be limited to the gums of four
or five teeth. The gums of decayed teeth are usually the seat of the
most marked inflammation. Infants may have scurvy as well as
adults — especially if fed exclusively on sterilized milk or malt prepa-
rations. (See Scurvy-rickets.)
The Gums in Lead-poisoning. The Blue Line. In lead-poisoning
a blue line is seen at the margin of the gums. The line is preceded by
a row of separate black dots occupying the seat of the papillae of the
mucous membrane. If examined with a magnifying glass, the line is
readily seen to be an interrupted one. It does not always extend
along the entire margin, but may be limited to a few front teeth in either
the upper or lower jaw. In the more advanced cases there is some
salivation and a sweetish metallic taste in the mouth and metallic fcetor
of the breath.
The Teeth. In all diseases of the gastro-intestinal tract it is im-
portant to investigate the state of the teeth. Cases of indigestion are
often due to defective mastication, rendered so by decayed teeth. Per-
sistent aural, nasal, and ophthalmic affections may have their primary
origin in disease of the teeth. Caries of the teeth may cause headaches
or neuralgias, near or remote (see Headache), and may explain many
cases of foul breath. Pitting of the surface of the teeth and thinning
of the enamel in transverse grooves are held by some to be due to mer-
cury. There is no doubt that infantile stomatitis, independent of mer-
cury, is the cause of these changes. They must be distinguished from
the so-called Hutchinson's teeth. In stomatitis the molars are often
honeycombed to an extreme degree, the incisors becoming affected
next. In addition to pitting and erosion the color may be darker. A
transverse furrow crosses all the teeth at the same level.
The Teeth in Gout. Erosion of the teeth takes place in gouty sub-
jects. There are wasting and loss of polish of the labial surface, fol-
lowed by deep grooves which extend into the body of the teeth.
Pyorrhoea alveolaris is another expression of gout. There is, first,
usually a marginal inflammation of the gums ; second, inflammation
and necrosis of the pericementum ; third, loosening of the teeth and
the formation of so-called calculi.
The Teeth of Congenital Syphilis. The upper central incisors of the
permanent set are affected. They are dwarfed, narrowed, and short.
Fig. 186.
Notched teeth. Malformation of permanent teeth found in hereditary syphilis.
(Me. Jonathan Hutchinson.)
The middle lobe of the tooth is so atrophied as to leave a single
broad vertical notch in the edge of the tooth. A narrow furrow some-
692
SPECIAL DIAGNOSIS.
times passes upward from the notch on both anterior and posterior sur-
faces, nearly to the gum. It is seen from the above that the appear-
ances of the permanent teeth may be an index of the condition of
nutrition of the child in infancy.
Teething. During the period of infancy it is well to remember
the influence of the eruption of the teeth upon the general constitution.
While many prominent authorities believe that the eruption takes place
without the occurrence of general or reflex symptoms, equally careful
observers, on the other hand, believe that nervous phenomena often
attend the process. The latter class of observers attributes the fever-
ishness, insomnia, restlessness, loss of appetite, and gastro-intestinal
disturbance to this cause. Convulsions at this period are believed to
be due to the pressure of the tooth, which cannot break through the
mucous membrane, upon highly sensitive nerves at the root. Even in
later life reflex convulsions are held by some to be due to the teeth.
Slowness in the development of the teeth may be due to rhachitis,
which should be looked for. The student should be familiar with the
periods of development, the number of teeth that appear at each period,
and the date of the eruption.
Dates of Eruption of the Teeth.
Milk Teeth.
2 M 1C 41 1C 2 M
2M 1C 41
Eruption of central incisors about
lateral incisors ''
' ' first molars
" canines
' ' second molars ' '
1C 2M
20
7th month. 1
9th "
15th "
18th "
24th "
Permanent Teeth..
3M 2B 1C 41 1C 2B
3M
3M 2B 1C 41 1C 2B
Eruption of anterior molars about
" central incisors "
" lateral incisors "
' ' anterior bicuspids ' '
" posterior bicuspids "
' ' canines ' '
" second molars "
third molars ( wisdom teeth ) about
3M
32
7th year.
8th "
9th "
10th "
11th "
11th "
12th to 14th year.
18th to 25th "
Stomatitis. This inflammation is not limited to the mouth alone,
but extends to structures within the mouth, as the gums, and may
invade the tongue. The inflammation is recognized by the subjective
and objective signs common to such inflammations. There is pain,
and hence the child (for it usually occurs in children) refuses to nurse
or take the bottle, or cries when food is given. The pain is accom-
panied by foetor of the breath. This occurs in all forms of stomatitis.
Its origin, as well as the origin of the pain, is readily determined by
inspection.
1 Lower incisors first.
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAOUS. 693
On inspection we note the usual signs of inflammation. They are
rarely general, being, as a rule, localized to small areas, which may
rapidly become ulcerated. When general the mucous membrane is red
and hot ; the color extends to the gums, lips, and tongue. This is seen
in the catarrhal form ; the follicles are also enlarged. The tongue be-
comes red and smooth, or may be covered with a white coating, through
which the prominent red fungiform papilla? project. Accompanying the
inflammation there is increased secretion, which dribbles from the mouth,
or is constantly discharged by older patients. The red hue of the mucous
membrane is attended by swelling. The heat of the mouth is often suffi-
cient to raise the temperature of the exhaled air, so that the breath is hot.
A peculiar form of inflammation of the mouth is seen in gouty sub-
jects. It occurs at intervals. Pain is not so marked, but the heat,
redness, and burning are associated with a superficial glossitis and sali-
vation. The saliva is highly acid, and causes a dermatitis on the chin.
Other mucous membranes are involved at the same time, as the vagina.
An acid mucoid discharge sets up irritation at the vaginal outlet and
causes much distress.
Aphthous Stomatitis. Local areas of intense inflammation are
sometimes followed by ulceration. Thus in aphthous stomatitis small
yellowish-white spots appear, at first discrete, but soon dotted over the
mucous membrane inside of the cheeks, in the roof of the mouth, along
the sides of the gums, and on the tongue. They subsequently break
down into shallow ulcers with raised red margins.
Aphthous ulceration is seen in foot-and-mouth disease. The local
process is characterized by greater swelling, with softening and ulcera-
tion of the soft parts, than in other stomatitis. In foot-and-mouth
disease there is a history of infection, profuse diarrhoea, followed by
constipation, and considerable physical depression.
Ulcerative Stomatitis. The disease occurs in ill-nourished sub-
jects, and is often intercurrent with exhaustive disease, as chronic diar-
rhoea. It may be seen in epidemic forms in camps and in penal and
other institutions, on account of unsanitary conditions. In ulcerative
stomatitis the inflammation is more pronounceol on the gums. They
are swollen, red, and covered with ulcers. The gums in which teeth
remain are affected, and the ulcers are usually at the gingival border.
Gums without teeth are not affected. The ulcers are covered with
yellowish material. The flow of saliva is much increased in this affec-
tion. It is acid in reaction. The submaxillary glands are enlarged.
The fcetor of the breath is very great.
Parasitic Stomatitis. Thrush. In parasitic stomatitis, or thrush,
raised white patches are seen looking like small curds of milk. The
patches vary in size, and on the tongue may cover an area as large as
a three-cent piece. (See page 690.) The white patches are distinguished
from milk-curds because they cannot be removed by the napkin or
brush. The parasite has been called the o'idium albicans (see Fig. 184) ;
but Forchheimer prefers to group it under the saccharomyces.
Stomatitis Materna. Painful ulcers occur in the mucous mem-
brane of the lips and cheeks in nursing- women. They are solitary,
and interfere with mastication.
694 SPECIAL DIAGNOSIS.
Gangrenous Stomatitis. The affection appears as a gangrenous
inflammation of the gums, mucous membrane, and deeper tissues of
the cheek. At first a small, dark red, hard spot is seen, which in-
creases in size, and becomes of a purplish color. The cheek rapidly be-
comes swollen, tense, and brawny. On the surface of the more indu-
rated portions a bleb forms which soon breaks with rapid ulceration.
The ulcer is dark and gangrenous and soon perforates the cheek. It
extends to the jaw and is followed by necrosis of that bone. The
characteristic odor of gangrene attends the process. While the affec-
tions previously mentioned are generally dependent upon poor nutri-
tion, gangrenous stomatitis is always secondary to depraved, depressed,
or debilitated states of the system. Cases may occur simultaneously
in asylums for children in which the hygienic conditions are bad and
the food-supply poor.
Mercurial Stomatitis. Mercurial stomatitis, or ptyalism, par-
ticularly affects the gums. It also involves the salivary glands.
The inflammation is caused by mercury. It may occur from the
medical use of the drug, particularly in persons who are unduly sus-
ceptible, or are not particular in regard to mouth-cleansing. The in-
flammation is painful and attended by profuse discharge of saliva,
hence the name, salivation. The tongue is swollen, marked on the
sides by the teeth, and may be protruded with difficulty on account
of its size. It is tender to the touch. It is covered with a heavy,
creamy coating. The gums are swollen, red, sore, and bleed on the
slightest touch. Ulcers along the border occur, may become diffused,
and in some instances extend to the jaw. The teeth become loosened.
The f oetor of the breath is heavy, offensive, and of a metallic character.
The inflammation is usually preceded by a metallic taste in the mouth,
and the patient notices pain on mastication, which increases in severity
as the inflammation develops. In mild cases it is limited to the gums,
in others the tongue and salivary glands and the mucous membrane of
the mouth are affected.
Leprosy. This affection frequently invades the mouth. The nod-
ular and ulcerative lesions are seen. It is always associated with the
characteristic lesions of the skin. Scraping or sections would show
the characteristic micro-organism.
Glanders may invade the mouth from the nasopharyngeal space.
Actinomycosis results from the entrance of the ray-fungus through
carious teeth or an abraded mucous membrane. Often there is first
disease of the alveolus, as pyorrhoea, or a periosteal abscess ; then the
jaw is involved. Before this a general stomatitis may be set up.
Ulcers. In addition to the above forms of ulcerative stomatitis,
solitary ulcers are seen in herpes, secondary to gastric or uterine dis-
turbances, and syphilis. The herpetic ulcers are of frequent occur-
rence at the menstrual period or during the course of lactation. The
tendency to their formation is often hereditary. I have seen them
occur at the menstrual period or in pregnancy in the women of three
generations. In the secondary stage of syphilis mucous patches are
seen as bright red, symmetrical, oval, or crescentic patches or erosions,
occurring on the mucous membrane, sometimes on the tongue and
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 695
fauces. They are generally covered with a scanty grayish-white secre-
tion, and are not usually painful.
Sublingual Ulcer. This form occurs on the frsenum of the tongue.
It is seen in whooping-cough, and is due to the rubbing of the tongue
against the teeth in the act of coughing.
Scleroderma. This rare tropho-neurosis occasionally invades the
mouth. It is characterized by a submucous infiltration of cartilaginous
hardness, the surface of which is denuded of epithelium or covered
with crusts. The invasion comes from the nostrils or the nasopharynx.
Later the infiltration changes to a yellowish-red or a tendinous-like
scar.
The Tongue.
Examination of the tongue is made for diagnostic purposes with a
greater show of wisdom on the part of the examiner, and greater satis-
faction to the patient, but with less satisfactory results from a diag-
nostic stand-point, than the examination of any other portion of the
body. The mucous membrane of the tongue is examined because it
is the only mucous membrane of the body, except the oral and faucial,
which is open to inspection, and is, therefore, supposed to enable us to
judge of the effects of general diseases upon mucous membranes. It
is thought to be indicative of disorders of the gastro-intestinal tract
because of its relations with it, but recent studies by Hutchinson,
Butlin, and other observers have resulted in the promulgation of differ-
ent views. Both the above-mentioned distinguished gentlemen are
surgeons, and look upon the tongue as a local organ. Investigating
it as such, they concluded that the changes in the coating, which had
been considered to have so much clinical significance, depended largely
upon parasitic invasion, and were not due to changes in the epithelium.
The parasitic invasion, they hold, is largely dependent upon local con-
ditions, which, it is true, are on their part dependent upon a state of
the system. Since the writings of Hutchinson and Butlin, Dickin-
son returned to the investigation on the lines laid doAvn by older
teachers, and has, in a measure, restored the tongue to its original
position as a diagnostic feature in an estimation of the state of the
general system and in diseases of the gastro-intestinal tract.
We study the tongue to ascertain its color ; the character of erup-
tions if they are present ; the occurrence of indentations, excoriations,
furrows, or fissures ; the occurrence of ulcers and of patches. Plaques,
nodes, and nodules are also seen on the tongue. Inflammation of the
tongue occurs, and it is the seat of atrophy and hypertrophy and of the
various tumors in the parasitic diseases. The movements of the tongue
are also observed, as an indication of the power of muscles which are
under centric influence closely related to important centres in the
medulla oblongata. Surgical affections of the tongue will not be con-
sidered ; local affections will only be referred to in connection with
general diseases.
Discolorations of the Tongue. Yellowish-white, oblong patches,
soft, but slightly raised, are sometimes seen along the sides of the
tongue — xanthelasma. They are sharply defined, and vary in size from
&
696 SPECIAL DIAGNOSIS.
a split pea to a three-cent piece. Xanthelasma is also situated upon
the eyelids and upon the palms of the hands, rarely in other portions
of the body. It occurs in jaundice, or in persons who are said to be
subject to bilious attacks.
Pigmentations. Dark purple, bluish-black, or black marks are
seen on the tongue as well as on the surface of the lips, where they
may be brown. They are sharply denned, neither raised nor de-
pressed, and vary in size. Such pigmented spots are seen after glos-
sitis and in Addison's disease. In the latter affection other pigmented
areas are found. Blood-stains are observed in purpura. Bright red
spots the size of a split pea or larger, patches, known as ecchymoses,
are of frequent occurrence. They are not removed by pressure.
Hemorrhagic infarcts are sometimes seen on the tip of the tongue.
Black Tongue. This rare condition is of parasitic origin. It has
recently been described anew by Cohen. It is also known as nigrities.
The affected portion is of a brownish-black or black color, varying
in size and usually situated in the middle of the dorsum of the tongue.
It looks like an iron-stain, and in some instances the surface is rough-
ened. The papilla? are abnormally enlarged. It usually begins as a
small spot, and extends slowly, so that at the end of a month the
dorsum is covered. The centre is blacker than the circumference.
After the entire dorsum is covered the spot begins to disappear from
the circumference toward the centre, and is followed by desquamation.
This series of phenomena is repeated and the entire affection subsides
slowly. Desquamation may last from a few days to two months. The
papillae of the affected surface, too, look like " a field of corn laid by
the wind and rain." The sensations of taste and touch are not altered,
but a feeling of dryness is marked. It must be remembered that
a black tongue is sometimes the result of deliberate deception.
Inflammation of the Tongue. Acute glossitis is a rare affection,
more common in adults than in children, and more frequent in men than
in women. It occurs more frequently in the summer. The onset is rapid.
After a short period of tenderness on mastication the movements of the
tongue are stiff and painful, or there are pains in the muscles of the neck
and submaxillary region. In a few hours the tongue swells. It rapidly
increases, and at the end of fifteen to twenty hours is three times its
natural size, protrudes from the mouth, is indented by the teeth, and
is almost immovable, feeling heavy, painful, and tender. It is coated
with a thick fur on the dorsum. Salivation accompanies these symp-
toms, speech is impossible, dysphagia extreme, and dyspnoea not un-
usual. The glands underneath the jaw are swollen. The temperature
rises to 101°, rarely above it, even if the case is severe. Death may
occur in a few hours from suffocation, or after a longer interval from
diffuse suppuration, gangrene, exhausting septic fever, or pneumonia.
Gangrene is more frequent than spontaneous resolution. If resolution
is to be established, the swelling begins to subside in three or four
days. Small ulcers form on the surface of the tongue, and by the end
of a week its normal appearance is regained. The fever and distress-
ing symptoms subside with the local swelling. It is said to be due to
colds, to bites and stings of animals, to mercury, and to corrosive and
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 697
acrid substances. It may occur in fevers. The diagnosis is easy. It
must be distinguished from acute oedeniatous swelling due to salivary
calculus or affections of the floor of the mouth. Acute ranula some-
times causes considerable swelling of the tongue, simulating acute
glossitis. JSemiglossitis sometimes occurs. The local symptoms are
not so great, because only half of the mouth is occluded. I saw a case
in which the inflammation was limited to half the side of the tongue
on the posterior surface. It went on to suppuration, but was not
attended by serious symptoms, except discomfort in eating. It was
preceded by a definite nodule in the substance of the inflamed part.
Glossitis from mercurial poisoning has been described in connection
with stomatitis.
Chronic superficial inflammation of the tongue may also occur. The
surface is smooth and deprived of papilla? over the affected area, which
is redder than natural. The margin of the raw patch is sharply de-
fined, but the area has no depth. The epidermis alone is removed.
When associated with dyspepsia it covers a considerable area of the
surface of the tongue. The tongue may be deprived of papilla? on the
anterior part of the dorsum while the fungiform papilla? remain. The
tongue is enlarged and the borders marked by the teeth. The surface
looks glossy. The tongue feels stiff and uncomfortable. Movement is
irksome, irritating foods are painful. Spirits and tobacco cause dis-
tress. Indiscretions in diet and slight traumatism quickly produce
fresh inflammation. One observer, Hack, has described a form of
glossitis hereditary and peculiar to women. He observed a row of long,
oval areas, caused by previous inflammation. They commenced in early
childhood. The tongue was smooth over remaining large areas, with
red excoriations here and there. There was no syphilis.
Sequelce of glossitis. Indentations occur when the tongue is swollen,
as in mercurial and other forms of glossitis. The borders of the tongue
are indented by the pressure of the teeth. But in states of debility
a flabby tongue with indented borders is often seen. Sometimes the
swelling is so great that the pressure of the teeth causes ulceration.
Furrows, or grooves and wrinkles, are seen on the dorsal aspect
of the tongue. They are not necessarily tokens of disease ; hi many
persons they are of constant occurrence. Furrows vary from a few
lines to an inch or more in length. In many this is most striking in
the middle line of the tongue. The median furrow is liable to become
ulcerated on slight provocation. The edges of the fissures are smooth
and without papilla? or fur. Other furrows are directed horizontally
and vary in depth. They may be curved and forked. They are more
frequent in older persons, especially if the tongue is too large to lie
within the circle of the teeth. They are an evidence of past inflamma-
tion, or rarely of hypertrophy. They resemble the median furrows as
regards smoothness and absence of fur. Inflammatory furrows occur
in chronic superficial inflammation, but more commonly after chronic
inflammation which has left the tongue enlarged. The furrows are
sometimes so abundant that the surface of the tongue looks like the
eyelid. The raised areas become sore, due to irritation of a foreign
body (food) or a tooth. They are an indirect result of inflammation.
698 SPECIAL DIAGNOSIS.
True inflammatory furrows, described as dissecting glossitis by Wun-
derlich, occur. Dissecting glossitis is only a more aggravated form of
superficial glossitis. Furrows of this character may be due to syph-
ilis, and dissecting glossitis sometimes has a syphilitic origin. Fissures
and clefts are frequently caused by the rubbing and deep indentation
of a rough and jagged tooth. The area around the fissure is inflamed
and its base indurated. The sides and bottom are ulcerated. It is
recognized by its relation with the offending tooth. It may be mis-
taken for syphilis, another common cause of fissures.
Syphilitic Lesions. It must be remembered that the tongue is
always predisposed to inflame and ulcerate in syphilis. In secondary
syphilis fissures are always found on the borders of the tongue ; they
are almost certain to occur if the teeth irritate the border. They may
be due to the ulceration of a mucous tubercle which is developed upon
the border of the tongue. The ulcer is stellate, and gradually deepens
until it becomes a foul fissure. Two processes cause the ulceration —
the specific infection and the irritation of the teeth. Syphilitic ulcers
are not very angry, as are non-syphilitic sores and fissures which may
occur in persons in poor health. They may be sensitive, however, on
account of the involvement of the tongue. The absence of active in-
flammation, the large number of sores and fissures, and the associa-
tion with other lesions of the disease upon the tongue, cheeks, and lips
point to their syphilitic origin. Tertiary syphilitic ulcers are more
pronounced and deeper than other forms. They may be as long as
two or three inches ; they are sinuous and branched. Gummata may
occur on the tongue at the same time. The gummata may be circum-
scribed or linear, and may break down and ulcerate. Sclerosis of the
tongue, as described by Fournier, follows the healing of these ulcers.
It is curious to note that the lymphatic glands are seldom enlarged in
association with syphilitic fissures. The fissures must be distinguished
from carcinoma and tuberculosis. In carcinoma there is a distinct
tumor, which may become fissured. Tuberculous ulceration is a sign
of the presence of tubercle in other organs. The tuberculous fissures
are small, at first single ; tubercle, however, rarely begins as a fissure,
but as tuberculous ulcers on the tip or borders of the tongue. They
are stellate or irregularly branched. They are shallow at first, and
deepen later, but do not widen in a corresponding manner. The
lymphatic glands are always involved. (See Tuberculous Ulcer.)
Ulcers of the Tongue. They may be simple, aphthous, or trau-
matic. Simple ulcers follow long-standing superficial glossitis. They
form in the centre of vthe tongue, or of the inflammatory area.
They are due to sloughing, or simple melting away of epithelium.
The ulcer is smooth, red, glazed on the surface. The edges are callous
and inactive, and the shape irregular. It is sensitive, and may be pain-
ful. The signs of chronic glossitis continue with it. Dyspeptic or
catarrhal ulcers occur on the tip, or on the dorsum near the tip. The
dorsum of the tongue, from the tip backward, is very red, and filiform
papillae are absent. The ulcers are small and superficial without defi-
nite shape or character, except that they are red and irritable. Dys-
peptic ulcers may occur from the breaking down of vesicles on the
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 699
tongue. They are small, circular, well-defined ulcers, with sharp-cut
edges, in size from a pin's head to a split pea, and are the source of
considerable pain and much annoyance. They are recurrent. Saliva-
tion may attend them. Aphthous ulcers are seen in children and adults,
and when multiple are attended with the same symptoms as aphthous
ulcers of the mouth, with slight fever. Foetor is characteristic. When
single they occur with indigestion, or in women at the menstrual period.
The tendency to their formation is inherited. Traumatic ulcers from
sharp teeth may persist a long time if the general health is bad. When
indolent they may be mistaken for syphilitic, tuberculous, or cancer-
ous ulcers. The rapidity of formation, the location opposite a rough
tooth, and the absence of other signs of syphilis point to the true
nature of the ulcer. Chancre can be excluded by the greater hard-
ness and circumscription of the lesion, its seat near the tip, and its
association with enlargement of the lymphatic glands. The latter is
not present in traumatic ulcer, unless it is acute and angry. Traumatic
ulcer is distinguished from tuberculous ulcers by the absence of signs
of tubercle in other organs and by the result of an examination of the
scrapings of the ulcer ; from cancer by the age. In cancer all the
glands become affected later.
Excoriations on the surface of the tongue, or rawness, arise from
injury, and may also be seen in dyspepsia.
Tubeeculous Ulceb. The tuberculous ulcer presents an uneven,
pale, flabby surface, covered with a yellowish-gray viscid or coagulated
mucus. The edges are sometimes sharp-cut, sometimes bevelled,
seldom elevated. They are not usually very red. There is but little
surrounding inflammation, and the adjacent portions of the tongue are
but slightly swollen. The borders of the ulcer may be sinuous, and
the shape oval or ovoid, or elongated. In the neighborhood of an
ulcer a number of tiny yellowish gray points may be observed. The
ulcer is painful, and attended by salivation. I saw in the Philadelphia
Hospital a case of tuberculous ulcer of the tongue, in a young man
twenty-five years of age, with pulmonary and intestinal tuberculosis.
The dorsum of the tongue was covered with a dozen ulcers, with sharp-
cut edges and pale, flabby granulations, without induration or inflam-
mation around them. They were yellowish-gray, and tubercle bacilli
were found in the scrapings. Tuberculous ulceration must always be
carefully distinguished from syphilitic and cancerous. The associate
symptoms are often most reliable. Ulcers due to lupus are also seen
upon the tongue.
Patches and Plaques. Space forbids further consideration than
the naming of the plaques which are seen on the tongue. First, there
is the smoker's patch, on the middle of the dorsum about the point
where the tobacco-pipe rests, or where the stream of smoke from the
pipe or cigar strikes the tongue. This is a slightly raised area of oval
shape. It is not ulcerated, but is smooth and red, or livid. Some-
times it is bluish-white or pearly in appearance. The smoothness is
characteristic. White and bluish-white patches or plaques are seen in
leucoma, leucoplakia, ichthyosis, keratosis, and are also known as opaline
plaques. The smoker's patch belongs to the same class, and is proba-
700 SPECIAL DIAGNOSIS.
bly an early stage of these affections. It is a whiteness, or white
opacity of the surface of the tongue, usually on the dorsum. It is
almost always the result of the direct action of irritants. These patches
are unknown under twenty years of age, do not commence after sixty,
and very rarely attack women. They are not attended by subjective
symptoms usually. There may be a sensation of induration and dry-
ness. The course is always chronic.
Wandering Rash. Ringworm, or circular exfoliations — the geo-
graphical tongue — occurs most frequently in children. One or more
patches on the dorsum of the tongue are observed, smooth and red,
but not depressed or elevated. The filiform papillae have been shed.
The patch spreads and becomes a ring, circular or oval. The border
is faintly or decidedly yellow, and usually slightly raised and sharply
defined. The circles may widen and contract from time to time. No
subjective symptoms are noted except itching in a few cases. The
cause is not known. The diagnosis is easy. It may continue for
months or years.
Mucous patches are multiple lesions of syphilis in the mucous
membrane. They have been referred to in the section on Diseases of
the Mouth.
Eruptions. Eruptions of variola, measles/ and erysipelas are seen
on the tongue. Herpes and aphthous ulcers, preceded by vesicles, are
met with on the surface of the tongue.
Nodes. Nodules in the tongue are always tuberculous or syphilitic.
Atrophy. Atrophy of the tongue is very unusual. Hemiatrophy
may occur as the effect of central or peripheral causes, as softening,
hemorrhage, or tumors of the region of the hypoglossal nucleus. Other
centres near the nucleus are affected, hence other forms of paralysis are
seen, due to the lesions of the medulla. These are seen in progressive
muscular atrophy and bulbar paralysis, and in cases of hemiplegia.
It is not difficult to recognize it on inspection. The functions of the
tongue are not affected.
Hypertrophy. Enlargement of the tongue, or macroglossia, is gen-
erally congenital, but may occur late in life. The tongue enlarges, and
is accompanied by pressure symptoms due to such enlargement.
Hypertrophy of the tongue is sometimes seen in idiots and cretins.
The hypertrophy is more frequently the result of lymphatic obstruc-
tion, on account of which there is lymph-stasis. The diagnosis is easy.
Inflammatory hypertrophy occurs in stomatitis,- and syphilitic hyper-
trophy occurs with gummata.
Cysts. Various cysts occur in the tongue. Mucous cysts and
blood-cysts are the most common. The cysticercus cellulosse and the
echinococcus occur rarely. Ranula is a cyst underneath the tongue
that causes suffering from mechanical obstruction. It is easy of recog-
nition.
Parasitic Disease. Thrush is the most common. Other infections
of the mouth extend to the tongue in most instances.
The Tongue in General and Remote Disease. The Coating.
With a view to estimate the condition of the system in general by
the appearances of the tongue, excluding all local conditions, the
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 701
following characteristics are observed : First, the color ; second,
the fur ; third, the degree of moisture ; and, fourth, the movements.
The student should bear in mind that changes in the condition of
the tongue are frequently of local origin ; that dryness, for in-
stance, may be due to the open mouth, or that a coating may be
unusually marked because the tongue had not been used in mastica-
tion. Often coating is seen on one side of the tongue. This has been
referred to as due to disease of the nerves of one side. It is just as
likely to be due to an absence of mastication on that side, of the mouth,
the bolus of food being kept on the other side because of pain, diseased
teeth, or other local cause.
Clinical experience has shown that certain conditions in the tongue
are associated with certain general conditions which render the appear-
ance somewhat diagnostic. The term diagnostic must be qualified,
because the changes are so often local, or are modified by conditions
independent of the general system. For convenience, the classification
of Dickinson as to the appearance of the tongue in disease may be
utilized. In the Lumleian lectures this eminent authority described
the average healthy tongue based on extensive observations. Depart-
ures from the normal were arranged and afterward classified. It re-
sulted in the formation of eleven classes :
1. The Stippled or Dotted Tongue. The tongue is moist and
dotted with little white points, due to an excess of white epithelium
on the papillae. It is usually seen in persons in poor health without
fever. It is not, therefore, a febrile tongue, nor one indicative of
grave constitutional disease. It is seen in cases of chronic disease,
usually one in which there are no grave symptoms.
2. The Dry Stippled Tongue. This is found in mildly acute dis-
eases, or in cases in which the constitutional disturbance is more marked.
3. The Stippled and Coated Tongue. The patients in whom
this is found are very frequently the subjects of acute and constitu-
tional affections. Fever is more frequently present with this variety
of fur.
4. The Coated Tongue. There is excess of white epithelium on
the papillae, and the coat is continuous. The intervals between the
papilla? are more commonly filled up with epithelium and accidental
matters than in the preceding types. It is seen in acute and febrile
diseases, and whether moist or dry, in pneumonia, pleurisy, and typhoid
fever. It is associated with a far greater degree of prostration and
pyrexia, while the saliva is absent in the larger proportion of cases.
5. The Strawberry-tongue. The tongue is coated and injected ;
the fungiform papillae shine through the coat, particularly at the tip
and edges. It is the tongue of scarlet fever, but may often be seen in
any acute febrile disorder. In scarlet fever, however, it appears by
the second or third day — most marked after the second. Pyrexia is
more common in this class than in the preceding.
6. The Plaster-tongue. A thick, uniform coat, edges abrupt
and striking, covers the tongue. The papillae are elongated and the
intervals crowded with accumulations, among which are bacteria ; it
is the tongue of acute febrile disease. Fever was marked in a number
702 SPECIAL DIAGNOSIS.
of cases Dickinson studied, and prostration was a common attendant.
Saliva was deficient.
It is thus seen that, beginning with the healthy tongue, Dickinson
described a series of groups, in each succeeding one the coating becom-
ing more marked, with or without moisture. The clinical association
that he found is a common experience. Each successive group was
attended by more fever, greater exhaustion, and less saliva than the
preceding group, and in each the tongue became more and more furred.
7. The Furred or Shaggy Tongue. When moist the papilla?
are greatly elongated, composed mostly of horny epithelium. It has
the same appearance as if the tongue were dry. The moist, furred
tongue is not so common as the other. It is most commonly seen in
old age and in constipation. The dry, furred, or shaggy tongue may
succeed the dotted tongue or the coated tongue in the course of ad-
vancing disease. It is the result of disease and want of moisture.
The saliva is deficient ; it indicates that there has been fever, and that
possibly but little food was taken.
8. The Incrusted, Dry Brown Tongue. Over the surface of
the tongue there is a dry, thick, felted coat, which is continuous and
dips down between the papilla?. The coat is largely made up of para-
sitic material. In the course of fevers it is the outcome of a preceding
condition, the coated tongue, and is indicative of the typhoid state. It
occurs in the fevers with high temperature, but may be seen in condi-
tions of low temperature, as from cancer, phthisis, albuminuria, chronic
nervous diseases. There is much depression or prostration associated
with it, and there is absence of saliva. If the patients with a dry
brown tongue recover, it retrogresses to the furred or incrusted tongue,
which in turn becomes bare gradually, at first in small layers ; the latter
is thin, usually dry, but is more moist than the dry brown tongue.
As the incrustation disappears it may become bare, red, and dry.
9. The red dry tongue indicates a more serious condition usually
than the dry and brown. It is the tongue of chronic wasting diseases.
It occurs in phthisis in the later stages, and, as the raw-beef tongue, is
associated with dysentery and also with liver abscess. There may be
fever associated with the cases. It is in a measure the tongue of
chronic diarrhoea. The tongue is shrunken, red, polished, and smooth.
The papilla? have disappeared and the epithelium is stripped off in
patches. It may be associated with aphtha?. If the patient is to im-
prove, the redness fades, the papillae become softer, and the moisture
returns.
10. Red and Membranous ; otherwise as (9) the red denuded
tongue.
11. Cyanosis, or Venous Congestion of the Tongue. The
tongue is of a bluish or purplish color, the surface is smooth and wet,
and the papilla? are almost indistinguishable. It is not confined to
organic heart disease or cyanosis. It is of quite frequent occurrence
in albuminuria. With the venous congestion in the albuminuric cases
there is always a superabundance of deep epithelium. When the sur-
afce is examined it looks as if the papilla? were fused together and
overlaid by a moderate coat.
DISEASES OF MO UTH, FA UOES, PHAR YNX, (ESOPHA G US. 703
Classification op Tongues.
To the naked eye.
1. Healthy, moist.
Microscopically.
White epithelium in small amount on papilla?, not
continuous or superabundant.
2. Stippled, moist, dotted with
white.
2 (D). 1 Stippled, dry.
Excess of white epithelium on papilla?, not extend-
ing between them.
Ditto.
3. Stippled + coated ; moist.
Coat continuous in parts.
White epithelium on papilla? in excess, with partial
filling of intervals.
4. Coated white ; moist. Coat
continuous.
4 (D). Coated white, dry. Coat
continuous.
Excess of white epithelium in papilla?. Intervals
more or less filled up with epithelium and acci-
dental matter.
Ditto.
5. Strawberry, coated 4- injected,
especially showing in fungi-
form papillae.
Like the coated or plastered, but with more injec-
tion.
6. White, plastered, thick, uni-
form coat ; edges abrupt and
striking.
More elongation of papilla? than with coated
tongue, more filling of intervals with superficial
accumulation.
7. Furred or shaggy, moist.
Greatly elongated papilla?.
7(D). Furred or shaggy, dry.
Extravagantly long: papillse, mostly of horny epi-
thelium.
Ditto.
8. Incrusted, dry, brown; thick,
felted dry coat over papilla?.
Continuous crust on and between papilla?, largely
of parasitic matters.
9. Furred or incrusted, becom-
ing bare. Generally dry.
Crust breaking away, together with more or less of
normal surface.
10. Bed, denuded. Absence of
normal covering.
General absence of all epithelium excepting the
Malpighian layer ; sometimes of that also.
11. Red, smooth, dry, membranous
covering.
Level membrane replacing epithelial processes.
12. Cyanosed.
Injected ; hypernucleated ; excess of deep epithe-
lium.
Moisture of the Tongue. The moisture is due to the saliva,
any deficiency of which causes dryness of the tongue. It is natural,
therefore, to conclude that any changes in the moisture of the tongue
are due to altered secretion of the salivary glands. This is almost
always deficient when fever is present, and hence the tongue is dry.
1 The letter D is used to imply dryness. Thus, to Class 2 a certain description is
attached. Class 2D presents the same characteristics with the addition of dryness.
704 SPECIAL DIAGNOSIS.
At the same time, it must be remembered that this failure of secretion
of the salivary glands does not depend upon gastro-intestinal disturb-
ance.
Deyxess of the tongue, it must not be forgotten, may be due to hir
crease of evaporation from keeping the mouth open, as well as to
diminution of the salivary secretion. All states, therefore, in which
the mouth is open will lead to dryness of the tongue. Again, in
chronic fever, dryness of the tongue is a constant characteristic.
Dryness is due to the effects of the temperature upon the secretions
in general, but it is not the effect of high temperature, curiously,
but rather a temperature which has persisted for a considerable
length of time. Thus, in pneumonia, with a temperature of 105°,
the tongue may be moist ; whereas, in typhoid fever, with a tem-
perature of 103°, the tongue is dry. General dehydration of the
body causes dryness of the tongue, even without local diminution of
secretion. This dehydration is seen in diarrhoea, in which disease
simple or uncomplicated dryness of the tongue is the common symp-
tom. It is curious to observe that in cholera the tongue remains moist
even until death ; whereas, if the patient is about to improve and the
discharges cease, reaction and fever setting in, the tongue begins to dry
and becomes quite brown. Local causes may explain this. The watery
vomit may keep the tongue moist, and the temperature of the body
may contribute to the change. Xext after diarrhoea we have excessive
discharge of urine as a frequent cause of dryness. Hence, in diabetes
in all forms extreme dryness of the tongue is seen. The osmotic action
of the sugar in the blood is the cause of a reaction in diabetes mellitus,
just as it is in cases of dehydration of the lens in cataract. The final
cause of dryness of the tongue is prostration. Asthenia in all forms
continuing over a moderate period of time, as a week or ten days,
causes lingual dryness.
The Effects of Food. These must be studied before deciding
upon the clinical significance of changes in the tongue. The immedi-
ate results of taking of food influence the coating and the degree of
moisture. The act of eating cleanses the tongue. In disease, there-
fore, in which this act is not performed, it is natural that we observe
more fur on the surface, and in conditions in which diet is limited to
fluids the effect is marked. In cases of liquid diet the tongue is likely
to remain furred. It is particularly seen in patients who are kept
upon a milk-diet exclusively.
The Tongue in Relation to Diseases of the Alimentary Canal.
So much lias been written on this subject that it is Avell to give the
experience of Dickinson briefly. He has not been able to discern
any relationship between any state of the tongue and dyspepsia, or
ulcer of the stomach, apart from that which might occur from loss of
appetite or restriction in the amount of food. With regard to the
bowels, some forms of constipation are often connected with changes
in the tongue, but such connection is not constant. The author rather
tl links it to have been a coincidence, and cannot even point to the
diagnostic significance of the tongue in obstruction. The state of the
tongue in the latter condition is dependent not upon the intestinal
DISEASES OF MOUTH, FAUCES, PHARYNX, ESOPHAGUS. 705
lesion but upon the constitutional disturbance. A dry tongue is well
known to occur in acute obstruction, due to deficiency of salivary
secretion. In chronic obstruction, unless, however, there is consti-
tutional disturbance, the tongue will not change. In diarrhoea all con-
ditions of dryness, furring, and incrustation are observed. The
absence of saliva, dehydration, and pyrexia help the desiccation. In
diarrhoea and dysentery, therefore, the change in the appearance of
the tongue is more marked than in any other disease.
Other Diseases. As regards the relation of the tongue to other
individual diseases but little can be said. Of more direct association,
we have the cyanotic tongue in heart disease ; the dry tongue in
chronic albuminuria and diabetes inellitus ; the strawberry-tongue of
scarlet fever ; and the dry brown tongue of typhoid fever. Of course,
the so-called typhoid tongue represents but one stage of typhoid fever.
Throughout the disease it may present all varieties in direct succes-
sion, from the stippled, the coated, the plastered, the furred, to the
incrusted. In lobar pneumonia the same changes occur as the disease
advances. In bronchitis the lower degrees of coating are presented,
while in rheumatism the variety is considerable. In conclusion, it
may be stated that the tongue seldom points to solitary organs or iso-
lated disorders, but is a gauge of the effects of disease upon the system.
The Tongue in Prognosis and Treatment. Clinical observers
agree with Dickinson, that the condition of the tongue is due very
largely to the four states with which he has associated it — dehydra-
tion, exhaustion, pyrexia, and local conditions about the mouth. As
these conditions modify the state of the tongue, it is evident that the
first sign of improvement, as return of moisture, denotes a diminution
in temperature. Its appearance is, therefore, of good prognostic omen.
The degree of fever, the state of the nervous system, the maintenance
or abeyance of secretions, and the failure of vitality, are indicated by the
condition of the tongue. The return of moisture, the removal of fur, the
subsidence of tremor, at once indicate that the patient is getting better.
The persistence and increase of these signs show that the disease is get-
ting the better of the patient. As to indications for treatment, the dry-
ness, furring, and incrustation are connected with the want of saliva.
The processes by which this want is brought about differ. They have
previously been referred to, and the indications for treatment are obvious.
One can infer from the state of the saliva the condition of the intesti-
nal canal, a matter of the highest importance practically. There is no
doubt that, except possibly in diabetes, when there is diminished
saliva, there is also diminished gastro-intestinal secretion. Such
diminution is followed by loss of appetite and impairment of digestion.
The indication is at once to administer material that is digested with
the least difficulty. Hence, liquid food and stimulants are to be used.
The dry and bare tongue is of serious prognostic omen in all conditions.
While it may be due to want of saliva alone, it also occurs as a part
of the failure of nutrition in hectic fever, suppuration, and other condi-
tions. It is an indication for the use of tonics, stimulants, and liquid
and highly nutritious food. The weak pulse docs not more surely tell
of an asthenic tendency than the red, dry, and polished tongue.
45
706 SPECIAL DIAGNOSIS.
Movements of the Tongue When the patient is asked to put out
his tongue it is done without other movement than that required for
its ejection. Interference with its motility occurs in disease, when the
projection is attended by abnormal movement. It may be tremulous,
as in alcoholism or in simple weakness alone. It may be slow or im-
peded in the various stages of paralyses. It is tremulous and the seat
of fibrillar contractions in general paralysis. It cannot be projected
at all in glosso-labial paralysis ; it can be projected, but with difficulty,
and may have to be aided by the finger, in general paralysis and diph-
theritic paralysis, progressive muscular atrophy, and hemiplegia, be-
cause the paralysis is only partial. The tongue points to the paralyzed
side of the body in hemiplegia when the face is involved.
Angina Ludovici. Angina Ludovici is characterized by slight
inflammatory congestion of the throat out of proportion to the symptoms
of the inflammation in the external structures. Woodeny induration
of the connective tissue, which will not pit on pressure ; spreading of
this induration, which is circumscribed, so that it is bound sharply by
unaffected cellular tissue, is characteristic. The induration may extend
from the rami of the jaws to the face. With this there is a hard swell-
ing hi the tongue and along the lower jaw, causing thickening of the
floor of the mouth. This is observed by palpation with the finger in
the mouth. The glands are not affected. For a long time the nature
of this affection was not known. It is now believed to be due to
actinomyces. (See Parker, Lancet, 1879, and Anderson, Transactions of
the Medico- Chirurgical Society, 1891.)
The Fauces and Pharynx
The passageway between the mouth and the respiratory passages is
lined with mucous membrane, which is subject to diseases to which
they are liable. The symptoms thereof are similar to the symptoms
of mucous membrane inflammation elsewhere. The large muscles of
the pharynx which aid in deglutition are subject to affections which
belong to muscular tissue generally, hence rheumatic inflammation and
loss of power of muscle, or paralysis occurs. Paralysis of the pharynx
has not the same practical importance in diagnosis of central lesions as
paralysis of other structures, such as parts of the larynx. This is due to
the fact that the nerve-supply of the pharynx is derived from a nerve
(glosso-pharyngeal) which supplies other structures, paralysis of which
is more evident than pharyngeal paralysis, more readily ascertained,
and which causes more pronounced symptoms. (See Cerebral Nerves.)
From its exposed situation the pharynx is particularly liable to infec-
tion from micro-organisms. The infection may extend from the mouth,
or from the nares above, or the micro-organisms may affect it primarily.
The fauces and pharynx may be the seat of morbid processes which
occur secondarily to diseases in other portions of the body with a mod-
erate degree of frequency. Inflammations of the mucous membrane
of the pharynx are of rheumatic or gouty origin in a large number
of cases. Indeed, gouty inflammation of the pharynx seems to be
more common than gouty inflammations of mucous membranes in other
DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 707
situations. The large majority of subacute or chronic pharyngeal in-
flammations are secondary to dyspepsia. They also occur from exten-
sion of the disease from cavities related to the pharynx.
Affections of the tonsils are usually more common in rheumatic
states, and bear some relationship to the rheumatic diathesis. Inflam-
mation of the tonsils may follow acute rheumatism or may alternate
with it. A patient who is predisposed to rheumatism may at one
season have tonsillar inflammation, at another rheumatism. The
writer has seen tonsillitis immediately followed by rheumatism, and
then the latter replaced by the former.
Apart from what has just been said, diseases of the pharynx bear
but little, if any, diagnostic relationship to disease elsewhere. While
there may be cyanosis of the mucous membrane, or tuberculous ulcer-
ation, or other changes which we have noted, the signs of the primary
disease are so much more marked that we need not rely upon the
appearance of the pharynx or symptoms of pharyngeal disease for
diagnostic purposes. The only general affection which may be diag-
nosticated from the appearance of the pharynx alone is measles. In
obscure cases of sudden fever, with nasal catarrh, the appearance of
the eruption in the situation just indicated may lead to the recogni-
tion of measles Avhen the external eruption is not apparent. For
the purposes of the therapeutist it should be borne in mind that symp-
toms referable to the pharynx are very frequently due to disease in
the nares, particularly in that portion of the pharynx which is not
open to direct hispection — the nasopharynx.
The general symptoms of pharyngeal disease are not marked, except
in diphtheria, in erysipelas, in retropharyngeal abscess, and in affec-
tions of the tonsils. In the latter the general symptoms appear to be out
of proportion to the local process. The high fever, the intense head-
ache and backache, and rapid pulse, seem to point to a process which in
extent and severity should far surpass that which occurs in the tonsils.
As a passageway or channel, affections of the pharynx are liable to
obstruct it, causing symptoms of occlusion. As a channel for the pas-
sage of air, obstruction in the pharynx will lead to dyspnoea. In addi-
tion to its function as a simple channel, the pharynx is concerned in
the act of deglutition. When, therefore, there is obstruction of the
pharynx, deglutition is made difficult, or may even become impossible.
Attention cannot be too strongly directed to the investigation of the
nasopharynx in children who are poorly developed physically and men-
tally, and who present appearances that, to the practised eye, are most
familiar. The experienced observer will at once judge, and judge cor-
rectly, that this combination of symptoms is due to disease in the naso-
pharynx. Eeference must be made to the remarks on adenoid vegeta-
tions of the nasopharynx, but it is proper to state here the relationship
and the importance of investigating the structures in the class of cases
just indicated.
The Data Obtained by Inquiry.
Pain. In affections of the fauces and pharynx pain is one of the
most common subjective symptoms. It is due to the fact that the
708 SPECIAL DIAGNOSIS.
functional acts of the pharynx require movement of all the struc-
tures. When they are the seat of inflammation, or ulceration, the
movement excites pain. It is, therefore, a symptom of great severity
in inflammation of the tonsils and pharynx, of rheumatism of
the muscular structure of the pharynx, and of tuberculous and can-
cerous ulceration. Pain in the pharynx is a frequent accompaniment
of post-nasal inflammations, although the pharynx itself is not
affected.
Dryness. Dryness of the fauces, with a tickling sensation and a
more or less constant desire to hawk, occurs in pharyngitis. Hawk-
ing, however, is not a symptom of disease of the pharynx alone. It
may also be due to disease in the posterior nares.
The Odor of the Breath. In follicular tonsillitis the breath has
a peculiar odor. This is more marked in the milder forms of inflam-
mation, with retention of the secretion of the glands. The odor is in-
tense and foetid. In cancer and syphilis there is also fcetor of the
breath. The foetor may be of diagnostic significance in distinguishing
cancer from tuberculosis.
Dysphagia. The symptom varies in degree from slight difficulty
in swallowing to complete prevention of the act. Any disease which
occludes the passageway causes dysphagia ; pain is also a cause. It
is, therefore, present in all painful affections of the pharynx. Dysp-
noea is seen in tumors, in inflammation of the tonsils, in the rare form
of erysipelas of the pharynx, and in retropharyngeal abscess. It
occurs from occlusion of the passages, and is more marked in retro-
pharyngeal abscess and erysipelas than in other conditions. In cer-
tain forms of abscess of the tonsils it may be very extreme.
Spasm of the pharynx is a subjective symptom complained of in some
cases of pharyngitis. The degree of spasm or the amount of choking
sensation is largely dependent upon the neurotic constitution of the
individual. It may be extreme when only a moderate amount of inflam-
mation is present. It is seen in the most aggravated form in hydrophobia .
The Data Obtained by Observation.
Examination of the Fauces. Method. For this purpose examin-
ation is made by the unaided eye, illuminating the throat as in the ex-
amination of the larynx. The difficulties of examination arise from the
tongue and the uvula. The mouth should be opened as wide as is con-
sistent with comfort and in an unrestrained manner. The tongue is
pressed out of the way by the use of a tongue-depressor. In many cases,
however, even with the tongue-depressor, the tongue muscles will con-
tract and the organ bunch up in the mouth. Moderate, quiet, full
breathing, gently opening the mouth as the deeper inspirations are made,
causes the tongue to relax and lie in the bottom of the mouth, and at
the same time elevates the uvula. At the time of a full breath the
part may be inspected throughout. Sometimes the fauces can be ex-
amined if the tongue is protruded and held with a soft napkin between
the finger and thumb by the patient. In the fauces the tonsils and
uvula are to be observed, following out the routine method of ascer-
DISEASES OF MOUTH, FAUCES, PHARYNX, GESOPHAGUS. 709
taming all facts. Attention is then paid to the posterior Avail of the
pharynx, with the same object in view.
Inspection. In examining the fauces and pharynx observation is
made of the color of the parts, the appearance of the mucous mem-
brane and its glands, the appearance and position of the uvula, the
size of the tonsils, the character of the secretions on the pharynx, and
the presence or absence of swellings and abnormal exudations.
Color. The color of the mucous membrane is generally dark red.
In the acute forms of pharyngitis the color is bright red. In cases of
heart disease, when there is cyanosis, the veins are congested and the
surface dusky. In obstruction of the superior vena cava by tumor there
is a cyanotic hue of the surface of the pharynx.
Appearance of Surface. The capillary vessels may pulsate in aortic
regurgitation. Bleeding-points may be seen over the surface of the
pharynx, the discharges of blood from which may simulate pulmonary
hemorrhage. The blood may be swallowed and then vomited, and
hence gastric hemorrhage is simulated. When the hemorrhage occurs
at night it is seen on the pillow as yellowish stains. It is often due
to adenoid vegetations in the nasopharynx. In chronic pharyngitis the
membrane is dry, the glands are prominent, and the secretion viscid.
On examination of the posterior wall of the healthy pharynx little
elevations due to glands are seen upon its surface, and moderate-sized
vessels are seen coursing through the mucous membrane.
Eruptions. Eruptions may be observed in the pharynx in some of
the specific fevers. Thus, in measles, the appearance of the rash on
the pharynx and on the soft palate may be observed before the devel-
opment of the rash on the skin. The eruption of scarlatina is also seen
in the pharynx, and the papules and pustules of variola are frequently
observed in that situation.
Ulceration. Follicular Ulceration. Small superficial ulcers cor-
responding to the follicles may be seen over the posterior wall of
the pharynx. They occur in chronic catarrh, and are due to in-
flammation of the follicles. In addition, ulcers secondary to infectious
processes are sometimes seen, as in typhoid fever. In syphilis, in the
secondary stage, small, shallow ulcers are seen on the posterior wall of
the pharynx. They do not cause pain. Mucous patches are observed
at the same time, not only on the pharynx, but also in the mouth.
In the tertiary stage deep ulcers, followed by scars, are seen on the
posterior wall of the pharynx. Although the absence of pain renders
it probable that they are of syphilitic origin, nevertheless the history
of infection and of the primary lesion, and the evidence of the disease
in other structures, ought to be secured before a diagnosis is fully estab-
lished. In the tertiary forms it may be necessary to resort to the
therapeutic test. (See The Infections — Syphilis.)
Tuberculous ulcers are irregular in shape, and the floor grayish.
They are seen in tuberculosis in its later stages. They are the source
of extreme pain. There is usually ulceration in the larynx at the same
time, and, in extremely rare cases, tuberculous ulceration of the tonsils.
In tuberculous ulceration, after the application of cocaine, a portion
may be scraped off and examined microscopically for tubercle bacilli.
710 SPECIAL DIAGNOSIS.
Cancer of the pharynx is rare, and is usually secondary, the dis-
ease having spread from other situations.
Exudations. On the pharynx the exudation may be due to
diphtheria, to pseudodiphtheria, or to thrush. The method of dis-
tinguishing the various forms will be considered in the articles on the
respective affections. In diphtheria the membrane is made up of
fibrin arranged in a network, in the meshes of which epithelium,
blood-corpuscles and pus-corpuscles and micro-organisms are found.
When removed, hemorrhagic abrasions and raw purulent inflammatory
areas remain. Two forms of bacilli are found in the membrane — the
pseudodiphtheritic bacillus and the true, or Klebs-Loffler bacillus.
(See Bacteriology.) The Loffler bacillus is best detected by cultiva-
tions. After the membrane is removed and washed in a 2 per cent,
solution of boric acid, it is cultivated in blood-serum. The pseudo-
diphtheritic bacillus likewise grows, but its appearances are different.
Anaesthesia. Some of the results of inspection may be confirmed
by means of the probe, and alterations in the sensibility of the phar-
ynx may be detected. Sensations may be absent in the whole poste-
rior wall of the pharynx. Loss of sensation may occur in hysteria, in
bulbar paralysis, and in diphtheritic paralysis. On the other hand,
there may be an apparent hyperesthesia. In some individuals the
pharynx is particularly sensitive to the presence of foreign bodies, such
as inflammatory exudates, and may resent their presence by sudden
coughing and retching. Inflammations increase the hyperesthesia of
the pharynx. The condition is sometimes observed in hysteria.
The Uvula. In health it hangs midway from the palate. It varies
in shape from congenital causes, and may be elongated, on account of
disease. This takes place particularly if there has been hawking or
coughing, on account of chronic nasal catarrh. When elongated it is
pointed and may extend almost to the base of the tongue. The uvula
may be swollen and oedematous. The oedema is usually associated
with subcutaneous oedema in acute Bright' s disease. It may occur
in debility. In both conditions it may become so enlarged as to
interfere with swallowing and breathing. In some cases of pharyn-
gitis the uvula is the seat of intense inflammation and great oedema.
In addition to the constant cough which it causes there may be dysp-
noea and repeated attacks of choking.
Hemorrhagic infarcts may take place in the uvula. In two in-
stances under the writer's care the intense infarction led to sloughing,
and in one the uvula was swallowed.
The Cervical Glands. The pharynx is in such intimate rela-
tion with the large lymphatic glands in the neck that diseases of the
former are frequently attended by enlargement of the latter. The
glands at the angle of the jaw are increased in size. The glands ex-
tending along the vessels of the neck may also be enlarged. In cases,
therefore, of enlargement of the glands in this situation, it is absolutely
essential to examine the fauces and pharynx.
The Tonsils. The tonsils are situated at the sides of the pharynx,
between the anterior and posterior folds of the palate. They are
small bodies, not larger than a filbert in the adult. Their entire
DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 71 1
surface can be seen by ordinary inspection. If enlarged, the posterior
surface cannot be seen, although a larger view may be obtained by
causing the patient to gag or retch, during which they are brought
forward to the light. They are pathologically of much importance.
They are made up of glandular structure arranged in follicles and held
together by connective tissue. The crypts of the follicles open on
the surface, and in disease are visible. The diseases of the tonsils
have nothing to do with their function as far as known. The tissue
and gland follicles are liable to inflammations, which may be bacterial
or may be the result of rheumatism. The tonsils become enlarged ;
the swelling takes place rapidly in the acute forms. They may be
simply enlarged and the covering membrane intensely red. In other
forms of inflammation the surface may be dotted over with white
points, due to exudation from the follicles ; these may be covered with
a white or grayish membrane, which is removed with difficulty, leaving
an abraded surface beneath. Repeated attacks of inflammation cause
chronic enlargement of the tonsils. They are enlarged sometimes to
a great degree, filling almost entirely the lumen of the fauces. The
surface is irregular, and may be scarred. The mouths of the follicles
may be dilated. By virtue of their position, enlarged tonsils from any
cause are a source of dyspnoea and dysphagia. The tonsils may be
the seat of sarcoma and tuberculosis.
Ulcers. Tuberculous ulceration is rare. In a patient, a lad of
sixteen years, under the writer's care, the large tonsils were of a honey-
combed appearance, on account of the grayish, irregular ulceration.
Deglutition was absolutely impossible, on account of pain, and the
young man died of starvation.
Exudations on the tonsils are due to inflammation of the follicles,
to diphtheria, to the pseudodiphtheritic inflammation which attends
scarlatina, or which arises secondarily to other infectious debilitating
diseases, and to thrush.
Leptothrix of the Tonsils. In healthy persons the plugs
which block the tonsillar crypts are found to be made up of cells and
segmented fungi. The latter stain bluish-red with iodo-potassic iodide
solution. Sometimes the micro-organisms extend beyond the follicles,
covering the surface of the tonsils with patches of various size. They
are thus seen in follicular tonsillitis.
Tonsillitis. Acute inflammation of the tonsils may affect the folli-
cles, to which form the term follicular tonsillitis is applied, or it may
be limited to the mucous membrane, when it is known as catarrhal
or erythematous tonsillitis. If with the catarrhal inflammations vesi-
cles appear on the surface of the mucous membrane, the term herpetic
tonsillitis is used. When the inflammation extends to the stroma of
the glands it goes on to suppuration. It is characteristic of all forms
of acute tonsillitis to recur frequently in the same subject. The rela-
tionship to rheumatism has been spoken of. This relationship applies
to both the acute and the suppurative forms. The various forms of
tonsillitis occur at any age, although it is least common under ten
years of age ; the suppurative form occurs most frequently in adoles-
cence. Tonsillitis occurs in both sexes. It may follow exposure to
7 1 2 SPECIAL DIA GNOSIS.
wet and cold, although patients who are subject to the attacks bear
exposure, unless they are at the same time unduly fatigued. The fol-
licular form of tonsillitis is apparently associated with bad drainage
or other unhygienic conditions, which makes it possible that noxious
emanations act as an exciting cause. Several persons of the same
family may be affected at one time, so that it is often difficult to dis-
tinguish the cases from diphtheria. The disease, however, is not con-
tagious. Persons brought in contact with the family, but who do not
reside in the same house, escape the disease. This applies as well to
children, who would, if the cases were diphtheritic, be most liable to
become infected. The disease occurs more commonly in the spring
than in any other season of the year, more especially in cold and wet
seasons.
Symptoms. In follicular tonsillitis, with or without a rigor, but
always with chilly sensations, the temperature rises rapidly to a great
height. The subjective sensation of fever is very quickly noticeable
to the patient, and is generally more pronounced than in other affec-
tions. With the chill and during the rise of temperature there are
some frontal headache and severe pain in the back and limbs. The
pain in the back is most excruciating. In a short time the patient
complains of pain in the throat. Swallowing is difficult, and there is
a sense of fulness. The throat is dry and burning. On examination
the tonsils are found to be swollen, and a yellowish-white exudation is
seen on the crypts. In twenty-four hours the points may coalesce to
form a patch. The glands expand slightly, and may extend only
slightly beyond the arches, or, in younger subjects, one-quarter of the
way into the lumen of the fauces. Sometimes one gland is affected
before the other. The difficulty in deglutition increases and the voice
becomes nasal. There is usually some enlargement of the cervical
glands. The general symptoms continue for forty-eight hours, the
temperature remains at 105°, and the pulse is very rapid. After the
first twenty-four hours the pain in the back lessens. The tongue is
coated and the breath heavy. The urine is loaded with urates. At
the end of the fifth day the fever, which subsides gradually, has disap-
peared. The local symptoms, however, may remain longer ; that is,
the tonsils are still enlarged and the exudation disappears slowly.
Sometimes the prostration and general symptoms are very severe, so
that after the fever has subsided convalescence may be very slow.
Albuminuria, due in all probability to the fever, frequently occurs ;
in some cases, undoubtedly, acute nephritis attends the attack and
retards the convalescence. In a case under the writer's care the
patient first had acute rheumatism ; this was replaced by a severe attack
of tonsillitis, during which albumin, blood, and granular casts were
found in the urine. The swelling of the tonsils subsided in due course,
but the Bright's disease continued for a long period, finally ending,
however, in complete recovery.
In herpetic tonsillitis the severe pain and intense general symptoms
are out of proportion to the local lesion.
In suppurative tonsillitis the constitutional disturbance is also very
great. The temperature rises high, 104° to 105°, and the pulse is
DISEASES OF MOUTH, FAUCES, PHARYNX, (ESOPHAGUS. 713
very rapid, from 110 to 130 in the adult. The inflammation usually
begins in one tonsil, and the other may be involved later. The
tonsils at first are enlarged and firm and very red. There is swelling
of the surrounding tissues. In twenty-four hours deglutition becomes
almost impossible, and there is salivation. At the end of forty-eight
hours the patient presents a striking appearance. The glands of the
neck are enlarged, the patient is unable to open his mouth, the voice
is nasal or almost suppressed ; there is dribbling of saliva from the
mouth. The face may have a dusky hue in spite of the capillary con-
gestion due to the fever. There is constant desire to discharge saliva
and accumulated secretions from the back part of the mouth. The
patient cannot lie down. The pain is extreme, and is aggravated by
swallowing. It is sometimes of a throbbing character, and often shoots
to the ears. Indeed, earache may be the chief complaint. The patient
does not take food, and exhaustion soon ensues. During the twenty-
four hours before rupture takes place the previously reddened face
becomes blanched from exhaustion. The fever is continuous during
this time, with great rapidity of the pulse. The patient may be delirious.
Sometimes the delirium is marked and the patient resists efforts to keep
him in bed.
The suffering is out of proportion to the danger of the case. About
the fourth or fifth day suppuration is over, and if the finger can be
inserted into the mouth between the almost closed teeth, fluctuation
is detected. In cases in which the mouth is opened a little more
freely, in addition to the swelling of the tonsils below the arches,
marked swelling and projection forward of the half-arches may be
seen. The fluctuation may be detected through the anterior fold of
the palate, and, if lancing is to be performed, the pus can only be
reached through this structure. In short, a peritonsillitis takes place.
After spontaneous rupture, which usually takes place into the mouth,
instant relief is experienced. Rupture may take place into the pharynx
and cause suffocation from entrance of pus into the larynx. In rare
cases it has opened into the carotid artery, causing instant death from
hemorrhage.
Diagnosis. The diagnostic features of acute tonsillitis are the
sudden high fever, severe backache and headache, pain in the throat,
and albuminuria. The characteristic appearance of the face, the sali-
vation and pain, with suppressed voice and difficult deglutition, should
distinguish it from trismus or tetanus. In both the jaws are closed.
It must not be confounded with smallpox, which it resembles during
the first twenty-four hours.
Cases of follicular tonsillitis are frequently mistaken for diphtheria.
The follicular inflammation in tonsillitis is limited to the gland, on
which patches of a yellowish-gray color, easily removed without leaving
bleeding surfaces, are seen. In diphtheria the membrane is of an ashy-
gray color, not in points or small patches, or separated by red tonsillar
tissue ; it extends to the pillars of the fauces, and may appear on the
uvula. There are, nevertheless, many cases which are doubtful, when a
bacteriological diagnosis must be resorted to. (See Bacteriological Ex-
amination.) A history of exposure sometimes helps us to arrive at a
714 SPECIAL DIAGNOSIS.
conclusion. The cases that particularly increase our anxiety are those
of adults who are subject to attacks of follicular tonsillitis. In the
grave and extensive forms of diphtheria with asthenic symptoms (sep-
ticaemia) the diagnosis is not difficult.
Enlargement of the Tonsils. Chronic Tonsillitis. The ton-
sils may be enlarged, on account of repeated attacks of acute inflamma-
tion or from chronic inflammation. They do not appear to cause
serious symptoms unless associated with adenoid vegetations in the
nasopharynx. They may interfere with hearing, however, and with
breathing, and cause snoring at night. Foetor of the breath may be noted,
particularly if the secretion lodges in the crypts. The latter may be
recognized by its characteristic yellowish color and by its odor on
removal. The enlarged tonsils are irregular in contour.
Foreign bodies in the tonsils are not of common occurrence. They
give rise to local symptoms, as the sensation of the presence of a mass
causing repeated efforts at swallowing. If calculi are present the
patient may complain of a rough sensation. The calculi follow frequent
attacks of quinsy. Hydatids are sometimes located in the tonsils.
Adenoid Vegetations of the Nasopharynx. Adenoid vegetations
cause more or less obstruction in the nasopharynx. The symptoms
may be classed as primary and secondary. The former are local, and
due to the foreign substance, per se ; the latter are local and general.
The former are catarrhal ; the latter the result of stenosis.
Local Symptoms. In a large number of cases there is discharge
from the nose. This may be mucopurulent, or be associated with
crusts. If the discharge is not constant, the child is subject to coryza,
with its customary discharge, on the slightest provocation. With or
without the chronic purulent nasal discharge mucus and blood may
be passed at night and found on the pillow in the morning.
The hearing is frequently impaired. There may be simply dulness
of hearing, or it may amount to marked deafness, either because of
pressure of the adenoid vegetations, or extension of secondary inflam-
mation to the Eustachian tubes. The senses of taste and smell are often
much impaired. There is increase in the secretion of pharyngeal
mucus, which in older persons causes difficult expectoration.
Rhinoscopic Examination. The roof of the pharynx is covered
with rounded or villous projections, often concealing the posterior
nares. Rarely the villi may be seen projecting below the soft palate.
In children the examination is difficult, and hence digital exploration
must be used under an anaesthetic. The finger readily detects the
masses, which sometimes are soft, at other times tough and of fibrous
or cartilaginous consistency.
The Appearance. The expression of the face is characteristic.
It is dull and stupid, and may be drawn. (Fig. 187.) The mouth is
kept open in breathing. The lips are dry, and may be cracked. They
are thickened. The palatal arch is high and narrowed.
The nostrils are flattened laterally. Rarely they may be depressed.
In one instance, which the writer saw with Dr. Harrison Allen, the
exterior of the nose suggested inherited syphilis, all the more because
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 715
Fig. 187.
of our knowledge of the possible presence of the disease. There were
no other evidences of hereditary syphilis in the child or in any mem-
ber of the family.
The Voice. It is thick and muffled, becoming indistinct upon the
occurrence of slight cold.
The Chest While there is a general lack of physical development,
the appearance of the chest is most striking. The cases have been
frequently mistaken for rickets, however ; in this country adenoid veg-
etations are a common cause of chest-
deformity, whereas in England and on
the continent rickets is the most frequent
cause. The ribs are prominent in front,
the sternum is angulatecl forward at the
manubrio-gladiolar j unction and grooved
at the gladiolar-xiphoid junction. A
saucer-shaped depression is found at
the lower costal cartilages. The ribs
behind are closely compressed, so that
the intercostal spaces at the lower part
of the chest are obliterated. The chicken-
breast appearance is most striking, with
the depression in the lower portions of
the chest. The diaphragm may be
drawn in during inspiration in the
middle and lateral thoracic regions.
In addition to the " chicken " or
" pigeon-breast " the more advanced
deformity known as the "funnel-breast"
or trichterbrust is seen. In children
who suffer from asthma and bronchitis,
the chest becomes emphysematous.
Mental and Neevous Symptoms.
Headache, listlessness, and indisposition
for mental exertion are marked. The
patients are usually backward in their
studies and are unable to fix their at-
tention for any length of time upon any
subject. The child is forgetful and can-
not study without effort. Aprosexia is
the term applied to this condition.
Choreiform spasm of the face occurs
in connection with it. Enuresis is a
frequent associate symptom. The child
is subject to frequent attacks of indiges-
tion. I have seen the following occur in many cases : Prior to opera-
tion the child had an abnormally poor appetite and was subject to fre-
quent attacks of indigestion, characterized by vomiting, with fever.
After the operation the appetite improved and continued good, and
the attacks of indigestion disappeared entirely. The cases had been
under observation before and after the operation for a number of years.
Appearance in adenoid disease.
(Dawson-Williams.)
716 SPECIAL DIAGNOSIS.
The indigestion seems to have been due to the fact that, owing to the
obstruction, the child would have to eat rapidly, in order to keep the
lumen of the mouth free for breathing puq:>oses. The rapid eating,
of course, prevented proper mouth-digestion, and hence the occurrence
of gastric catarrh.
Symptoms from Embarrassed Eespiratiox. In addition to
mouth-breathing, the patient snores at night, and sleep is always dis-
turbed. The respirations are irregular, with a pause between, fol-
lowed by noisy 'inspirations. The difficulty of breathing is the cause
of restlessness, and the child will often wake up in the night with
dyspnoea. Night-restlessness, with dyspnoea and irregular respirations,
should point, therefore, to obstruction in the nasopharynx.
Diagnosis is based upon the facies, which is very characteristic, and
the physical examination. In children, digital examination is neces-
sary. The finger can readily detect small, flat bodies or grape-like
masses in the nasopharynx.
The student cannot become too familiar with the symptoms and
signs of adenoid disease of the nasopharynx. There is no doubt that
in our large cities this local affection is of more common occurrence
and more disastrous in its results than any other that we have to deal
with in children. It may be said that in children in poor health,
ansemic, with impaired digestion, and lack of muscular and physical
development, if the causes are not due to impure air and improper
diet, or to improper sanitation generally, it is almost certain that there
is disease of the nasopharynx. The writer has seen a very large num-
ber of cases in recent years in his practice, and has had the satisfac-
tion of seeing the entire picture of the child change after proper opera-
tions. It may be said in passing that this change does not take place
at once, but after three to twelve months the child will be fully
restored in physique, if during that time attention is paid to proper
exercise and the development of the chest. ^Notwithstanding all this,
however, the natural shape of the chest and appearance of the face are
only resumed gradually.
Inflammations of the Pharynx. Inflammation of the pharynx,
acute pharyngitis, or sore-throat, follows cold or exposure, particularly
after the patients have been physically depressed. The acute inflam-
mation may be associated with rheumatism or gout. The inflammation
often involves the tonsils as well as the pharynx. The symptoms are
pain on swallowing, with dryness and a constant desire to hawk and
cough, on account of the tickling sensation. There may be slight
laryngitis and inflammation of the Eustachian tubes, with deafness.
Stiffness of the neck and enlargement of the cervical glands attend the
local inflammation. The general symptoms are not marked. The
attack is ushered in by chilliness and slight fever. On examination
the mucous membrane is seen to be congested, dry, and fflistenino-,
and covered m spots with sticky secretions. The uvula may be very
much swollen. AVhen the submucous tissues are involved the parts
are more swollen and there is greater dyspnoea. The dysphagia is
more marked, although the pain is not any greater. The fever is
higher. The larynx is always involved, causing aphonia.
DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 717
Phlegmonous Inflammation. A diffused inflammation of this
character occurs. The writer saw one case with dyspnoea, nervous
symptoms, and high temperature, simulating severe pneumonia.
Pneumonia was thought to be present because there were congestion
and oedema of the lungs. It occurred during the prevalence of the
recent epidemic of influenza. The disease began in the pharynx ; the
tissues were swollen and infiltrated. The early symptoms were phar-
yngeal. The dysphagia was extreme, and there was an abundant
mucopurulent expectoration, which did not contain pneumococci.
Death took place on the ninth day from exhaustion. The autopsy
showed a high degree of congestion of the lungs, and phlegmonous
inflammation of the pharynx, larynx, and trachea. While, therefore,
the recognition of an acute phlegmonous inflammation is not difficult,
it must not be forgotten that it is a grave disease, which may present
such marked pulmonary and systemic symptoms as to lead to the sus-
picion of pneumonia.
Angina Ludovici is an inflammation of the cellular tissue of the
floor of the mouth and neck. It is probably a form of actinomycosis.
The swelling is most marked below the jaw of one side. The symp-
toms are very intense and both local and general. There are general
septic symptoms from the outset. With the swelling there are oedema
and board-like induration. Redness and the rapid formation of an
abscess occur rarely. The throat is not affected. Death takes place
from reflex suffocation or in coma. (See The Mouth.)
Rheumatic pharyngitis is of short duration, without objective
symptoms. Pain is intense, deglutition difficult. The usual concomi-
tants of rheumatism are present. It frequently gives place to torti-
collis, lumbago, or rheumatism in some other situation.
Chronic pharyngitis follows acute attacks, and is a frequent
accompaniment of nasal catarrh. It is common in smokers and' alco-
holic subjects ; the use of the voice in loud tones, as bv clergymen,
auctioneers, etc., is also a cause. It is a frequent attendant upon in-
digestion, due probably to the eructations. The objective signs are
relaxation of the mucous membrane, with dilatation of the veins. The
membrane is covered with a thick secretion, which is dry and glisten-
ing. In the granular form the Avail of the pharynx is covered with
millet-seed projections and is congested. Tough mucus is seen in
small areas.
Retropharyngeal Abscess. The inflammation may begin in
the submucous connective tissue, and a retropharyngeal abscess form.
There are high fever and dysphagia, with stiffness of the neck and
enlarged glands. On examination a projection into the pharynx can
be seen or distinctly felt on the posterior wall. The disease* may be
difficult of recognition in infants, in whom it is not possible to gei a
good view of the pharynx. On the other hand, it may be simulated
by disease of the cervical vertebra?, in which there may be stiffness.
difficulty in deglutition, and possibly a tumor. It must not be for-
gotten that retropharyngeal abscess may result from caries of the cer-
vical vertebra?. In children the abscess is attended with dyspnoea and
alteration in the voice, so that laryngeal disease may be suspected. I
718 SPECIAL DIAGNOSIS.
recall a case of retropharyngeal abscess in which the dyspnoea was so
severe as to suggest croup ; in fact, preparations for tracheotomy were
made, when sudden rupture of the abscess revealed the nature of the
disease. Fortunately the child had been kept in the upright position,
so that pus was discharged into the mouth, or suffocation would have
ensued.
Inflammation of the Parotid Gland. First, specific inflammation
or parotitis (see Mumps) ; second, symptomatic parotitis occurs in
tvphoid fever, pneumonia, pyaemia, and septicaemia. The process is
intense, characterized by swelling, redness, and heat over the parotid
gland. There are pain and difficulty of mastication ; suppuration
rapidly ensues in the septic form. It is thought to be an unfavor-
able symptom, but I have seen two cases in typhoid fever get well.
In a case of septicaemia it did not advance to suppuration. Stephen
Paget has described a symptomatic inflammation in disease of the
abdomen and pelvis. He collected 101 cases, 50 of which were due
to injury, disease, or temporary derangement of the genital organs,
as by slight blows, or in females to the introduction of a pessary. It
may occur before the menstrual period or during pregnancy. Septi-
caemia or pyaemia does not attend the process — indeed, many of the
cases are afebrile. In 78 cases, 45 suppurated and 33 resolved with-
out suppuration.
Gowers describes a case of parotitis which occurred in the course of
fatal peripheral neuritis.
The (Esophagus.
The oesophagus is open to all affections which arise in mucous mem-
branes, although its histological structure, its position, and its func-
tions largely protect it from involvement in disease. Should morbid
processes arise, the symptoms expressive of these processes are the
common symptoms of disease of the mucous membrane. But the oesoph-
agus is a closed tube, the function of which is to convey food from
the pharynx to the stomach. It is subject to all the affections common
to channels. Any disease of the tube interferes with its function,
made evident by the symptom common to all disorders of the oesoph-
agus — dysphagia. As this symptom occupies a position of such promi-
nence in the symptomatology of disease of this tube, it is evident that
the diagnosis of disease resolves itself into the differentiation of all
forms of difficulty of deglutition.
Before beginning the discussion along the lines indicated, the sub-
jective and objective symptoms of disease of the oesophagus must be
considered.
The Subjective Symptoms. Pain is a common symptom of dis-
ease of the oesophagus. In acute inflammation it is extreme, and is
complained of in the neck, between the shoulders, and along the verte-
brae for a short distance. Its character depends upon the cause. Severe
burning pain, often agonizing, is due to inflammation caused by hot
or caustic fluids. Absence of pain after the ingestion of such sub-
stances, or its disappearance in a short time, points to extreme corro-
sive action and gangrene. Pain attends and is a part of the symptom
DISEASES OF MOUTH, FAUCES, PHARYNX, OESOPHAGUS. 719
— dysphagia (q. v.). Cough attends such diseases of the oesophagus as
exert pressure upon the bronchus, as carcinoma.
The Objective Symptoms. Stiffness of the neck is seen in acute
inflammation of the oesophagus and in peri-cesophageal abscess ; it
may also occur in traumatism. The expectoration in diseases of the
oesophagus is characteristic. It is usually a glairy mucus, often frothy
or viscid. It is not coughed up, but after welling into the pharynx
is hawked up. It is abundant in acute and chronic inflammation and
in cancer.
Hemorrhage from the (Esophagus. Hemorrhage from the
oesophagus occurs from varicosity of the veins at the lower portion of
the gullet. It may occur in old people, from senile disease of the
liver, kidney, and spleen, or at any age in cirrhosis of the liver. In
hemorrhage from the oesophagus the blood is usually bright in color,
has not been acted on by an acid, as in hsematemesis, and is, therefore,
alkaline in reaction, and is not discharged by vomiting, although vom-
iting may occur after the blood is poured out. In a grave case of
purpura under the care of the writer hemorrhage took place from the
lower end of the oesophagus. Small bleedings from the oesophagus are
usually indicative of cancer, especially if, in addition to the hemor-
rhage, there are present the symptoms of occlusion. Hemorrhage is
also seen in foreign bodies : (1) from trauma ; (2) from ulceration.
Emaciation is the most characteristic general symptom of oesophageal
disease. It is, of course, more striking in cancer, but occurs to a mod-
erate degree in all forms of stricture. Foetor of the breath attends
dilatation of the oesophagus.
Emphysema of the subcutaneous connective tissue should always lead
to investigation of the oesophagus. Usually it is found to have been
preceded by pronounced symptoms of disease of the oesophagus. In
rare cases ulceration of the oesophagus may progress without symp-
toms, and extend into the air-passages. The passage of air through
the fistulous communication causes subcutaneous emphysema. It is of
frequent occurrence when foreign bodies lodge in the gullet.
Physical Examination. Examination of the oesophagus is made
by inspection and auscultation, and by means of palpation with or
without a bougie.
Inspection can be made only with an endoscope.
Auscultation of the oesophagus, while the patient is swallowing
fluids, sometimes confirms the results obtained by instrumental palpa-
tion as to the seat of an obstruction. A gurgling sound is audible to
the left of the spine as the fluid passes the obstruction.
Palpation. The oesophagus behind the trachea in the neck may be
palpated when it is enlarged, as in abscess. Palpation yields the
most positive results.
It must not be forgotten that the normal constriction of the oesoph-
agus is situated nearly opposite the fourth dorsal vertebra, ten inches
from the teeth. The bougie is used to determine the cause of diffi-
culty in swallowing. If the cause is due to paralysis or to spasm of
the oesophagus the bougie can usually be passed with ease. If, on
the other hand, it is due to organic disease, an obstruction will be
720 SPECIAL DIAGNOSIS.
found. In organic disease this is generally in the upper half of the
oesophagus. If near the pharynx, the obstruction is due to cicatricial
stricture. If the obstruction is encountered nine inches from the teeth
or about the position of the bronchus, it is usually due to cancer.
The bougie should not under any circumstances be passed if there are
grounds for believing there is an aneurism. Fatal rupture has fol-
lowed its passage under such circumstances.
Method. The patient should be seated with the head thrown back
sufficiently far to make the passage from the pharynx to the oesopha-
gus almost continuous. The operator may stand behind or in front of
the patient. The bougie, held like a pen, should be passed through
the pharynx, guided by the fingers, close to its posterior wall. But
little force should be used. It should be passed slowly, when the
gagging will soon be overcome. The bougie should be warmed and
oiled before it is introduced. The handles should be flexible, the bulb
olive-shaped.
Obstruction of the (Esophagus. Dysphagia is a symptom com-
mon to all diseases of the oesophagus. It may vary from simple pain-
dvsphagia to complete obstruction of the tube. Dysphagia from ob-
struction of the oesophagus is due (1) to disease outside of the canal
(external pressure), (2) to disease of the canal itself, and (3) to the pres-
ence of a foreign body in the canal. In the consideration of this symp-
tom, therefore, these conditions must be studied.
1. External Pressure. The oesophagus at different parts of its
course is in intimate relationship with the trachea, the thyroid gland,
the carotid artery, the left bronchus, the bronchial glands, the arch of
the aorta, and the descending aorta. Disease of these structures at-
tended by enlargement may, therefore, cause difficulty in swallowing.
It is not likely that difficulty of deglutition from disease of the trachea,
thyroid gland, or carotid arteries will be overlooked. If the trachea
is affected, dyspnoea will be a prominent symptom ; if the thyroid
gland, dyspnoea will be associated with dysphagia, and the enlarged
gland will be visible from the outside. Disease of the vertebra? is
not likely to cause obstruction of the oesophagus, for it would not press
that organ against any other solid structure. Disease of other struc-
tures, however," may cause difficulty of deglutition by pressing the
oesophagus against the vertebrae. Within the thorax, disease of the
mediastinal glands, aneurism of the arch, or descending portion of the
aorta, an enlarged left auricle, a pericardial effusion or disease of the
left bronchus might cause constriction of the oesophagus. The medi-
astinal glands are enlarged from tuberculosis, carcinoma, sarcoma, or
syphilitic disease. The occurrence of physical signs of a mediastinal
tumor, with a history of syphilis or the general symptoms of tuber-
culosis, sarcoma, or carcinoma, would point to the presence of these
affections. In aneurism of the aorta, in its arch or transverse portion,
the physical signs and subjective symptoms of aneurism — with accent-
uation of the aortic second sound and the presence of atheroma —
would lend color to the view that the obstruction was of this nature. In
both instances just mentioned the obstruction rarely goes to the extent
of preventing the passage of liquids. In enlargement of the left auri-
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 721
cle and in pericardial effusion the degree of difficulty may amount
simply to a temporary sense of obstruction or pain about the point
where food passes these structures. If the early physical signs are
associated with an enlarged auricle, with mitral stenosis, or with peri-
cardial effusion, the diagnosis of the causal condition is easy. It is
particularly important, in considering difficulty of deglutition from
external pressure, to remember that the oesophagus is in close relation
with the bronchus on the left side, at about the fourth dorsal vertebra
—ten inches from the teeth — in case it is desirable to investigate the
obstruction with a probe. Obstruction from aneurism of the descend-
ing portion of the arch of the aorta is also located at the upper portion
of the oesophagus, nine inches from the incisor teeth.
2. Organic Disease. Difficulty of deglutition, due to disease of
the oesophagus itself, occurs in acute inflammation, in chronic inflam-
mation, and in stricture, which is always the result of traumatic in-
flammation, syphilis, or cancer.
Acute inflammation is recognized by severe pain on swallowing. It
is associated with the sensation of a foreign body in the lower portion
of the throat. There may be tenderness on pressure along the course
of the pharynx. The pain is aggravated by speaking. The pain may
extend along the vertebral column to the cardiac end of the stomach,
and is usually of a burning or raw character. When the inflammation
is due to traumatism, as the swallowing of acids or other caustics, the
mouth and pharynx show the effects of the inflammation, and, in addi-
tion, there is agonizing, burning pain at the root of the neck and be-
tween the shoulders. The inflammation is usually attended by erosion
of the mucous membrane, and hence not only frothy mucus of a glairy
character is expectorated, but also blood and shreds of membrane.
The effect of the corrosive poisoning on the general system is marked.
There is great prostration. Because of the accompanying gastritis
there is intense thirst. Acute inflammation of the oesophagus may
end in ulceration or in resolution. The traumatic inflammation is
followed by chronic inflammation, which ultimately results in stricture.
Chronic inflammation is attended by pain in the act of swallowing ;
liquids are swallowed readily, but solids with great difficulty. Viscid
mucus is expectorated, usually in large amounts.
Abscess of the Oesophagus. The acute inflammation may terminate
in abscess. The abscess usually develops slowly, with pain on swal-
lowing and on movements of the neck. When the abscess is high
up in the gullet it may present on the exterior of the neck. If it is
situated outside of the oesophagus, and is secondary to disease of the
vertebrce, it is slow and chronic in its course ; fever and rigors attend
its development.
Stricture of the oesophagus due to the healing of ulcers, following
traumatic inflammation, is recognized, first, by the gradual development
of the symptoms, by the painless nature of the obstruction in the large
majority of cases, and by its seat. It is readily found by the use of a
bougie ; the patient can sometimes localize the area in the upper por-
tion of the oesophagus. The difficulty of deglutition continues over
such a long period of time that the nutrition is but slowly interfered
46
722 SPECIAL DIAGNOSIS.
with, but gradual emaciatiou with coincident anamiia develops eventu-
ally.
Carcinoma of the (Esophagus. In cancer of the oesophagus dys-
phagia is the most prominent symptom. It comes on gradually. The
patient expectorates a considerable quantity of frothy mucus, often
containing blood, and revealing, on careful examination, cancerous
tissue at times. Pain is not generally very severe. Cough is usually
present, due to pressure of the cancerous mass on the recurrent laryn-
geal or pneumogastric nerve. Sometimes the cancer develops in the
anterior wall, and ulcerates into the trachea or bronchus. When this
complication takes place the cough is violent. Dyspnoea from pressure
is likely to occur. Perforation of the oesophagus into the air-passages
is followed by pulmonary abscess or gangrene, or the sudden appear-
ance of dyspnoea, and shortly the onset of aspiration pneumonia.
"When ulceration causes a pulmonary oesophageal fistula the condition
may simulate that of phthisis.
The difficultv of deglutition due to cancer must be distinguished
from that of traumatic or syphilitic stricture and from spasmodic stric-
ture and paralysis of the oesophagus. The history of the case aids in
the recognition of traumatic or syphilitic stricture, while the ready
passage of a bougie indicates that the difficulty is spasm or paralysis.
Cancer usually occurs late in life and is attended with rapid emacia-
tion. Its complications, more common than in other obstructions, are
attended with fever and rapid prostration. Cancer may be distin-
guished from disease outside of the oesophagus by the condition of the
stomach beyond the point of stricture. If there is cancer, atrophy is
more likely to take place, the change in size being recognized by a
tube or by inflating the stomach with air or fluids.
Sarcoma of the oesophagus is very rare. It occurs most frequently
in males and presents symptoms like those of carcinoma.
3. Foreign Body. Stricture or difficulty of deglutition from the
presence of foreign bodies is usually recognized with ease. The diffi-
culty of deglutition is due both to the foreign body and to the spasm
excited by the mass. In consecmence of the latter regurgitation of
food takes place. In the first place, there is a history of the swal-
lowing of a foreign material. Sudden pain succeeds the act, while
there are great anxiety and distress, particularly if the body is a large,
hard mass. Xot only is there difficulty in deglutition, but also dysp-
noea. The latter is due to pressure, but is aggravated by the nervous
state. "When the foreign body is small the dysphagia is moderate in
degree and the reflex irritation slight, although nausea and vomiting
may be common. If it cannot be removed, ulceration and abscess
result, the further course of which depends upon the seat of the ob-
structing material. Pain, hemorrhage, subcutaneous emphysema, and
the emission of air are symptoms which follow. The exact location
of the foreign body may be ascertained by the use of the Eontgen rays,
as in the remarkable case of "White's.
Harrison Allen 1 , in his exhaustive essay, calls attention to several
1 "Foreign Bodies in the (Esophagus." Allen : New York Medical Journal, August
17, 1895.
DISEASES OF MOUTH, FAUCES, PHARYNX, CESOPHAGUS. 723
features. Many of the symptoms are primary and some are secondary.
The former are due to the trauma and the presence of the foreign body ;
the latter to the secondary ulceration. This softening and ulceration
of the walls may take place rapidly. Allen does not think that pain
or the occurrence of convulsions is of much significance, but that em-
physema, the excessive secretion of mucus, and the emission of air are
important signs. Anxiety he considers of very common occurrence
and very suggestive. The excessive secretion of ropy mucus, saliva-
tion included, is, in Allen's judgment, pathognomonic of disease in
the pharyngo-larynx or in the oesophagus, at or above the level of the
left bronchus. Tins secretion may be an early indication of cancer of
the oesophagus. It may occur in aneurism.
Dilatation of the (Esophagus. Primary dilatation of the oesopha-
gus is an extremely rare affection. The chief symptom is the regurgi-
tation of food, which is neutral or alkaline, and may be returned some
time after the act of swallowing. The patient sometimes complains of
a sensation of distention along the course of the oesophagus, with heat
and burning. The odor of the breath is foetid. If the oesophagus is
not deflected, a bougie can be passed through its course.
If the dilatation is secondary, the amount of dysphagia depends
upon the obstruction. Food, however, is not returned immediately.
After remaining an indefinite time, not longer than two hours, it is
regurgitated unchanged. Bougies, of course, do not pass. In saccu-
lated dilatation, which usually takes place in the posterior wall near
the pharynx, a bougie may sometimes pass, and at other times may be
caught in the sac. The sac may be enlarged, so as to retain a consid-
erable amount of food, which is regurgitated some time after it is swal-
lowed. A sacculated diverticulum, from traction on the outside of
the oesophagus, may occur when there is glandular disease of the neck,
with adhesions to the oesophagus.
Functional Affections of the (Esophagus. The functional affec-
tions are quite as common as organic disease. They are of longer
duration, but are unattended by the same grave effects upon the gen-
eral system. Spasm is one of the most frequent affections. It may
be so intense as to lead to temporary stricture. It usually occurs in
women. The attack comes on suddenly during the act of swallowing
food. The food is at once regurgitated. After the subsidence of the
perturbation, swallowing can be accomplished, if it is done slowly.
It usually occurs in hysteria. The patient may have had some slight
accident in the performance of the ordinary act of deglutition, out of
which grew the idea that swallowing cannot be accomplished. In
consequence, the further acts are performed with trepidation, and slight
emotional disturbance at the table may cause a recurrence of the sud-
den spasm.
Unfortunately calling attention to the act of swallowing always has
the effect of embarrassing the patient, and the taking of a meal under
unusual circumstances is sure to be attended by complete dysphagia.
Sometimes the idea is conceived that certain forms of food alone <"in-
not be swallowed. It is usually thought that solid food gives the
distress. Mitchell says that the dysphagia occurs early in cases of
724 SPECIAL DIAGNOSIS.
hysteria ; unless relieved, the hysterical symptoms are likely to be
transferred to the stomach. I saw a female patient who, after an
ordinary choking attack, for several years could not swallow food in
the presence of strangers, or after the slightest emotional disturbance,
or if hurried. The spasm disappeared after treatment with bougies.
In paralysis difficulty of deglutition is the main symptom. The
course of oesophageal paralysis depends upon its cause. The larynx is
usually affected at the same time, so that laryngeal symptoms are
present. Paralysis generally comes on very gradually. It may be
due to cerebral hemorrhage, tumor, bulbar paralysis, or to general
paralysis of the insane. The bougie passes easily, and does not cause
irritation. In paralysis there is no regurgitation of food.
PLATE XXXV.
w,
■Quadrants of the Abdomen. Position of the Viscera.
Liver and colon— red lines. Stomach, kidneys and bladder— solid green lines.
Pancreas— dotted green lines.
CHAPTER V.
DISEASES OF THE STOMACH, INTESTINES, AND PERITONEUM.
The abdomen is divided arbitrarily into regions, to enable us to
locate the various organs in health and in disease. Simplicity is essen-
tial, and a method of delimitation that is commonly used in the subdi-
vision of other regions should be adopted, for the sake of uniformity of
description and to assist the memory of the learner. For these reasons
Ballance's method of dividing the surface is the best. This author
includes the abdomen within a circle which has the umbilicus as its
centre. The circle is divided into quadrants by diameters drawn at
right angles, corresponding to the median and transverse umbilical
lines. The portions to the right of the middle lines are the right
upper and lower quadrants, respectively ; the portion to the left, the
left upper and lower quadrants. (See Plate XXXV.)
With the abdomen thus divided, the umbilicus and fixed bony struc-
tures in the periphery of the circle serve as points from which meas-
urements are made to indicate the exact position of the structure. The
circle may be further divided by other radii. To locate a tumor in
the right lower quadrant, for instance, the umbilicus, pubic bone, and
anterior spine of the ilium may be used as points from which to meas-
ure the distance. Measurements may also be made along the radii
extending from the umbilicus to fixed points. The following illus-
trates a useful method : A tumor is situated in the right lower quad-
rant ; the centre of the tumor is two inches below a point on the transverse
umbilical line, three inches from the centre ; it is also three inches
to the right of a point on the median line, two inches from the umbili-
cus. The size of the tumor can be defined by measurements from its
own centre. Organs bisected by the median line, as the bladder and
uterus, can be described as situated in the median line, so many inches
to the right and left, as the case may be, and so many inches from the
pubis.
The right upper quadrant includes the right lobe of the liver, the
gall-bladder, the hepatic flexure of the colon, and part of the trans-
verse colon, a portion of the pancreas, the pyloric orifice near the me-
dian line, and, deeper, the upper half of the kidney ; the left upper
quadrant, the left lobe of the liver, the stomach, part of the transverse
colon and the splenic flexure, the pancreas, the upper portion of the
kidney and the spleen ; the right lower quadrant, the caecum, the ascend-
ing colon, appendix vermiformis, right tube and ovary, a portion of
the bladder and uterus, and, above, the lower part of the kidney at the
end of full inspiration ; the left lower quadrant, the corresponding tube,
ovary, and portions of the bladder and uterus, the descending colon,
and the sigmoid flexure, but not likely the lower part of the kidney,
as it is one-half inch or more higher than the right (Holden). About
726 SPECIAL DIAGNOSIS.
the centre and extending to the periphery on all sides are the small and
large intestines.
The Data Obtained by Inquiry. The Subjective Symptoms
of Abdominal Disease.
This class of symptoms will be discussed in the articles devoted to
affections of the particular organs of the abdomen, because the symp-
toms are usually directly referred by the patient to the affected organs.
They are local sensations of heat, fulness, or distention, of burning,
of pain, of weight, or of undue motion. Local sensations of weight,
fulness, or distention are due to enlargements or to displacements of.
organs (liver, kidneys), or to tumors. Heat or burning is described
in inflammatory tumors, as pyosalpinx. It is often difficult for the
sufferer to define the location of pain in the abdomen and describe its
features. Moreover, the pain is frequently due to disease of the walls
of the abdomen, which may increase the confusion. Pain must be in-
vestigated by an examination of each structure in close proximity to
the part complained of. The state of the function of each organ must
also be inquired into.
Paix Confixed to the Abdominal Walls. The skin, the
nerves, the muscles and fascia, the connective tissue, may be the seat
of pain. If the skin is affected, the pain is usually localized and of
moderate degree of severity. There is superficial tenderness. There
are evidences of inflammation, as erythema or ulcers. Pain due to
affections of the nerves is seen in simple neuralgia and herpes zoster.
Herpes zoster is recognized by the localized neuralgic character of the
pain in the distribution of superficial nerves and the peculiar eruption
which follows. Xeuralgias are recognized by the well-known points
of tenderness, the intermittent character of the pain, and the association
with ansemia ; neuritis may be present, with the usual objective signs.
Rheumatism, The muscles and fascia may be the seat of rheuma-
tism, causing severe pain. The muscles are tender. Movement always
increases the pain, and sighing, laughing, or coughing aggravates it.
The pain may be diffuse and severe, causing it to be confounded with
peritonitis. The presence of rheumatism in other muscles, of moderate
fever without gastro-intestinal disturbance, of uric acid and urates in
excess, due to the rheumatic diathesis, point to the true condition.
Referred Paix. A common cause of pain in the abdomen is dis-
ease of the vertebra?, with pressure upon the peripheral nerves at their
emergence from the spinal column. The pain is situated in the median
line, either below the ensiform cartilage or around the navel ; it is an
intermittent pain. Aneurism of the abdominal aorta, with pressure
upon and erosion of the vertebrae, causes the same kind of pain.
Paix withix the Abdomex. The seat of the pain, if general or
local, will be considered in discussing the special organs and their
diseases. In general, it may be said that the seat of the pain is a fair
index of disease of some structure in the part indicated. When the
pain is general it points to rheumatism or to peritonitis.
Charade- of Pair). Attacks of severe pain in the abdomen may be
sudden in onset, or the culmination of slight sensations of discomfort
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 727
progressively increasing in severity. The pain may be of brief dura-
tion or may continue over a long period of time. Sudden acute pain
points to inflammation, to perforation of some one of the hollow viscera,
to gastralgia, to enteralgia, flatulent distention of the stomach or of
the intestines, or to occlusion of channels, of which the abdomen
contains so many. Attacks of sudden pain are spoken of as colic ;
the onset is sudden ; the pain is paroxysmal ; each spasm of pain may
be attended by vomiting, rapid pulse, cold extremities, cold sweat, and
more or less collapse, except in lead-colic. Such pain is seen in intes-
tinal colic, hepatic colic, renal colic, and in uterine and vesical colic.
Sudden acute pain occurs in 'perforation of some one of the hollow
viscera, indicated by the history and location of the disease of the part
affected and the character of the symptoms attending the pain. Thus,
in a case of gastric ulcer, sudden pain indicates possible perforation,
which may take place in the course of the disease. Chronic pain points
to ulcer, to chronic processes, or to gastric or intestinal neurosis.
The Data Obtained by Observation.
The Objective Symptoms. It must be remembered that objective
symptoms of abdominal change are not alone due to disease of the ab-
dominal contents, but also to disease elsewhere. Thus the abdomen
may be enlarged from the ascites of cardiac or renal disease, contracted
in tuberculous meningitis.
Disease or paralysis of the diaphragm alters the appearance of the
upper half of the abdomen and its movements in respiration. Fluctu-
ating changes in size occur in hysteria and gastric neurasthenia, and
permanent change in tuberculous meningitis.
Inspection. We note the appearance of the abdominal walls, the
movements of the abdomen, its general shape and size,local enlargements.
The Abdominal Walls. A glance suffices to tell of the thick-
ness of the abdominal walls. Thin walls are due to absence of adipose
tissue and of muscular structure associated with general atrophy (see
Emaciation), on the one hand, or sometimes in consequence of intra-
abdominal pressure. Frequent pregnancies, previous ascites or ante-
cedent growths (ovarian tumor) lead to atrophy of the muscles ; the
recti separate and hernia-like protrusion of abdominal contents results.
Furthermore, a conical projection of the lower median portion of the
abdomen is brought about, especially if ascites is present. Such pro-
jections are often confusing when tapping is to be resorted to. Thick
walls are due to oedema or to increase in fat.
The Color. The abdomen, in general, partakes of the hue of the
skin. It is darker around the umbilicus. In Addison's disease a dis-
tinct areola often forms. The median line, from the umbilicus to the
pubis, darkens in pregnancy — the " brown line." It is sometimes
seen in men. The skin of the abdomen is the seat of specific erup-
tions, as in typhoid fever, and of sudamina. The Avails may be pale
and glistening in oedema.
Markings. In first pregnancies and great ascites, less frequently in
obesity and tumors, strice arc produced in the parts of the skin where
728 SPECIAL DIAGNOSIS.
the tension has been greatest. In pregnancy they form sinuous lines
upon the lower lateral portions of the abdominal wall and upon the
upper inner portions of the thighs. When first developed they are red-
dish, but subsequently become, by a process of fading, more glistening
and white than the rest of the skin. They are also known as " water
lines," and linece albicantes. Rarely they are seen after typhoid fever.
The umbilicus may project from hernia or may be prominent in
ascites. The veins about the umbilicus are often enlarged in cirrhosis
even to such an extent as to produce a large soft tumor, the caput
Medusae. Not infrequently the walls around the umbilicus are infil-
trated with carcinoma, occurring secondarily to gastric carcinoma.
In tuberculous peritonitis, as pointed out by Henry, this infiltration,
more inflammatory, however, is seen. Removal of such nodules for
microscopical study often establishes a correct diagnosis of the internal
disease.
Glands. Sometimes isolated lymphatic glands are seen in the ab-
dominal wall. They may be utilized by a microscopical examination
to confirm any suspicion of malignant disease.
The Veins. Enlargement of the superficial veins is a common
accompaniment of cirrhosis of the liver, adhesive pyelophlebitis, and
of any cause which obstructs the free circulation in the inferior vena
cava. In order to complete the collateral circulation they may anasto-
mose with the mammary veins above or the epigastric veins below.
The caput Medusce has already been described.
The Movements. (See the Lungs — Dyspnoea.) The movements of
the abdomen are of respiratory, vascular, gastric, and intestinal origin.
Much is learned by carefully observing them.
Respiratory Movements. The upper half of the abdomen swells or
rises synchronously with inspiration. In enlargement of the abdomen
and in tumors within the upper half the movement is restricted. In
paralysis of the diaphragm it falls in with inspiration, reversing the
normal movement. If such paralysis is limited to one side, as in large
pleural effusions, the inspiratory collapse is unilateral. In laryngeal
and tracheal obstruction, inspiratory retraction is noteworthy and its
extent significant of the amount of obstruction. Respiratory move-
ment causes the liver to rise and fall. In persons with thin walls, its
shadow can be seen to descend with inspiration, the extent indicating
the degree of respiratory expansion, the size and position of the liver.
Such information is of great value. A tumor connected with the liver
and an enlarged gall-bladder will move synchronously with respira-
tion. Other growths are fixed, unless adherent to the liver. Rarely
an exception is seen in movable right kidney.
Vascular Movements. They are noted in the median line and usually
in the upper half of the abdomen. In moderately thin subjects the
aorta may be the cause of such pulsation. (See Epigastric Pulsation.)
If the pulsation is wide and extends to the right or left of the median
line, an aneurism may be suspected, or the impulse may be trans-
mitted to a growth overlying the aorta, as a carcinoma of the stomach.
Aneurism of the coeliac axis will give rise to a movement near the
umbilicus and to the right or left of the median line. Pulsation of the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 729
liver, of vascular origin, and hence rhythmical with cardiac pulsation
is seen in the hepatic area in right-sided dilatation of the heart,
Gastric and Intestinal Movements. Peristaltic movement, either of the
stomach, the large or the small intestine, may be seen through the
abdominal walls. In gastric dilatation and gastroptosis the waves may
be seen in rhythmical succession, from left to right, in the centre of
the abdomen. Their general course may be from the left upper to the
lower right quadrant. If of the large intestine, the waves are confined
to the course of this canal ; if in the small intestine, to the region around
the umbilicus. It is due to obstruction of the pylorus, if gastric, or
of the lumen of the bowels if intestinal. The application of a cold
napkin will excite the movements.
The Shape. In general enlargement the shape is uniform. In
large accumulations of fat, in women with relaxed abdominal walls,
the abdomen may be pendulous. In ascites the tissue over the umbil-
icus may protrude, changing the uniform appearance. Abdominal
enlargements due to ascites, in women whose abdominal walls have
previously been relaxed, sometimes assume a peculiar cone-shape ; the
base corresponding to the plane of the abdomen, the apex rising below
the umbilicus. This is particularly the case if the patient has had to
assume the semi-erect position for some time. It is often difficult to
decide where to tap in such cases. In local enlargements the surface
is often irregular, the prominences corresponding to the seat of the
enlargement. The shape changes in hysterical distention. In enlarge-
ment due to wasting disease of the viscera, as cancer of the retroperi-
toneal glands, the abdomen retracts in the later stage of the disease,
causing undue prominence of the viscera affected.
Gexeral Exlargemext of the Abdomex. The abdomen
differs very much in size in different persons, depending not only upon
the thickness of the fat in the abdominal walls and omentum, but
upon the calibre of the intestines themselves, which are apt to be much
distended in those accustomed to eat large meals. In general, the
belly is more protuberant in infants and children than in adults.
Enlargement occurs in obesity, and it is often difficult to tell whether
the excessive deposit of fat in the abdominal walls and omentum
accounts for the whole enlargement or only serves to mask the presence
of a tumor. Enlargement of the belly is only a part, though fre-
quently the most pronounced evidence of obesity ; whereas, in enlarge-
ments of the abdomen from tumors and ascites, there is usually a
marked contrast between the size of the abdomen and that of the rest
of the body.
Ascites.
In enlargement from ascites, when the patient is lying upon his back,
the front of the abdomen is flattened, while the flanks bulge. If he
turns upon his side, the flank which is uppermost becomes hollowed
out and the front of the belly is prominent. This is the appearance in
moderately large effusions which have existed long enough to stretch
the lateral abdominal muscles. When the effusion is enormous all
parts of the belly are distended, and the abdomen is barrel-shaped ;
no change of shape occurs upon change of posture.
730 SPECIAL DIAGNOSIS.
Ascites is the accumulation of fluid in the peritoneal cavity. The
causes may be local or general. Its local origin may be, first, simple,
cancerous, or tuberculous inflammation of the peritoneum ; second,
portal obstruction from disease of the liver, as cirrhosis, or disease of the
portal veins, either from compression or inflammation. Tumors of the
abdomen are often attended by ascites, particularly solid tumors of the
ovary. The general causes of ascites are those which give rise to dropsy.
Physical Signs. (Plate XXXVI.) Inspection. The abdomen is
uniformily enlarged. The surface is usually smooth. The skin is
tense if the effusion is large, and linece albicantes may be seen. The
navel may project. If the ascites is due to liver disease or disease of
the portal vein, the superficial veins enlarge, although the enlargement
is sometimes seen when any effusion continues a long period of time.
Palpation. On palpation fluctuation can usually be detected. Care
must be taken not to confound the wave of the abdominal walls,
produced by percussion, with the wave of true fluctuation ; the former
must be cut off by the hand of an assistant placed vertically in the
median line. The left hand should be applied firmly against one side
of the abdomen, while with the right percussion or tapping is gently
performed at the opposite point. The points selected should be at
about the level of the fluid. At first the hand should be placed on the
flank, and if the fluctuation is not revealed, then with each successive
percussion it should be brought forward toward the median line.
Sometimes light percussion will yield the sign, at others more firm per-
cussion must be employed. The faintest tap may be sufficient. In
order to ascertain the position of solid organs in ascites, dipping is em-
ployed. This consists in suddenly pressing the tips of the fingers over
the organ sought for. The fluid is thus displaced and the edge or
surface of the organ readily felt.
When the abdomen is percussed in the usual manner there is dulness
over the fluid. As the fluid gravitates to dependent portions the dul-
ness is found in these parts. Sometimes the colon gives rise to tym-
pany in the flanks, as pointed out by Tyson. When the patient is
lying down, it is in the flanks, and may extend arouud the lower por-
tion of the abdomen. If the patient stands up, the dulness may reach
to the umbilicus in the median line and to the same level in the mid-
clavicular . line.
Aspiration In ascites it is important to ascertain the nature of the
fluid. This can only be clone by aspiration. If the fluid is serous, it
has the characteristics belonging to that fluid. Hemorrhagic effusions
usually occur in cancer and 1 tuberculosis, although both of these dis-
eases may occur with clear serum. In ruptured tubal pregnancy the
effusion is hemorrhagic. In rare cases a chylous, milky fluid is found
in disease of the lymphatics. In one instance this occurred from per-
foration of the thoracic duct. Chylous ascites may, however, be due
to an excessive milk-diet. In other instances it is due to filaria. The
patient on a mik-diet is often lipsemic, in consequence of which effu-
sions are made turbid.
The sub/erf ire symptoms are those due to the cause of the ascites and
to mechanical pressure.
PLATE XXXVI.
Ascites.
Blue shading shows level of dulness in recumbent posture. Dotted lines
indicate change of level of fluid in other postures.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 731
Ascites must be distinguished from enlargement of the abdomen due
to ovarian tumor, enlargement due to pregnancy, and enlargement due
to an overdistended bladder. In ovarian tumor the development at
Fig. 188.
Ascites. Upper limits of duluess indicated by the dotted line. Umbilicus prominent.
first takes place to the right or left of the median line. When large
the signs may be in the central region of the abdomen. The flanks,
however, are always tympanitic on percussion. On vaginal ex-
FlG. 189.
Ascites from sarcoma of ovary. Dislocation of liver and spleen. X is apex beat, not lifted
because of fallen abdominal organs.
animation the local disease may be ascertained. A distended bladder
should always be thought of, and catheterization performed in doubt-
ful cases. Cysts of the pancreas may be mistaken for ascites, and
732
SPECIAL DIAGNOSIS.
large hydatid cysts connected with the liver may simulate an accumu-
lation of fluid in the peritoneal cavity. The history and the appear-
ance of the fluid on aspiration point to the diagnosis.
Enlargement from accumulation of gas within the bowels is gen-
eral, and may attain a very high degree, giving the abdomen a uni-
form arched appearance resembling a barrel. The diaphragm may be
pressed upward so far as to interfere seriously with respiration and
heart-action. In debilitated children the enlargement due to flatulency
is associated with flaccid abdominal walls, causing lateral and central
enlargement. Moderate degrees of distention from gas in the intes-
tines may be the result of eating certain articles of food, such as tur-
nips or beans. Excessive accumulations are met with in typhoid
fever ; peritonitis, operative and non-operative ; and in stenosis of the
colon or rectum from any cause. They are also common in hysteria.
In the last month or two of pregnancy enlargement of the abdomen
is general, especially in a woman who has previously borne children.
General enlargement of the abdomen may be due also to fecal accu-
mulation, cancer of the peritoneum, to hydatid cyst, and to cancer of the
bowel.
It has been observed in children in dilatation of the colon. The dila-
tation may take place temporarily in constipation with obstruction. In
rare cases it may become permanent. In such the distention of the
abdomen is enormous. It often begins in childhood and continues
through adult life. Congenital obstruction, the eating of oatmeal and
similar food, with attendant constipation are causes. The bowels are
constipated. The constipation may continue for several weeks, during
which period there is increasing dulness in the tract of the colon, with
Fig. 190.
Case of dilatation of colon. (Griffith )
fecal tumors distinguished by palpation. This condition is relieved
by diarrhoea, which may continue for two or three days, during which
enormous amounts of feces are passed. It may be preceded by vomit-
ing\>f a fecal character. After the bowels are open the distention
continues, the dulness being replaced by tympany. The abdomen was
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 733
uniformly enlarged in Hughes' and Osier's cases. Coils of the intes-
tine, with waves of peristalsis, were seen through the thin abdominal
walls. Formad's patient was an adult. It must be remembered, as
described on page 729, intestinal peristalsis is observed in constriction
of the bowels. The motion of the intestine above the seat of stricture
is wave-like or worm-like, and the bowel itself dilated.
From a consideration of the recorded cases of so-called idiopathic
dilatation of the colon, Treves believes that, although enormous dilata-
tion of the large intestine may undoubtedly occur in adults indepen-
dently of mechanical obstruction, in children it is probably due to
congenital defects in the terminal part of the bowel.
Enlargement of the abdomen simulating ascites may be due to retro-
peritoneal and peritoneal lipomata. Fluctuation even may be detected,
but repeated puncture fails to secure fluid ; the negative aspiration
should always suggest lipoma. This is all the more likely if the en-
larged abdomen is due to a slowly growing tumor, which is probably
more visible on one side than the other, but which causes little if any
general disturbance except progressive emaciation, dyspnoea, and some-
times oedema of the legs. The tumor is usually crossed by a portion
of the intestine.
Other causes of abdominal enlargement are diseases of the liver and
gall- bladder. When these are enlarged a local swelling may be de-
tected in the right upper quadrant ; but when they attain very large
dimensions, as happens not infrequently in cancer, amyloid disease,
and hydatid liver, inspection may be able to detect only general en-
largement, with small prominences corresponding with cancerous nod-
ules or small cysts.
Splenic enlargements, which attain the greatest size, are from leu-
kaemia or chronic malarial poisoning, and are usually visible only as
general enlargements of the belly. There may, however, be greater
prominence over the lower left ribs and in the left upper quadrant
posteriorly.
In diseases of the kidney producing great enlargement there is usu-
ally visible a prominence in the lateral and lumbar region of the side
corresponding with the kidney involved, unless there is considerable
emaciation ; anteriorly the enlargement, if any be visible, usually
appears to be general.
Enlargements of the abdomen which begin in the lower quadrants
are usually of pelvic origin. The most common are those due to preg-
nancy, retroperitoneal sarcoma, cysts of the ovary or parovarium, fibroids
and fibro-cysts of the uterus, and abscesses or effusions (chronic perito-
nitis). A greatly distended bladder may cause confusion ; it is a good
rule to be sure that the bladder is empty, by having a catheter passed
before proceeding further with the examination.
Local Enlargement or Tumors of the Abdomen. In the
space below the xiphoid cartilage and between the ribs (epigastrium)
local enlargements may be due to a distended or dilated stomach or to
a tumor of the pylorus, which is almost always cancerous. Promi-
nence in this region is seen in large eaters. But enlargement in this
region is sometimes due to cysts, sclerosis or cancer of the pancreas,
734 SPECIAL DIAGNOSIS.
to aneurisms, to cancer of the large intestine or tumor of the left lobe
of the liver. It is in this region or to the left of the median line and
nearer the umbilicus that the effusions into the lesser peritoneal cavity
are found.
A rigid rectus muscle is capable of simulating a tumor. Likewise,
in hysterical subjects, rigid abdominal muscles, with tympanites, give
rise to a swelling known as " phantom tumor." Such swellings are
less constant in shape and character than genuine tumors, and although
dull on percussion appear more superficial ; they sometimes disappear
under friction with the hand, and certainly under full anaesthesia ; the
stigmata of hysteria are present.
Enlargements in the right upper quadrant (right hypochondrium)
are most frequently due to diseases of the liver {q. v.) and to affections
of the gall-bladder. Less frequently, a much enlarged kidney or a
hydronephrosis causes swelling in this region. The differential diag-
nosis is made by the history of the case and by noting the direction in
which the tumor has grown, by examination of the urine, and by the
relation which the ascending colon bears to the tumor ; kidney tumors
carry it in front of them as they grow ; hence, their dulness is obscured
by the superficial tympany of the colon.
Primary malignant disease of the suprarenal bodies — a rare affec-
tion — is often attended by a tumor in the upper abdomen (Ptolleston
and Marks, American Journal of the Medical Sciences, 1898.) The
clinical picture is not one of Addison's disease even when both the
organs are invaded. Some of the symptoms occur partially, as pig-
mentation, vomiting, asthenia, pain in the back. The growth extends
forward, and resembles in many respects renal tumor. It also, how-
ever, may resemble tumors of the liver, enlarged gall-bladder, or pan-
creatic cyst.
Enlargement in the right hirer quadrant (right iliac region) is most
frequently due to affections of the csecum and appendix, to tumors of
the ovary, and to pelvic abscesses.
The diseases of the ccecum and appendix causing enlargement in the
right iliac fossa are fecal accumulation, typhlitis, fecal abscess, peri-
typhlitic abscess, carcinoma, and stricture of the ileo-csecal valve.
The diseases of the ovaries and tubes causing enlargement in this
region are ovarian tumors, cysts of the broad ligament, pelvic abscess
(usually tubal in origin), and extra-uterine pregnancy.
Other affections which need to be considered are tubercular peri-
tonitis, acute and chronic, and enlarged or movable kidney.
Enlargement in the left upper quadrant (left hypochondriac region)
is due to dilatation or carcinoma of the stomach ; enlargement of the
spleen, movable kidney, or tumors of the kidneys, and effusion in the
lesser peritoneal cavity. Enlargement in the left lower quadrant (left
iliac region) is due to tumors (cancerous) of the sigmoid flexure and to
the tumor due to volvulus, and to the same causes of enlargement of
the right side which are possible on the left.
Enlargement about the centre of the abdomen (umbilical region) may
be due to umbilical hernia, to a floating kidney, spleen, or liver, or to
tubercular disease of the omentum or mesenteric glands. It is seen
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 735
in retroperitoneal sarcoma. It is seen in cases of dilatation after a full
meal. This region is frequently enlarged, in conjunction with a more
prominent swelling extending from the sternum, in cancer of the stom-
ach ; and from the ribs on the right in cancer of the liver or gall-
bladder, or other diseases of these viscera ; from the ribs on the left, in
effusions into the lesser peritoneal cavity, disease of the pancreas or
the spleen.
Undue projection of the vertebrae must not be mistaken for tumors.
Enlargement above the pubis (hypogastric region) is due most fre-
quently to enlargement of the uterus from pregnancy, fibroid tumors,
or fibro-cysts, or to distention of the bladder ; but it is also common
in gastric dilatation and gastroptosis ; flattening of the upper half is
then seen, and the lesser curvature is then made out.
Enlargement in the lateral regions and behind {lumbar region) may
occur in malignant tumors of the kidney, in hydronephrosis and
pyonephrosis, in perinephritic abscess, and in renal cysts of large size.
Usually renal enlargements of any kind are not observed behind,
however. It may also, in the left side, be due to perigastric sub-
diaphragmatic abscess and to enlargement and displacement of the
spleen. On the right side the cause may be enlargement of the liver,
or a hydatid cyst, or a retroperitoneal sarcoma.
Diminution in Size. The abdomen is diminished in size in
wasting diseases, or such as result in insufficient food being taken.
This class comprises cancer of the oesophagus and stomach, chronic
lead-poisoning, anorexia nervosa, and chronic diarrhoea and tubercu-
losis of childhood. In the second stage of tubercular meningitis in
children there is retraction of the abdomen. The wasting of the sub-
cutaneous and the omental fat and atrophy of the abdominal organs
cause the abdomen to be concave or scaphoid.
Palpation and Percussion of the Abdomen. Palpation and per-
cussion in diseases of the abdomen may be discussed together.
Position of Patient. Generally the best position is the recumbent
one, because it admits of examination without too great exposure, and
because in that position the abdominal muscles are partly relaxed.
When the muscles need to be still further relaxed the patient should
lie upon the back, with the head and thorax partly elevated and the
knees drawn up. In certain obscure tumors much can be learned by
having the patient rest on the hands and knees, or assume a knee-
chest position. By this means we can determine if the pulsation is
due to aneurism or to a tumor. The latter falls away from the vessels,
and hence pulsation is lessened thereby in the knee-chest position.
A tumor surrounded by coils of intestine may thus become more pal-
pable. A good plan to secure relaxation for palpation of the liver
and spleen is to have the patient sit on a chair with the body leaning
forward ; then flex the thighs, supporting the feet on a stool 'or the
rung of another chair.
Method! The examining hand should be warm, as the application
of a cold hand throws the abdominal muscles into involuntary contrac-
tion. By grasping the abdominal walls between the thumb and fingers
their thickness and the relative proportion of fat can be estimated.
736 SPECIAL DIAGNOSIS.
So, too, the presence or absence of oedema of the skin can be readily
detected. This oedema is general, but is especially marked in the
lateral and posterior portions of the abdomen. Relaxed abdominal
walls occur after dropsy and pregnancy. Redundant skin remains
in folds when pinched up. This is particularly so in abdominal
cancer.
When it is desired to explore deeply the patient should be instructed
to breathe with the mouth open, and the examining hand pressed
firmly in during respiration, and held there, if need be, during several
long respirations. The palm of the hand should be laid upon the sur-
face ; after the muscles are relaxed the flexed fingers may be used to
palpate. The same procedure is adopted when we desire to get the
percussion-note of a body lying deep in the abdomen : the finger is
pressed firmly and deeply in, and then percussed. In this way any
superficial resonance due to overlying intestine is largely eliminated.
When palpating to determine the lower edge of the liver or spleen
the palmar surface of the fingers is pressed into the abdomen at differ-
ent levels from below upward until the edge is felt. The edge of
the right lobe of the liver in its normal position extends to the margin
of the ribs. It may be detected by pressing the fingers in as de-
scribed and having the patient take a long breath.
By palpation the information obtained by inspection is confirmed ;
the character of the abdominal walls and of swellings is determined ;
the precise location of pain is ascertained ; the condition at the hernial
rings and the movability of tumors are investigated. The condition
of the integument should first be determined. Passing the hand gently
over it is sufficient to decide whether it is normal, smooth and elastic,
or harsh and dry. Any marked unevenness, such as is produced by
umbilical and inguinal hernia, by strise, or by large tumors of the
pylorus, or cancerous nodules, and hydatid cysts of the liver, can
readily be detected. The degree of tension of the abdominal walls is
easily appreciated. It is increased, of course, in all forms of great en-
largement, but not equally ; some persons are so sensitive to touch
that any attempt at palpation throws the abdominal muscles into such
rigid contraction that examination is impossible. Rigidity of the
abdominal walls may be the only sign of acute peritonitis. It is com-
mon in local peritonitis. The recti muscles contract quickly on hurried
palpation. Local contractions point to inflammation underneath. In
tuberculous peritonitis we see distention with board-like rigidity or
preternatural hardness. The term carreau is used by the French for
this condition. Peritoneal friction may be detected most frequently
over the liver and in chronic peritonitis.
Palpation and Percussion of the Lower Quadrants. On
the right side, the groups of affections connected with the csecuni and
appendix, the uterine appendages, and the peritoneum, which cause
enlargement in this region, have been mentioned already under local
inspection of the abdomen. Palpation and percussion, however, are
the methods which afford the most exact information of their physical
characteristics, and, with the clinical history, enable us to distinguish
one from the other.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 737
Diseases of the Appendix and Ctecum. The information supplied by
palpation and percussion in perforation of the appendix will depend
upon the rapidity with which perforation has supervened and upon
the stage at which the examination is made.
Generally speaking, after the sudden onset of pain in the right iliac
fossa, in a person previously in good health, there is tenderness on
palpation in that region. This tenderness is first localized, but may
spread with great rapidity over the whole abdomen. Or the tender-
ness may at first be general, and subsequently become localized over the
appendix. Subsequently, the tension in the part is increased, the over-
lying abdominal muscles are rigid (spasm) and firm, and the percussion-
resonance impaired. Examination with the finger in the rectum may
discover a tense, swollen appendix, or a tumor in the pelvis.
But the disease may be fulminating in character, perforation being
followed by the rapid development of peritonitis, with collapse, so
that when the patient is seen there will be no more tenderness over
one part of the abdomen than over another.
Again, the appendix may be subject to repeated attacks of inflam-
mation without perforation, but with the development of local peri-
tonitis. There is increased thickness in the region of the crecum,
tenderness, diminished resonance, and increased resistance to the
percussed finger. Sometimes an enlarged and hardened appendix can
be made out by palpation, both during an attack and in the intervals.
In still other cases, of slower development, a distinct perityphlitic
abscess develops. In addition to local pain and tenderness a swelling
appears above Poupart's ligament. The skin over it becomes brawny
and pits on pressure with the finger-tips. The tumor is dull on percus-
sion, and on palpation obscure deep-seated fluctuation may be secured.
A fluctuating tumor may also be made out by rectal examination with
the finger.
In fecal impaction of the ccecwn a tumor forms, following the course
of the crecuni, and directed upward from Poupart's ligament. It is
usually oblong and rounded, and may appear uneven or lumpy on
closer palpation ; it is not tender unless the csecum itself becomes in-
flamed. It has a doughy consistency. Fecal tumors give rise to
some distention of the abdomen. To distinguish these tumors from
solid growths, Gersuny calls attention to the "adhesive symptom."
If strong pressure is slowly made with the finger tips on the tumor,
and then the pressure be withdrawn gradually and the hand removed
from the abdomen, a peculiar sensation due to the separation of the
intestinal mucous membrane from the fecal matter is transmitted to
the hand. If the feces are dry and hard, the sensation may not be
observed until an oil enema is used. When the feces are soft natur-
ally or artificially, the tissues remain depressed and only gradually
separate from the mass and return to their normal position. Slowness
of the separation of the abdominal walls from the tumor is also charac-
teristic of the fecal accumulation. The diagnosis is made by the situ-
ation and character of the tumor, and the absence of pain, tenderness,
and constitutional symptoms, and by its disappearance under the influ-
ence of purgatives.
47
738 SPECIAL DIAGNOSIS.
If the impaction causes a localized colitis, or so-called typhlitis, the
tumor is tense, tender, and painful, dull on percussion, the dulness
being sharply limited by the boundaries of the caecum.
Appendicitis.
This is by far the most important affection of the intestinal tract.
It is of frequent occurrence compared with intestinal obstruction, and,
if recognized, is amenable to relief in a very large percentage of the
cases ; whereas intestinal obstruction is more frequently fatal. We
see twenty-five cases, at least, of appendicitis in all its forms to one
case of any form of obstruction. Its importance, therefore, is readily
recognized. Appendicitis occurs most frequently in the young — in
the large proportion of cases under thirty. I have seen it as early as
two years of age, although from the fifteenth to the thirtieth year it
is more frequent than at any other period. The symptoms vary, but
clinically may be divided into those of appendicitis without perforation
and appendicitis with perforation. Appendicitis without perforation
is characterized by relapses, and is known also as recurring appendicitis.
Appendicitis without Perforation. Cases of catarrhal appen-
dicitis probably occur, although I am not prepared to say that
catarrhal inflammation of the appendix gives rise to marked local
symptoms, for in cases on the post-mortem table in which the lesions
of catarrh were found there had not been any symptoms during life,
due either to intestinal catarrh or to any symptoms pointing to appen-
dicitis in any form. Moreover, many cases in which the attacks of
appendicitis had at first been slight, finally developed into appendicitis
with perforation. In the milder cases, if operative measures are re-
sorted to during the intervals between the attacks, the appendix is
always found to contain a fluid loaded with micro-organisms which
are capable of causing purulent inflammation, as the staphylococcus or
streptococcus. Clinically, therefore, all forms of appendicitis should
be considered infectious, with, on the one hand, escape of the contents
into the bowel, and natural relief of the symptoms ; or, on the other,
complete obstruction with perforation. After removal of the appendix
in cases of recurring appendicitis, I have always found pus or a muco-
purulent material which was charged with streptococci or staphylococci,
as well as the bacillus coli communis, natural to the intestinal canal
in this region.
Symptoms of the Attack. After exposure to cold rarely, fre-
quently after an indiscretion in. diet, the patient is seized with pain,
referred to the right lower quadrant of the abdomen. It is paroxysmal
in character, increasing in intensity, and may be complained of as
colicky. The pain is usually such as to require the patient to take to
bed and attempt to secure relief by local applications. The severity
of the pain may be so slight that the patient pays but little attention
to it. He may even go about his business during the time and seek
professional advice at the office of a physician. Such cases as these
are attributed to ordinary cholera morbus or intestinal indigestion.
The attack may be only moderately severe, particularly if there is
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 739
diarrhoea. With the onset of the pain vomiting usually occurs. The
bowels may be open or they may be confined. Vomiting may not
occur if there is diarrhoea. It is usually attended by some nausea,
although this is not marked. The vomiting is complete, there is no
retching. It occurs at intervals, between which there is comparative
comfort. The contents of the stomach are ejected, and then mucus.
If the patients are to get well, vomiting does not return unless ex-
cited by food. If peritonitis supervenes, vomiting returns in the course
of two or three days. If in bed, the patient lies on his back with
his right leg flexed.
Even with a mild degree of pain the skin is hot and temperature
slightly raised. In the cases in which the pain is more severe the
general reaction is greater. The temperature rises rapidly to 102° to
103°. The skin is hot and dry, the face flushed. The pulse in a
young adult rises to 90 and 95. It is full and strong. On account
of the pain there is some restlessness. In some cases the patient corn-
plains more of the fever than of the pain after its first severity has
subsided. The tongue is coated ; appetite is lost.
On physical examination the area which was the seat of pain is
found to be tender. When examined with the tip of the finger press-
ing firmly, a point of more marked tenderness can usually be found
on a line midway between the anterior superior spine of the ilium and
the umbilicus. It is known as McBurney's point, and is most charac-
teristic. It indicates the site of the diseased appendix. The swollen
tender appendix may occasionally be palpable. On inspection the
affected area is slightly or may be considerably enlarged. Comparison
must be made with the opposite side. It will be seen that the usual
depression in front of the anterior spine, or the cavity toward the loin,
is not so deep as on the opposite side. In front the surface may be
even with the plane of the ilium. On palpation, in addition to ten-
derness and pain at the point previously indicated, fulness and en-
largement can be distinguished. There is resistance to pressure and
more or less rigidity of the abdominal muscles. On careful measure-
ment the semi-circumference will be found in most instances to be
larger than the semi-circumference of the opposite side. When
bimanual palpation is performed, the left hand being placed in the
loin behind and the right over the abdominal surface, resistance, in-
duration, and rigidity can more easily be detected. On percussion
there is change in the note compared with that of the opposite side,
and change in the percussion-note during the course of the disease.
This is particularly the case if the symptoms go on to perforation.
On careful deep percussion a dull tympanitic tone is elicited, or a
distinct area of dulness can be mapped out, but in some instances the
distended csecum yields tympany, which is greater than on the opposite
side.
The pain, is usually referred to the region above mentioned. The
pain may be in the lower quadrant on the left side instead of the right.
It is seen in those cases in which the appendix normally dips into the
pelvis. It may also be referred to the bladder or genitals, and be
attended with vesical tenesmus and frequent micturition. The char-
740 SPECIAL DIAGNOSIS.
acter of the pain and the bladder symptoms are such as to simulate an
attack of renal colic, with the passage of sand. On account of the
locality of the pain it may be attributed to the Fallopian tube or ovary,
and thought to be due either to pain on account of disease of these
organs or to dysmenorrhea. It is not likely to be mistaken for the
pain of dysmenorrhea if the patient is subject to pain at the usual
monthly period. If, however, the physiological and the pathological
affection should take place at the same time, or the latter occur about
the time of the monthly period, a mistake in diagnosis may occur,
particularly as increased abdominal pain may cause a uterine discharge.
The occurrence of fever would exclude dysmenorrhoea in cases in
which this symptom was present. The pain and leg-flexion simulate
hip-joint disease.
After the first twenty-four hours, during which the above-mentioned
symptoms described take place, the fever continues. There is anorexia,
but vomiting occurs only at long intervals if at all. The local symp-
toms continue, although modified usually by methods of treatment which
are applied. Both general and local symptoms frequently subside after
a free movement of the bowels, which occasionally takes place sponta-
neously. In other cases constipation continues a week or ten days,
and even over a longer period.
After five or six days at the furthest the fever subsides, the local
distention lessens, the paroxysms of pain disappear, and convalescence
ensues. There may, however, be localized tenderness for a consider-
able period of time, and diarrhoea, or at least two or three evacuations
each day, for a week or more. In rare instances peritonitis supervenes
without the occurrence of perforation. Its onset under these circum-
stances is gradual, but the symptoms are like those of peritonitis
under other circumstances. Infection takes place directly through the
appendix.
When the fever continues, with mild diarrhoea, intestinal pain, and
flatulency, the case may be mistaken for typhoid fever. The tempera-
ture is, however, more remittent in character in appendicitis, and the
diarrhoea is not characteristic of typhoid fever. The eruption of
typhoid fever does not occur, the spleen is not enlarged, and the symp-
toms of the typhoid state do not ensue. The diazo-reaction, the
bacteriological examination of the stools, and the serum test, may aid
in forming a conclusion.
Recurrent Appendicitis. Frequent attacks of mild appendicitis
occur ; they may occur as frequently as every three months, or the
interval may be as long as a year. The attacks are similar to the
attacks just described, although the duration is shorter. The local
symptoms in some instances are more marked, because there has been
a localized peritonitis previously. The induration is greater, and dul-
ness more marked. In some instances the attacks are comparatively
mild, continuing but twenty -four hours, and are described as attacks
of colic. Often they have been treated by the patient himself, by
household remedies alone. The patient spends a night in agony, with
cramps, but the next day follows his usual habits. It is possible
that there has been no fever with the attacks, but in all cases of
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 741
recurrent appendicitis which I have seen, fever, although often slight,
has been a constant accompaniment.
Appendicitis with Perforation. Before perforation takes place
the patient may have had symptoms of the mildest form of appendi-
citis for two or three days, or they may have extended over a long
period of time, without any symptoms except colicky pain. As obser-
vations are not made, the presence of fever cannot in such a case be
utilized as a diagnostic feature. The perforation may take place early
in the course of an acute attack, and result in localized peritonitis and
abscess, or in diffuse peritonitis. If the latter, after the characteristic
symptoms of appendicitis the symptoms of intense peritonitis set in. The
abdomen rapidly becomes distended, the characteristic vomiting ensues,
and collapse develops. Perforation under these circumstances has
occurred within the first twenty-four or at most within forty-eight hours.
Local inflammation about the appendix does not take place, and the local
signs of an inflammatory tumor are not present, although tenderness
at the special point can be elicited.
Abscess. If the perforation is more gradual, and there has been time
for the occurrence of local inflammation about the appendix, by which
pus is prevented from infecting the general peritoneum, or if perforation
takes place behind, in the connective tissue which surrounds the mass,
in which situation there is always inflammation, the local signs of ab-
scess or inflammatory tumor occur. There is swelling of the affected
side ; the normal outline is effaced. The area is indurated, and the
early pronounced rigidity gradually gives way to a boggy sensation,
with the appearance of oedema of the skin. This can be elicited by
pressure over parts that are hard and resisting, as the spine of the
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Tuberculous peritonitis. Subnormal temperature.
"While in a number of instances the symptoms are acute and alarm-
ing, in the larger proportion of cases the process is more chronic, and
is attended by characteristic local and general symptoms. In the pro-
longed and moderate cases there may be continued fever of moderate
degree, or it may be remitting in type. In old people the temperature
is frequently subnormal. (See Fig. 193.) There is more or less
rapid emaciation. The sweating is profuse and characteristic. The
fever is high but irregular in type, in more severe cases approaching
the remittent form. The general symptoms resemble typhoid fever.
Indeed, symptoms of the typhoid state may ensue.
PLATE XXXVII.
Tuberculosis of the Peritoneum.
Abdominal exudate (not freely movable); omental tumor, Consoli-
dation at apices.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 757
The Local Symptoms. Four classes are seen : (1) Abdominal en-
largement with effusion ; (2) enlargement with tumors ; (3) a combina-
tion of the two ; (4) enlargement without evidence of fluid or tumor
in the abdomen. In the latter form and in the forms in which tumors
are present the abdomen subsequently may undergo retraction.
1. Enlargement with Effusion. The local symptoms and physical
signs are those of ascites. The abdomen is never as distended, however,
as in the ascites of cirrhosis of the liver. Often the fluid is confined
by adhesions which may distinctly localize it in the right or left quad-
rant of the abdomen, in which situation fulness and fluctuation may
be readily detected.
2. Tuberculosis with Tumors. (Plate XXXVII.) The tumors are
usually in the upper zone of the abdomen, and may be localized in either
quadrant, or extend from the right to the left. They are usually due
Fig. 194.
Tuberculous peritonitis ; pulmonary tuberculosis. + The site of cardiac impulse.
to tuberculosis of the omentum, with secondary contraction. In some
instances a hard, indurated tumor, somewhat tender on pressure, may
extend across the abdomen midway between the xiphoid cartilage and
the umbilicus. It may be as low as the umbilicus, and vary from two
to four inches in width. It may be continuous with the liver-dulness.
In other instances more distinctly localized masses may be felt. These
may be to the right or to the left of the umbilicus. In other instances
they are hard, slightly tender, with an irregular surface. They may
be movable and vary with the position of the patient. I have
758 SPECIAL DIAGNOSIS.
never seen tuberculous masses in the lower quadrants. In chil-
dren with tabes mesenterica they may be made out close to the verte-
bral column in the median line, extending to the brim of the pelvis,
although at the lower portion they are not so distinct. The dulness
over the tumors is varying, depending upon the relation to the bowels
and the degree of intestinal distention. Instead of dulness a modified
tympany may be observed, or muffled resonance.
3. Cases in tohich Effusion and Tumors are Present at the Same Time.
These present symptoms common to the two conditions, although the
tumors are not so distinctly defined.
4. Absence of Effusion and Tumors. When effusion and tumors
are not present the thickened peritoneum and more dense intestinal
walls lead to a modified dulness over the entire abdomen. When re-
traction takes place the resonance is of a woodeny character, the abdo-
men is more or less tender, and ill-defined indurations may be present.
The term carreau is applied to this induration.
In not a few instances the local physical signs may apparently be due
to inflammation of the liver, on account of extensive perihepatitis. In
the case of a child under my care the local signs during life were of
this character, and the symptoms were simply those of loss of appetite,
with discomfort, weight, and fulness below the sternum. Both the right
and left lobes of the liver were covered with an enormous thickening
due to tuberculous inflammation. Simple plastic peritonitis occupied
the lower zone.
Apart from the general symptoms and the local physical signs the
other symptoms are not distinct save those due to tuberculosis in other
situations. The appetite is usually poor, there is some atonic dyspep-
sia, vomiting may occur at regular intervals ; the bowels may be con-
stipated, although in my experience they have usually been relaxed.
The patient becomes anaemic, the skin harsh and dry. Emaciation
may progress to an extreme degree. Eruptions and boils may break
out, some oedema of the ankles may occur. Death takes place from
exhaustion and from the development of tuberculosis in other localities.
The diagnosis is difficult. Cases belonging to the first and fourth
classes above mentioned probably present the greatest difficulties.
The age modifies the difficulty of diagnosis. Peritoneal tumors, with
or without effusion in young subjects, are almost always due to
tuberculosis. In the aged they must be distinguished from carci-
noma or chronic peritonitis from other causes. The association of
diarrhoea with the symptoms is rather against carcinoma. Sacculated
effusions may be confounded with abdominal tumors, as of the ovary.
The resemblance is more pronounced if the tubercles develop primarily
in the tubes or uterus. In a recent case the autopsy disclosed a large
caseating ulcer inside of the uterus, and tuberculosis of the Fallopian
tubes and peritoneum. The right tube was chiefly affected. The
effusion during life was sacculated in the right lower quadrant, was not
movable with the patient, and fluctuated both on external palpation
and with bimanual palpation per vaginam. It was impossible to dis
tinguish it except that there was dulness instead of resonance in the
flanks. As Osier has pointed out, the association with salpingitis
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 759
must arouse suspicion, particularly if at the same time disease is found
in some other organ of the body, as the apex of the lungs or the
pleura. In males the primary lesion is often in the testicles. The
history of the case and the deyelopment of the disease in an irregular
manner, associated with gastro-intestinal disturbance rather than dis-
turbance of uterine function, are points in favor of tuberculosis. Tym-
panites is of frequent occurrence.
Diseases of the Stomach.
The stomach is a canal in which the food is detained for the purpose
of solution. Its walls are made up of mucous membrane, muscle, and
peritoneum. It is richly supplied with bloodvessels. Because of its
great functional activity it has an abundant nerve-supply. It is, more-
over, surrounded by rich plexuses of sympathetic nerves, through which
and its special nerve, the pneumogastric, it is in intimate relation with
every organ of the body.
The Symptomatology. The local symptoms of disease of the stomach
are dependent upon : (1) The morbid process which affects it ; (2) the
effect of the process upon the anatomical structure of the organ (atro-
phy, dilatation, tumor), whereby the size is affected ; (3) the effect
upon its function.
1. The Morbid Process. The symptoms due to the morbid process are
not different from the symptoms of similar morbid processes elsewhere,
save that they are modified by the function of the organ or its special
construction as a canal. Hence, congestions are attended by discharge
of mucus ; inflammations are attended by pain and by a flow of mucus
and pus ; ulcers by pain and the accidents of ulceration (hemorrhage) ;
malignant disease by pain and swelling (tumor), and its accidents, hemor-
rhage and obstruction ; while to each belong the general phenomena
which attend it. But the stomach is highly sensitive and resents the
intrusion of disease or of that which (1) causes disease or (2) irritates
the affected part. Expression of this resentment is shown in hyper-
aesthetic symptoms (see the Neuroses), as pain; in the abolition or
derangement of function ; and in the great pathological reflex act of
the stomach — vomiting. It will be seen later that this may be a symp-
tom of eyery local morbid process of the organ, either directly because
of the disease or of its exciting cause, both of which are operative in
irritant inflammations ; or indirectly because the process has set up
undue sensitiveness. In the latter instance any material, as food, which
the stomach is accustomed to receiye, becomes as much an irritant as
mucus, pus, or blood.
2. Anatomical Symptoms. The morbid processes modify the ana-
tomical structure and lead to other morbid conditions, as we see when
dilatation succeeds inflammation or obstruction of the orifices. The
symptoms of the secondary conditions are the same as elsewhere — in
atrophy, diminution in size ; in dilatation, increase in size, with retention
and fermentation, and finally discharge of the contents by vomiting.
Nerve Mechanism. In the consideration of the symptomatology of
gastric diseases the anatomical relation, by its vascular and nervous
760 SPECIAL DIAGNOSIS.
connection, must be considered. The student is sufficiently familiar
with physiology and pathology to know that each organ has a represen-
tative in the central nerve-mass, the brain, and that disease in one
organ will influence the function and create morbid symptoms in
another which is related to it through intimate nervous connections.
The central representative or centre is influential in proportion to
the power and activity of its peripheral adjunct. It is, moreover, in-
fluenced by higher centres, the psychical, and it in turn modifies them.
It influences or modifies lower centres, (1) functional, (2) vasomotor,
(3) motor, or (4) sensory. The result of this mechanism is : 1. That
functional alteration or organic disease of (a) the gastric centre, or (6)
of centres of higher control, or (c) of the nerve that connects the centre
and the organ — pneumogastric nerve — produces gastric symptoms. 2.
That gastric diseases produce symptoms in other organs, as cardiac
palpitation (reflex). 3. That disease of other organs produces gastric
symptoms or disease, as the vomiting of pregnancy, or of renal calculus,
or of disease of the testicle, or the gastritis of nephritis. Thus vomiting
is caused by emotion (high centre), influencing the pneumogastric (lower
centre) ; by a tumor pressing or destroying the pneumogastric centre ;
or by a tumor, as aneurism, pressing on the pneumogastric nerve.
I have taken the simplest illustration. When we come to the study
of gastric neuroses the extraordinary influences of the nervous mechan-
ism will be appreciated ; or, when hysteria is studied, the physiology
of its extreme gastric symptoms will be recognized. When the mech-
anism and clinical course of vomiting are studied it will be found
among other causes to be frequently due to affections of the blood, the
poisons of which irritate cerebral centres or nerve plexuses in the
stomach.
Vascular' Mechanism. But gastric diseases also arise because of the
vascular supply. Thus in heart disease with venous stasis the gastric
veins become the seat of congestion, with consequent gastric catarrh ;
or hepatic disease will cause portal congestion and gastric catarrh.
3. Functional Symptoms. Any local disease of the stomach must
influence its f miction ; therefore, conversely, functional symptoms
must be present in all local diseases. But functional disorder may be
present without local anatomical change ; the impairment is nearly
always induced through the influences of the nervous system. The
functions of the stomach are to digest and to absorb the products of
digestion. The former function is motor and chemical, the complete-
ness of which depends upon mixture of the food with, and solution in,
the gastric juice. The symptoms, therefore, must be due to changes
(1) in the motor, (2) in the secretory, and (3) in the absorptive func-
tions of the organ. The functions may be increased or diminished ;
the former are the primary and usually temporary aberrations ; the
latter succeed the former, and are permanent. The functional symp-
toms, therefore, are the symptoms of what we know as indigestion or
dyspepsia. They are described in the account of the subjective symp-
toms and also in the section on Gastric Neuroses.
Toxic Symptoms. The toxic symptoms arising in gastric disease are
worthy of a few words. They are nervous symptoms due to the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 761
absorption of ptomaines or imperfect products of assimilation. If
absorption of the toxines takes place suddenly and in large amounts,
coma and convulsions occur (Kussmaul's symptom) ; or, if gradually,
hypochondriasis, melancholia, mental depression, with vasomotor phe-
nomena of various kinds, arise.
It is observed, therefore, in unravelling the symptomatology of gastric
disease, that we must first note : (A) The subjective symptoms due
(1) to morbid processes, (2) to alterations of function, (3) to alterations
of size (sense of fulness, etc.). (B) The objective symptoms due (1)
to morbid processes, (2) to alterations of function, (3) to alterations of
size.
Diagnosis from Disease of Contiguous Organs Functionally Related.
The student will soon learn that diseases of the stomach which are
functional in character cannot be differentiated with ease from diseases
in other organs functionally related. He will find that to draw hard-
and-fast lines between gastric and intestinal indigestion, or between
so-called disordered gastric and hepatic function, is generally impos-
sible. Organs which are closely related in physiological function, and
which have nerve-supply and blood-supply in common, cannot be dif-
ferentiated when disordered function is considered. Hence, indigestion
and biliousness, or simple acute gastritis and duodenitis, are beyond
the pale of close discrimination. In fact, the symptoms of each blend
in a manner.
In addition to the examination of the stomach, in order to judge cor-
rectly of the nature of gastric lesions, as may be inferred from what
has been written above, we must ascertain (1) whether the gastric symp-
toms are dependent upon disease of other organs — particularly the eye,
nose, and genitalia, the heart and kidneys — by an examination of each
organ ; and (2) whether other symptoms are created by gastric disease.
The Stomach in Other Diseases. Diseases of the stomach may
frequently mask other diseases ; in other words, patients will complain
of gastric symptoms which are but concomitant phenomena, behind
which there are graver conditions. Thus, in disease of the kidney, in
phthisis, in chronic bronchitis, in emphysema, in valvular disease of
the heart, catarrh of the mucous membrane of the stomach is of fre-
quent occurrence, depending upon the primary disease.
In tuberculosis the local gastric symptoms often are the more promi-
nent features. Thus in the earlier stages of phthisis loss of appetite
and vomiting are of constant occurrence. The dyspeptic symptoms
in a large number of cases precede the pulmonary symptoms, and may
be so pronounced as to mask them entirely. The patients are usually
delicate and anaemic ; they complain of loss of appetite and mild indi-
gestion ; there is some regurgitation of food ; they are feeble and
languid. They are treated for chronic catarrhal gastritis, but do not
improve. On examination of the lungs the physician is surprised to
find a small area of consolidation, and upon inquiry will find subjec-
tive symptoms of tuberculosis to have been present for a considerable
time. Every practitioner is familiar with the scores of patients with
phthisis, even when the disease is far advanced, who believe that their
symptoms are entirely due to disorder of the stomach. In addition
762 SPECIAL DIAGNOSIS.
to the early catarrh that precedes tuberculosis, other gastric symptoms
may occur. The well-known association of simple ulcer and phthisis
is familiar. Both occur at the same time of life, yet the gastric symp-
toms may prevent investigation into those of pulmonary origin. In
ancemia and chlorosis changes in the digestive tract are common. On
account of the general blood-condition the functions of the stomach
are impaired. Here, too, we frequently have the association of ulcer
with the general condition. Danger of overlooking either is not so
great as in tuberculosis.
In valvular affections of the heart, chronic catarrh of the stomach
may result from venous congestion. The symptoms may point to the
gastric condition alone. In all cases of chronic gastric catarrh it is
necessary to examine carefully into the condition of the heart. Over
and over again patients apply for treatment not on account of cardiac
symptoms, but because of gastric disorder. They will be treated in
vain unless the primary cardiac affection is ascertained. Many cases of
gastric catarrh have been cured by the use of digitalis. In disease of
the kidneys the stomach is frequently involved. Vomiting and other
symptoms of gastric disorder may occur long before dropsy or any
objective sign which would lead to a correct diagnosis. The gastric
symptoms are due to chronic uraemia. In other conditions of the
genito-urinary tract gastric symptoms also occur. This is particularly
noticeable in long-standing retention from chronic obstruction. Renal
tumors may cause only disturbances of digestion, while gastric symptoms
due to movable kidney are well known. The symptoms in the latter con-
dition arise, first, from mechanical causes, as the pressure of the kidney
on the pylorus, and, secondly, from the influence on the nervous system.
Disease of the Liver. The intimate relationship of the liver and
the stomach is such that when one is the seat of serious functional dis-
turbance the other is likely to be affected. Frequently it is impossi-
ble to draw fast lines as to which organ is the primary seat of disorder.
The abuse of alcohol frequently induces chronic gastritis, and also
causes cirrhosis of the liver. On the other hand, cirrhosis of the liver
is frequently the cause of chronic gastritis secondary to the portal
congestion.
Diseases of the Nervous System. The relationship of disease of the
central nervous system to disturbance of the gastric functions has
frequently been adverted to. (See Vomiting.) In sclerosis of the
posterior columns of the cord this is more striking than in any other
spinal disease. Not only do we have gastralgia and gastric crises, but
moderate symptoms of indigestion, with hyperesthesia and slight gas-
tralgia, may be the first symptoms of locomotor ataxia.
Diabetes. Diabetes may continue (in its course) for a long period
of time, during which the patient is thought to have stomach-trouble,
before an examination of the urine reveals the true nature of the case.
Opinions differ as to the relationship of gout and rheumatism to
gastric disorder. Some writers believe that a specific gouty inflammation
of the stomach, due to the uric-acid diathesis, is of frequent occurrence,
and that one of the prominent manifestations of gout is dvspepsia in
all its forms. The French consider gastric disturbances to be frequent
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 763
expressions of the rheumatic diathesis. The relationship of the two,
however, is thus far not fully developed, although, in these conditions,
it is not usual to overlook the presence of either of the diatheses when
symptoms of gastric disturbance occur. It is essential to bear in mind
that in persons of a rheumatic or gouty diathesis gastric disturbances
are more likely to occur than in healthy individuals ; their successful
management depends upon the recognition of the fundamental diathesis.
It is more than probable that gastric disorders, along with defective
metabolism, is primary in both affections.
The Data Obtained by Inquiry.
The Social, History. In no other group of diseases than in
those about to be considered, unless those of the nervous system, is it
more important to inquire into the social history. This is true, because
most of the so-called gastric disorders have their foundation in neuras-
thenic states, the probability of which, of course, must be carefully
sifted from the many possibilities. Age. Early age predisposes notably
to gastro-intestinal disorder. In later life the catarrhs which arise
from improper exposure or indiscretions in eating or occupation are
common. The menopause is often associated with gastric disorders.
The sex is not of great diagnostic significance, except from its relation-
ship to the excesses in eating and drinking of one class. Those occupa-
tions which prevent out-door exercise, or which compel exposure to
toxic substances, or require stooping or constrained positions, or over-
tax the eyes, invite gastric diseases. Habits of eating and drinking,
both as to time and mode of eating, and the character of food and
drink, must be brought out in the inquiry. The use of tobacco and
other stimulants and narcotics must be noted. The hours devoted to
vacation and work are to be learned, as fatigue bears a great part
in gastric disease.
The Family History. Heredity plays but a small part except
in gastric carcinoma and in gastric neurasthenia.
The History of Previous Disease. The occurrence of infec-
tious diseases antecedent to the gastric disorder must be inquired about,
for, either because of the attendant gastritis or of the resulting defec-
tive innervation, they predispose to gastric disease. The excessive
feeding in the convalescence of typhoid fever, it seems to the writer,
is frequently the cause of gastric dilatation. Any prolonged illness
which weakens the muscular system and lowers the tone of the nervous
system will be likely to cause gastric disease.
It will be learned elsewhere that gastric affections occur secondary
to many local diseases, as of the heart, the lungs, and the kidneys.
Inquiry as well as an objective investigation must be made, to deter-
mine the presence of possible primary diseases. Disorders which inter-
fere with the mechanical support to the intra-abdominal organs must
be inquired for. Pregnancy, antecedent ascites, or a large tumor may
so weaken the abdominal muscles as to lead to gastro-enteroptosis.
Finally, a history of the ingestion of corrosive poisons must be sought
for in cases of gastritis.
764 SPECIAL DIAGNOSIS.
It is very important to learn whether the patient has been subjected
to the various causes of neurasthenia, which, with the history of the
occurrence of neuropathic symptoms, make valuable data, pointing to
the nature of many gastric neuroses.
The Subjective Symptoms. The following subjective symptoms
may be complained of : Disorder of appetite, bad taste in the mouth,
thirst, eructations, pyrosis, distress or weight after meals, burning after
meals, flatulency, nausea, vomiting, constipation, diarrhoea, pain, vertigo,
and cardiac palpitation. Nearly all the subjective symptoms are gastric
neuroses, and will be detailed in the chapter devoted to the neuroses.
Bad Taste. It is usually due to acute catarrh. It may be present
in chronic catarrh. It is said to be characteristic of the acute form of
gastritis popularly known as biliousness.
Thirst. Thirst is not a symptom of gastric disorder alone ; it is a
symptom of diabetes and all conditions in which the body has lost
fluids, as water by sweating, vomiting, or purging, or by' evaporation
and combustion (fever) ; or blood by hemorrhage. It is common in
acute and chronic gastritis, particularly in the alcoholic form.
Distress, Weight, axd Burxixg. They are frequent complaints,
and may come on immediately after meals. They may be due to dys-
pepsia, hyperacidity, dilatation, bacterial fermentation, and flatulency.
They exist in varying degrees, either singly or combined. (See Gas-
tric Hypersesthesia.)
Nausea. This symptom is usually associated with vomiting. In
some persons it is impossible to excite vomiting, although they may
suffer intolerably from nausea. Xausea is akin to vomiting in its
mechanism and clinical associations (q. v.). It is a common incident
in chronic interstitial nephritis. In old people, with arterial sclerosis
and defective renal elimination, it is common. It may be due to irri-
tating iugesta, to hyperacidity, to gastrectasia, or to toxins formed
within the stomach.
Vomitixg. Vomiting takes place when the stomach is compressed
by the abdominal muscles and diaphragm, coincidently with relaxation
of the so-called cardiac sphincter of the oesophagus. Sometimes there
are nausea and violent efforts at expulsion on the part of the stomach,
but no vomiting occurs, because the cardiac orifice of the stomach is
not opened at the same time. Again, there may be profound relaxa-
tion of the oesophagus, but no compression of the stomach by the dia-
phragm and abdominal muscles. Both factors must operate at the
same time to result in vomiting. This explains why it is that some
persons suffer extreme nausea and have even violent retching, but are
unable to vomit.
It is to modern physiologists — Schiff and Budge and Brunton — that
we owe a correct explanation of the physiology of vomiting.
From them we learn that there is a nervous centre for vomiting,
which is seated in the medulla oblongata, in close proximity to and
intimately connected with the respiratory centre. It is to this centre
that impressions are sent from the brain itself or from various portions
of the body by their nerve-supply, and from this centre motor im-
pulses are transmitted to the muscles concerned in the act of vomiting,
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 765
and to the stomach and oesophagus. In his usually graphic manner
Brunton has described the entire mechanism.
By a very good diagram (see Fig. 195) the author indicates the
afferent nerves which transmit impulses to the vomiting-centre, ex-
citing it to action. They are : pharyngeal branches of the glosso-
pharyngeal ; pulmonary branches of the vagus ; gastric branches of
the vagus ; gastric branches of the splanchnic ; renal, mesenteric,
uterine, ovarian, and vesical nerves. Fibres pass downward from the
brain, conducting impressions to the vomiting-centre from the organs
of special sense, from the brain-substance or its membranes when the
seat of disease, or from central ganglia excited by emotion or imagi-
nation.
Fig. 195.
BRAIN
NERVOUS CENTRE
OF VOMITING IN
THE MEDULLA
OBLONGATA
SPINAL CORD
PULMONARY
I BRANCHES
SPLANCHNICS
GALL-DUCT
RENAL NERVES
/ mesfnter;c
I NERVES
UTERUS-
BLADDER
VESICA
NERVE
The nervous mechanism of vomiting.
From this it is seen that vomiting is a reflex act ; that its mechanism
is quite simple ; and that a proper understanding of this mechanism
is essential to a correct appreciation of its pathology and treatment.
Reference has not been made to the vomiting that occurs in the initial
stage of many fevers, and in septicaemia, uraemia and allied affections,
and to the vomiting of hysteria. In the former it is doubtless due to
the direct action of the poisoned blood on the centre, but it can also
readily be seen to be due to the propagation of impulses to the centre
from the brain that is irritated by the blood. If the phenomena of
hysteria are due to an abeyance of the processes of inhibition, the
occurrence of vomiting can be said to arise from the non-control, by
766 SPECIAL DIAGNOSIS.
higher centres, of this centre. (From "Vomiting, Physiological and
Clinical." Trans. Penna. State Med. Soc, 1887. Musser.)
The significance of vomiting in a given case can sometimes be deter-
mined very readily, and sometimes it remains in donbt after very
careful examination and questioning of the patient. In seeking for
an explanation of vomiting it is of importance to find out the previous
health of the patient ; whether it occurred after the patient had been
ill for a longer or shorter time, or suddenly, when he was in apparent
health, or whether it formed one of the initial symptoms of an acute
disease.
Again, inquiry should be made as to the supposed cause of the
vomiting ; whether it was excited by the taking of food, drink, or
medicine, or by some disgusting sight or odor.
Further, the time of the occurrence of the vomiting should be ascer-
tained, as well as its frequency, and whether preceded by nausea, pain
(noting its locality), injury, coughing, jaundice, or constipation.
The position of the patient at the time the vomiting occurs some-
times furnishes a valuable clue to its cause.
The effect of the vomiting is sometimes of aid in diagnosis. In
ulcer and migraine, for example, it affords marked relief.
Finally, the appearance and quantity of the matter vomited are
very important. (See Objective Signs.)
Character. Vomiting may occur occasionally, persistently, or peri-
odically. It may be projectile and painless, or difficult and painful.
The former is characteristic of cerebral disease or reflex vomiting ;
the latter of local gastric disease. When vomiting occurs suddenly,
without antecedent illness, it usually indicates some local affection of
the stomach, or is due to some nervous impression, or marks the onset
of some acute general disease.
Vomiting in Gastric Disease. The local affections of the stomach
attended by vomiting are acute and chronic gastritis (especially the
catarrhal form), dyspepsia, ulcer, cancer, and dilatation.
In acute gastritis there will be a history of an acute illness marked
by severe local and general symptoms. The cause of the gastritis may
be found to be overeating of highly seasoned or indigestible food ; abuse
of alcohol, narcotics, or sedatives ; drinking water to which the patient
is unaccustomed ; poisoning with such drugs as arsenic and mercury ;
sudden changes in atmospheric conditions in susceptible persons. The
vomiting is preceded by nausea, epigastric pain and tenderness, and
often followed by profound prostration.
The vomited matters consist, first, of the contents of the stomach
(which may throw light on the cause of the attack), then of mucus,
saliva (which has been swallowed), bile, and, in grave cases, altered
blood.
In chronic gastritis vomiting often occurs in from half an hour to an
hour and a half after eating, the food being only partly digested and
sometimes coated with mucus. It does not produce the prostration
that vomiting in acute gastritis does, and is followed by some relief to
the gastric uneasiness and pain. The emaciation may suggest cancer
of the stomach.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 767
In ulcer of the stomach vomiting is rarely absent. It occurs usually
soon after taking food, and its occurrence affords relief to the gastric
pain. There is nothing characteristic in the vomit unless it contains
blood. Welch thinks that gastric hemorrhage in recognizable amount
occurs in about one-third of the cases.
In cancer of the stomach vomiting is an almost constant symptom,
but it may not occur until comparatively late in the disease, or, more
rarely, may be one of the earliest symptoms. Usually it does not
appear until dyspeptic symptoms have persisted for some time. There
is no uniformity in the frequency of its occurrence or in the character
of the vomit. As a rule, vomiting occurs at a longer interval after
taking food than in the case of ulcer, and the ejection of food does not
give as much relief to the patient. Vomiting may occur every day or
several times a day in the early stages, but if dilatation of the stomach
develops, as it usually does in cancer of the pylorus, vomiting may be
deferred for several days, and then be correspondingly more copious
in amount. Blood, frequently altered by gastric juice so as to resem-
ble coffee-grounds, is a common constituent of the vomit. (See Under
Inspection.)
Vomiting in Infections. Vomiting frequently marks the onset of acute
diseases, especially pneumonia and the eruptive fevers and yellow fever.
Excessive vomiting generally indicates that the case will be severe.
Reflex Vomiting. Nausea and vomiting are excited in some persons
by the sight of blood, or by a horrible or loathsome spectacle ; others
are more susceptible to foul odors and disgusting tastes.
Vomiting is frequently reflex, that is to say, irritation at some point
is transmitted by the proper afferent nerve to the vomiting-centre and
then reflected to the stomach. Vomiting of this character occurs in
pregnancy, diseases of the appendix vermiformis, ovaries, uterus, bladder,
prostate gland, lungs, nose, eyes, kidneys, intestine, peritoneum, liver, gall-
bladder, and bile-ducts.
Vomiting is found to be of reflex origin when there is no local affec-
tion of the stomach present and no general disease to account for it,
and when a remote source of irritation can be discovered, the removal
or mitigation of which checks this vomiting. The particular organ
which is the source of the irritation must be determined by a careful
physical examination guided by the indications furnished by the age,
sex, time of occurrence, habits, and other symptoms which accompany
the vomiting.
The nausea and vomiting from which many women suffer during
the early months of pregnancy are most marked on rising in the morn-
ing ; they are aggravated if the patient has been on her feet much or
has been subjected to any exhausting or worrying influence ; on the
other hand, they are relieved by quiet and the recumbent posture. In
diseases of the ovary, uterus, bladder, and prostate there are local pain,
catarrhal symptoms, inflammation or noticeable enlargement.
The lungs are probably not often the cause of reflex vomiting.
Rarely, however, phthisis is so masked by gastric symptoms and vomit-
ing as to be overlooked. More frequently it is the act of coughing
and the effort to expel the sputa from the throat that produce the
768 SPECIAL DIAGNOSIS.
vomiting. Expectoration tickles the throat, and may have the same
effect as the finger or feather in inducing vomiting. This seems to be
the explanation of the vomiting which follows a hard spell of coughing
in pertussis.
Peritonitis may be suspected to be the cause of vomiting if there has
been injury to the peritoneum from a surgical operation, or if it has
been exposed to infection through the uterus and tubes, or from disease
of organs surrounded by it, as the vermiform appendix. Vomiting
may be the only symptom present except collapse. The fluid is not
only ejected, but regurgitated, and may appear to flow from the stom-
ach. Large amounts of fluid are discharged, clear or of a green color.
In the vomiting due to the passage of a renal calculus or gallstone
the colicky pains and their location definitely point to the source.
Vomiting in Toxcemias. Vomiting is also a marked symptom of tox-
aemias ; they produce vomiting probably by direct irritation of the
vomiting-centre. Among such diseases are the specific fevers, notably
scarlet fever and yellow fever ; sewer-gas poisoning ; diseases of the liver
and kidney, which produce chokemia and urcemia., particularly cirrhosis
of the liver and interstitial nephritis.
Cyclic Vomiting. This condition was described by Ley den in 1882
as periodic vomiting. Cases in children have been recorded by Snow
and others. Clinically, the vomiting is sudden in onset, severe, and
consists first of the contents of the stomach, and later of acid mucus.
There is usually a febrile reaction at the onset, but this may be absent
in adults. The abdomen is almost invariably retracted. There is
usually a degree of prostration which is out of proportion to the local
manifestations, and may be dangerous. There may be narcosis, del-
irium, or great restlessness. These gastric crises recur at intervals of
six weeks to six months, and will recur periodically in spite of the
utmost care as to diet. This disease is probably a gastric neurosis,
and has analogies with migraine. There is no reason to believe that
it is reflex in origin. It may be due to the accumulation of toxic sub-
stances.
The vomiting of urcemia usually occurs in the morning. It is ac-
companied by nausea and depression. Whenever morning nausea and
vomiting occur in an adult without obvious local cause the urine should
be examined. Other confirmatory signs are high-tension pulse, accent-
uation of the aortic second sound, and hypertrophy of the heart.
Cerebral Vomiting. Vomiting due to cerebral disease is well recog-
nized. In early life it is a characteristic feature of meningitis and
tumor of the brain. It is likewise of moment in later life. I am
of the conviction, however, that it is not sufficiently recognized as one
of the first symptoms of apoplexy. True, we find that apoplexy occurs
after a full meal, when the attack is associated with indigestion, with
efforts at vomiting ; and I do not here refer to such cases, but to cases
of painless, often watery vomiting, occurring without nausea and with-
out retching. A sudden, violent expulsion of the stomach-contents,
ceaseless, unrelieved by remedial measures, has been seen by the writer
to precede other signs of apoplexy by from thirty minutes to twenty-
four hours. In all cases of apoplectic character the pulse is slow and
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 769
full, while in nausea and vomiting; from other causes, in the aged par-
ticularly, it is weak and feeble. Moreover, some alteration of breath-
ing is noticed. It is either irregular, or slow, or unduly hurried. It
proves the intimate relation of the vomiting and the respiratory centres.
Further, strength is seen, not weakness ; in the apoplectic the face is
congested, not pallid as in simple sick stomach. The other peculiari-
ties of cerebral vomiting have been indicated.
Crises. Sudden attacks of vomiting with hyperacidity, with or
without pain, often occur in locomotor ataxia. Such attacks occur in
other affections, as hysteria. They occur in movable kidney, and are
known as Dietl's crises.
Diagnosis. Vomiting is readily recognized. It is often productive
of serious symptoms. It may cause apoplexy or cerebral congestion ;
it may cause acute overdistention of a dilated heart, as in aortic re-
gurgitation. If it continues for any length of time, and much fluid is
ejected, it is attended by anuria, and rapidly followed by collapse. It
also induces thirst.
Flatulency. Flatulency is an accumulation of gas in the stomach
or intestines. It is a very common source of complaint on the part of
patients. Gastric flatulency is marked by a distention of the stomach,
with the discomfort which it occasions, and by the eructation of gas at
variable intervals after the taking of food. When the gas is the result
of the fermentation which accompanies the production of the fatty
acids flatulency is frequently accompanied by pain, which is relieved
by eructations. When the distention is great or long continued, dis-
turbances in the action of the heart, particularly palpitation and inter-
mittency, are likely to occur. Occasionally it interferes with the
breathing, and, from the apprehension which this symptom and palpi-
tation excite, faintness and inaptitude for mental and physical work
may arise.
Flatulence may be due to carbonic acid, which is generated and re-
tained on account of motor deficiency. It is seen in the middle-aged
and in the old. Air swallowed with the food or the saliva is an occa-
sional cause. Flatulence may also be due to the regurgitation of
pancreatic juice, as in fixation of the stomach- wall and open pylorus.
It comes on four or five hours after eating, and is caused by de-
composition of the carbonates of the pancreatic juice setting free car-
bonic acid. Flatulence from bacterial fermentation is seen in dilatation
of the stomach, and is usually continuous. It also occurs in chronic
indigestion. Flatulence in rare instances is due to disturbance of the
interchange of gas between the blood and the contents of the stomach.
Normally it is known as g astro-intestinal respiration.
Excessive flatulency is a common manifestation of hysteria. Such
patients may complain of something rising into the throat from the
stomach and smothering them (globus hystericus). There may also be
tympanites, and even phantom tumor. It may be necessary to anaes-
thetize the patient completely, to diagnosticate the latter from genuine
tumor.
Vertigo. The stomach is but one of a number of sources of ver-
tigo. Some patients find by experience that certain articles of food,
49
770 SPECIAL DIAGNOSIS.
such as oysters or lobsters, have to be avoided because they produce
vertigo, although digestion is good, and more indigestible articles can
be taken without inducing any such result.
In other cases acute indigestion from overeating, particularly if it
result in the development of an acid condition of the stomach, is apt
to be accompanied by vertigo when the stomach symptoms are most
severe. Usually the vertigo is associated with headache, more or less
intense ; it is relieved by lying down and closing the eyes, but does
not wholly disappear until all the symptoms gradually subside after
free vomiting. Some persons are subject to so-called " blind " head-
aches — headaches accompanied by dimness of vision, more or less
mental confusion, and uncertainty of gait, possibly with staggering, and
often with vertigo. Such headaches appear to be due to an acid con-
dition of the stomach, and are relieved by alkalies or vomiting.
It is difficult to separate the vertigo of chronic gastric or gastroin-
testinal dyspepsia from that of lithsemia or latent gout. Probably
both are due, not to any local irritation transmitted to the brain, but
to the circulation in the blood of toxic products of digestion which
act upon the brain. The vertigo is not so severe as in acute indiges-
tion or acute dyspepsia, but is cftnstant. In some patients it is asso-
ciated with an unconquerable aversion to walking alone upon the street.
Pain. Cardialgia is a form of discomfort in the epigastrium
scarcely amounting to pain, but attended by heartburn or acidity.
Gastrodynia is a violent pain spoken of as cramp or spasm of the
stomach. The pain is transient. Gastralgia is a form of pain with
features like that of neuralgia, occurring when the stomach is empty.
(See Gastric Neuroses.)
Location. Pain in the Epigastrium. Pain referred to the stomach
is situated in the upper zone of the abdomen, below the ensiform carti-
lage, between the ribs of the two sides, usually in the median line. It
may be along and under the left ribs. Pain in this situation may be
due to a number of causes : 1. To myalgia, neuritis, or neuralgia of
the intercostal nerves, which terminate in this situation. (See Abdom-
inal Pain.) 2. Localized peritonitis or perigastritis, which may be
secondary to or caused by infection or injury of the peritoneum from
disease of contiguous organs. 3. Affections of the pancreas may cause
pain : a. Pancreatic colic, a rare condition associated with diarrhoea,
intestinal dyspepsia, and salivation. The pain is paroxysmal, the
attacks lasting two or three hours, b. Pain due to carcinoma of the
pancreas, darting or lancinating in character, associated usually with
tumor, jaundice, and emaciation, c. Pain clue to pancreatic hemor-
rhage. It is sudden and extremely severe, attended by collapse. 4.
Pain in this situation may be due to aneurism of the aorta or of the
cceliac axis. It is constant, of a boring character, and may be associ-
ated with shooting pains along the course of the lumbar nerves. The
physical signs of aneurism are present. 5. Pain in this region may be
due to hepatic colic. 6. It may be due to disease of the vertebra?.
We should look for the sixth or seventh dorsal vertebra to be affected,
hence higher up posteriorly than the area affected in front would indi-
cate. 7. Affections of the stomach. Of these we have : a. Gastralgia
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 771
in all its forms. (See Gastric Neuroses.) b. Acute and chronic gas-
tritis, c. Gastric ulcer, d. Carcinoma of the stomach. To the first
class belongs a peculiar pain which occurs in locomotor ataxia, and
which, on account of its sudden onset, with alarming and frequently
repeated vomiting, is known as a gastric crisis.
Pain in the Left Hypochondrium. It may be due to a dilated stomach
or distended colon.
Pain of Gastric Origin. In diseases of the stomach pain is a very
common symptom. It is of all degrees, from a mere sense of discom-
fort or uneasiness to agony. In atonic dyspepsia there may be no local
gastric symptoms except a feeling of weight and fulness, while in ner-
vous dyspepsia there is usually uneasiness or discomfort after eating.
In gastralgia the pain is characteristic : it usually comes on while the
stomach is empty, and frequently recurs daily at the same hour. At
first the pain is slight and easily borne, but it gradually increases in
severity. Each succeeding paroxysm is worse than the preceding one,
until a climax of agony is reached. In character the pain is gnawing
and cramp-like, doubling the patient up, and after subsiding leaving
him moist with cold sweat and in partial collapse.
In catarrhal dyspepsia there are pain and uneasiness in the stomach
after eating, with tenderness on pressure. If flatulence coexists, there
will be temporary relief to the discomfort upon the eructation of gas.
In ulcer there is a more or less constant feeling of soreness in the
epigastrium. After taking food the dull pain is aggravated and becomes
sharply localized. Frequently there is pain in the back at the same
point, a little to the left of the spine and between the midscapular
region and the lumbar vertebra?. The pain usually occurs sooner after
taking food than in the case of cancer, and is more frequently relieved
by vomiting. Attacks of gastralgia are not rare, and the pain may
shoot down the arm.
In gastric cancer pain may be wholly absent throughout the entire
course of the disease ; but, as a rule, pain is more continuous than in
ulcer, less severe, not so sharply localized, does not come on so soon
after taking food, and is not relieved to the same degree by vomiting.
Paroxysms of gastralgia are not so common.
In acute gastritis the pain and its character vary with the intensity
of the inflammation. If due to the irritation of some toxic agent
which has been swallowed, the pain is severe and burning ; if the
result of imprudence in eating and drinking, the pain is of a dull,
sickening character. In either case there is more or less tenderness on
pressure. Sometimes, in mild cases of catarrhal gastritis, firm press-
ure from a broad surface affords at least temporary relief to the dis-
tress.
Time of Pain. The significance of pain depends on the time of its
occurrence. Pain coming on before eating or when the stomach is
empty is due to gastralgia. It is relieved by food. When it comes
on after eating, it is usually due to organic disease of the stomach, as
ulcer or carcinoma ; but it may be due to neurasthenia. It must not
be confounded with the pain that occurs from two to four hours after
meals, caused by intestinal indigestion or some pancreatic affection.
772 SPECIAL DIAGNOSIS.
When the pain is diffused, it is due to hyperacidity and bacterial fer-
mentation, as in dilatation, catarrhal gastritis, and simple indigestion.
When localized, it is due to ulcer or cancer, and is associated with ten-
derness. It may extend to the back.
Alterations of Appetite. Loss of appetite, or anorexia, may be
due to a number of diseases. It is present in all forms of organic disease
of the stomach except occasionally in ulcer. In the majority of cases of
this affection it is present. It may or may not be present in gastric neu-
roses. Every one is familiar with the loss of appetite due to nervous
impressions, as emotions, anxiety, or mental care. It is of frequent
occurrence in disorders remote from the stomach, which modify the
condition of the organ reflexly. In the section on Vomiting will be
found statements showing the influence of central disease and disease
of distant organs upon the stomach. Through the same channels and
through the same mechanism, and hence by the same group of causes,
loss of appetite may be produced. Loss of appetite is a constant
accompaniment of the moderate gastritis which attends all fevers.
Reference cannot well be made to all the conditions which induce this
symptom. In all forms of anaemia, in all chronic wasting diseases, and
in functional and organic disease of the nervous system the appetite is
lost. The writer has been particularly impressed with the importance
of determining the presence or absence of suppuration in some portion
of the body, in all cases in which there is loss of appetite or disgust for
food, the cause of which is not of gastric origin.
Boulimia, or excessive appetite, sometimes occurs. It is popularly
thought to be due to worms in children. It is a common symptom in
the earlier periods of diabetes, and is said to be present in disease of
the mesenteric glands. It occurs also in gastric neuroses. Perversion
of the appetite, in which all sorts of substances are greedily swallowed,
occurs in hysteria, dementia, and pregnancy. It is known as pica.
Regurgitation of gases or food matter is a frequent symptom of
gastric disorder. It is also known as belching or eructation. It may
be limited to the discharge of gas, although sometimes imperfectly
digested food also regurgitates. (See Rumination.)
Regurgitation of the gastric juice alone causes an unpleasant taste,
and the fluid is hot and acrid. The juice is usually brought up in the
belching of gas.
Pyrosis, or waterbrash, is a common symptom in some forms of
dyspepsia. It may occur in the morning when the stomach is empty,
at which time large amounts of fluid are ejected. The fluid is thin
and watery, sometimes acid, sometimes tasteless. In other cases the
fluid is slightly alkaline. The fluid is ejected without vomiting.
Sometimes the discharge begins immediately after eating. The late
Dr. Chambers thought that the fluid was saliva which was swallowed
and retained in the lower part of the oesophagus by a spasm of the
cardiac orifice, and when a sufficient amount was collected, gushed back
into the mouth. Pavy and Handfield Jones believe that the fluid is
secreted by the stomach, while, on the other hand, Roberts, who found
the liquid to possess diastatic power, believes it to be due to saliva.
Acid eructations from hyperacidity or fermentation occur one or two
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 773
hours after meals. They rarely occur in dilatation, but are common
in overfeeding.
Palpitation. Increased action of the heart is a common symptom
of indigestion due to flatulency or an overloaded stomach. It occurs
in the middle period of life, in the anaemic and neurotic, in cardiac
disease, and in those who use tea and tobacco to excess.
Cough. Cough is a frequent symptom of gastric disorder. It may
be due to the pharyngitis, which has been set up by acid eructations ;
it may be mechanical, when a distended stomach presses upon the dia-
phragm, or it may be reflex. Cough after meals in patients with
tuberculosis or other pulmonary affection is usually due to pressure
upon the diaphragm.
Dyspncea. This occurs in many cases of dyspepsia if the subject
is the victim of asthma, is anaemic, or subject to cardiac disease. In
asthma it is usually reflex ; in anaemia it is due to atony 'of the stomach
and gaseous accumulation ; in cardiac disease it is mechanical from the
pressure of a gaseous distended stomach.
Hiccough, or singultus, is a spasm of the diaphragm. The con-
tractions take place at more or less regular intervals, attended by a
peculiar clicking sound. This sound is due to the sudden passage of
air through the glottis. Hiccough may be a serious symptom. It
may last but a few minutes or continue for several days. In the latter
case it causes extreme exhaustion. Its occurrence in chronic disease
is of bad prognostic omen.
Drowsiness is frequently seen in dyspeptics after meals. Sleepless-
ness is of frequent occurrence. It may be due to the irritation of food
remaining in the stomach over night or to the absorption of toxic products.
Constipation. This symptom will be discussed in the chapter on
Intestinal Diseases. It is present with gastric dilatation. In pyloric
stenosis it is always present.
Diarrhcea. The digestion is impaired and peristalsis is in excess.
Lienteric diarrhoea is an accompaniment of a gastric motor neurosis,
or it may be due to the absence of HO. In gastrectasia the fer-
mentative products set up gastro-intestinal catarrh, which induces
diarrhoea.
The Data Obtained by Observation.
The Objective Symptoms. One of the objective expressions of the
morbid process or of altered function is seen in changes in the charac-
ter of the contents of the stomach. The contents are obtained for
examination when discharged from the stomach (vomit) or when re-
moved artificially (washings). Both fluids are studied by inspection,
including microscopical examination and by chemical and bacteriologi-
cal examination. The sense of smell enables one to differentiate many
varieties of fluids. Alteration of function is also seen in alteration of
digestion, and is estimated by chemical and physiological methods.
The activity of the digestion must be determined by ascertaining the
duration of digestion and its degree of completeness, which depend upon
three factors : (1) The motor power ; (2) the absorptive power ; (3)
the digestive power of the gastric secretions.
774 SPECIAL DIAGNOSIS.
To secure objective data, therefore, the following are necessary :
I. Physical examination, to determine tenderness and the size, posi-
tion, and movement (peristalsis) of the stomach.
II. Examination of the gastric contents.
III. Examination of the digestive power of the stomach.
IV. Examination of the motor power of the stomach.
V. Examination of the absorptive power of the stomach.
I. Physical Examination of the Stomach. Inspection.
Direct inspection of the stomach region often affords much positive in-
formation. When there is much loss of abdominal fat and the stomach
is well distended its outlines can sometimes be traced with the eye.
The best position is behind and above the patient's head while he is
lying down. If the lower curvature can be traced considerably below
the navel, the stomach is almost certainly dilated, and if, at the same
time, there is a prominent swelling in the pyloric region, accompanied
by progressive loss of weight and cachexia, the dilatation is probably
due to cancer of the pylorus. A marked groove extending from the
umbilicus to the ribs, about or to the left of the nipple-line, is seen in
cases of dilatation when the stomach has fallen. It is the position of
the lesser curvature. The lower border is also marked by a groove
extending in a curve from the pubis toward the first groove.
Peristaltic waves may be seen to move spontaneously, or after tap-
ping the region or applying an' ether spray or faradism. When the
pylorus is obstructed anti-peristaltic waves may also be seen. The
waves of the muscular contraction begin at the cardiac end or fundus,
and extend to the pylorus ; hence, they begin under the ribs of the
left side and extend downward toward the right lower quadrant. They
vary in extent with the amount of dilatation. (See page 729.)
Distention of the stomach with carbonic oxide (see Percussion), or,
better, with air by means of a hand-bulb syringe, frequently brings
the outlines of tumors of the pylorus plainly into view, while at the
same time any tumor lying behind the stomach becomes less distinct,
and false tumors due to spasm of the gastric muscular coat vanish. Dis-
tention also helps to map out the whole stomach and to separate it from
surrounding viscera. It enables one to estimate the size and position of
the stomach. Hence, by this means descent can be told from dilatation.
Gastrodiaphany or Transillumination of the Stomach. Einhorn has
succeeded in transilluminating the stomach by an Edison lamp fastened
to a soft-rubber tube. The wires to the battery are carried through
the tube. After the stomach contents have been removed the patient
is to take one or two glassf uls of water. The apparatus after lubri-
cation is then inserted. The examination must be made in a dark
room. By means of gastrodiaphany the position and size of the stom-
ach are determined, to a certain extent, and the presence of tumors of
the anterior wall of the stomach is recognized. The results are not
strictly accurate, however, as transillumination of the intestines is
brought about if they are empty. The form and size of the stomach
are not so readily brought out as the topographic relation of tumors of
the stomach and those in the vicinity of that organ. It is of service
in some cases to distinguish dilatation from gastroptosis.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 775
Rontgen Light. The outline of the stomach may be observed by
the use of X-rays, provided the patient has been given 10 or 20 grains
of subnitrate of bismuth.
Palpatiox. Palpation of the stomach is closely associated with
auscultation, inasmuch as the former also elicits sounds (succussion,
gurgling) which are helpful in diagnosis. The hand must be placed
flat upon the abdomen and pressure made by bending the ends of the
phalanges. To make deep palpation, gradually increasing pressure
with a rotary movement must be employed. It may be of advantage
to palpate in the knee-elbow position, so that deeply seated tumors, if
movable, may fall to the abdominal wall. (See Auscultation.)
But palpation elicits information independently of auscultation,
chiefly in conditions of disease. Epigastric, 'pulsation is common in
anaemia ; in nervous dyspepsia ; in valvular disease of the heart, par-
ticularly tricuspid regurgitation, producing a liver-pulse ; and in the
rare cases of aneurism of the abdominal aorta.
Increased resistance may be due to the hypertrophy of the muscular
coat which coexists with distention of the stomach. When the stomach
is shrunken and the resistance increased, it may be due to a diffused
carcinoma of the Avails of the stomach ; or, rarely, to the so-called
" fibroid stomach," the atrophy and thickening of the walls being due
to chronic gastritis.
Increased resistance limited to the pylorus is found in carcinoma.
The same effect produced by a tense right rectus muscle must be ex-
cluded.
Position of Gastric Tumors. Cancers of the pylorus are situated
usually between the xiphoid cartilage and the umbilicus, frequently a
little to the right of the median line ; but they may be found below
the umbilicus, and, exceptionally, still lower down. Adhesions to
neighboring organs commonly prevent the tumor from being moved.
When it has formed adhesions to the liver or diaphragm it moves with
respiration.
As a rule, tumors due to gastric cancer are small, hard, and irregu-
lar, and gradually increase in size.
Non-malignant tumors are occasionally found, and also tumors due
to adhesions around old ulcers, and to puckered scars. The latter are
distinguished from cancerous tumors, not by the physical examination,
but by their duration and clinical history.
Another method of determining the position and size of the
stomach is by internal exploration combined with external palpation.
A bougie is introduced into the stomach and swept over its entire in-
ternal surface, the position of the bougie being followed from point to
point by the palpating hand. This method is not advisable when it is
possible to make a diagnosis without it.
Pain and Tenderness. Tenderness is elicited by palpation in gas-
tritis, in dyspepsia, especially the catarrhal form, in ulcer, and in
cancer. In gastritis and dyspepsia the tenderness is usually diffuse
and is not constant ; in cancer the tenderness is usually limited to the
seat of the tumor, but is not so marked nor so sharply localized as in
ulcer. In ulcer tenderness is rarely absent ; even when there is no
776 SPECIAL DIAGNOSIS.
pain, it is very decided, and is so localized, sometimes, that it can be
covered with the tip of the finger. Pain in the stomach from ulcer is
chronic, circumscribed, and variously described as burning and wound-
like. It is aggravated by palpation, and by food or drink, especially
hot stimulating drinks, and relieved by cold, soothing drinks. It is
accompanied frequently by pain in the corresponding vertebrae.
Diffuse pain is met with in acute and chronic gastritis, and in cancer
of the stomach-walls.
Peecussiox. Position of the Stomach. (Plate XXXVIII., Fig. 1.)
The stomach does not occupy a fixed position, and is a distensible
organ. It is depressed by downward pressure of the diaphragm in
deep inspiration, by emphysema, left pleural effusions, enlargements
of the liver and spleen, and tight lacing ; it is raised by any causes
which greatly distend the bowels or peritoneal cavity — tympanites,
peritoneal effusions, tumors, etc. Moreover, after food is taken, the
stomach is distended and its position changed, being rotated anteriorly
from below, the greater curvature rising and looking more forward,
while the anterior surface has a more upward presentation.
The cardiac orifice of the stomach is fixed by its passage through
the diaphragm and by peritoneal attachments which it receives there.
It is behind the sternal insertion of the left seventh rib. The pylorus,
on the contrary, is freely movable when the stomach is empty ; it is
nearly in the median line, but when the stomach is full it is pushed
several inches to the right ; it lies between the right sternal and para-
sternal lines, on a level with the tip of the xiphoid cartilage.
Obrastzow (Deut. Arch, fur klin. Medicin, Bd. xliii. 5, 417-456)
divides the space between the navel and the xiphoid cartilage into
three equal parts, and says that the lower border of the stomach, both
in men and in women, is in the lower or supra-umbilical third.
In children under fifteen years the lower border rarely extends to
the umbilical line ; after fifty years, on the contrary, it often extends
below the navel. In conditions of bad nutrition it falls nearly to the
navel.
According to Pacanowski and Wagner, the upper border of the
stomach, in the left parasternal line, lies at the lower border of the fifth
rib or in the fifth intercostal space, rarely at the fourth rib or in the
sixth intercostal space. In the left nipple-line it lies from the fifth
interspace to the sixth rib, occasionally in the fourth interspace or at
the seventh rib. In the anterior axillary line it lies at the lower
border of the seventh or eighth rib, rarely above the sixth rib, never
under the eighth rib.
Tranbe has called special attention to the left lower portion of the
thorax which projects over the stomach, " the half -moon-shaped space."
The upper limit is a crescentic line starting from the sternum in the
sixth interspace and extending, in a curved line corresponding approx-
imately to the curve of the rib, to the axillary line. It is known as
" Traube's line." In health this space gives a tympanitic note, unless
the stomach or transverse colon is full, or the omentum very fatty.
In left pleural effusion it is dull. (See Diseases of Lungs.)
A part of the anterior portion of the stomach and its lower border
PLATE XXXVIII.
FIG. 1.
Vb
Normal Position and Displacements of the Stomach.
Solid red line — Normal position of distended stomach. Blue line — Atonic
dililation. Dotted red line — Gastroptosis.
,
M M>
V5
%
Carcinoma of the Stomach with Pyloric Stenosis.
Metastases in the Liver.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 777
can be determined by percussion. Ordinarily, the most suitable posi-
tion for examining the stomach is the recumbent one, with the knees
drawn up, so as to relax the abdominal muscles.
The stomach contains air at all times, but the amount varies greatly.
The percussion-note is tympanitic, high in pitch, frequently with a
metallic ring ; its quality is peculiar — " stomach tympany."
The percussion-area of the stomach is increased (1) by causes exter-
nal to the stomach ; contraction of the liver, old pleurisy with retrac-
tion of lung, emphysema, former pregnancies, bad nutrition, and
tumors pulling down the stomach ; (2) by intrinsic causes ; distention
of the stomach.
Conversely, the percussion-area is diminished by causes external to
the stomach ; enlargement of the liver and spleen, left-sided pleural
effusion, pneumothorax, and hypertrophy of the heart.
Actual diminution in size of the stomach itself is difficult to demon-
strate clinically with certainty. If upon inflation the great curvature
remains at a higher level than 3 to 5 cm. above the umbilicus, diminu-
tion in size is highly probable. But even then the lower border may
be prevented from descending by adhesions to surrounding viscera.
Enlargement of the stomach is generally due to dilatation, and is
best marked clinically by a low position of the greater curvature.
Dilatation of the stomach, according to Boas, can be separated from
descent of the organ only when the greater curvature is more or less
below the level of the navel, and when the greatest height of the stom-
ach exceeds 10-14 cm. (4 to 5 J inches). But descent and dilatation
are frequently present together. (Plate XXXVIII., Fig. 1.) It
must not be forgotten that when there is descent the normal tympany
is lowered and the tympanitic area above the ribs is replaced by dulness.
Sometimes when the stomach is distended by air the right margin
will be seen to extend far beyond the ordinary limits. Michaelis
points out that this may be due to defective motor power, especially
if the right margin is more than 9 cm. from the median line. The
distention to the right is due to actual enlargement and not to disloca-
tion. The author believes that dilatation of the antrum of the pylorus
causes this enlargement. Enlargement of the stomach downward is
usually associated with good motor power, whereas enlargement to the
right is an indication of feeble motor power.
Auscultatory percussion is a most satisfactory method of determining
the borders of the stomach and its size. Its area can readily be de-
fined from that of the liver, spleen, and colon : First, with the stomach
normal ; second, inflated by gas ; third, filled with fluid. It is well
to determine the results in the recumbent posture, and then in the
upright, so as to determine if the stomach falls from its normal posi-
tion. Liquid maybe injected through the stomach-tube, or the patient
may drink successive portions, percussion being employed after each
amount (eight ounces) taken. After the site of the dulness is fixed,
have the patient lie down. The fluid falls backward and the air in
the stomach comes anteriorly ; the dull note is replaced by a tympan-
itic note. The change is a sign the fluid is in the stomach, and serves
to distinguish stomach from colon tympany. The force required for
778 SPECIAL DIAGNOSIS.
percussion should be very light ; indeed, a fillip with the nail is some-
times sufficient. It may even be well to allow the blow to glance from
the surface, as the perpendicular stroke brings out the general abdomi-
nal resonance. The use of coins is sometimes of advantage. In dila-
tation of the stomach the percussion-note sometimes varies in tone over
the viscus from dull to tympanitic, or vice versa, because the organ con-
tracts under the influence of the blows. Some have described a clink-
ing percussion-sound, not unlike that of the " cracked pot," over the
thorax.
Auscultatory friction is also employed in the same manner as auscul-
tatory percussion, while rubbing the finger tips over the surface lightly.
As long as the rubbing is made over the hollow organ over which the
stethoscope is placed, and not moved more than two inches from it,
the friction is heard distinctly.
In order to separate stomach tympany from that of the colon, which
resembles it, the stomach may be distended with gas, while the colon
contains solid or liquid matter ; or, if the colon be filled with gas, the
patient may be allowed to stand and drink a glass or two of water.
In either case the contrast between a dull and a clear note marks the
boundary between stomach and colon.
Ziemssen recommends carbonic acid (developed by mixing sodium
bicarbonate and tartaric acid) to distend the stomach ; the quantity
employed for adult men is seven grammes of bicarbonate of soda and
six grammes (one and one-half drachms) of tartaric acid. Adult
women should receive one gramme less of each.
As carbonic acid sometimes causes an uncomfortable oppression,
ordinary air is preferred by some. It can be forced in by a hand-
bulb syringe attached to an ordinary stomach-tube. The percussion-
note over tumors of the pylorus is imperfectly tympanitic. Welch
describes it as " tympanitic dulness." Less frequently it is dull, and
rarely it is flat.
Auscultation - . Auscultation can determine whether or not there
is obstruction at the cardiac orifice. On listening over the oesophagus
with the stethoscope, Avhen the patient is swallowing a liquid, a spurt-
ing sound is heard, followed in from five to ten or twelve seconds by
a second sound, which marks the escape of the fluid from the cardiac
orifice of the oesophagus into the stomach, so-called " deglutition-mur-
mur." When there is obstruction of the cardiac orifice the second
sound may be delayed as long as a minute.
When the stomach is partly filled with fluid a succussion or splashing
sound can be produced by moving the patient quickly from side to
side, or by quickly compressing the stomach and allowing it to rebound
again immediately. Such compression may be made alternately, first
in the neighborhood of the fundus of the stomach and then in the
region of the umbilicus. Both hands should be employed. The
splashing sounds are also developed by rapidly tapping, with the finger
tips held perpendicularly, the region between the ribs and the trans-
verse umbilical line on the left side. The ear need not be applied to
the body, but kept near by while the movements are made. Such
sounds are abnormal if they are heard lon^ after digestion should be
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 779
completed and the stomach empty. If they are heard more than three
hours after a light, or six hours after a full meal, it indicates slow
digestion or deficient motility, and gives the approximate position of
the lower boundary of the stomach.
Normally, after drinking fluids, a splashing sound is not developed
lower than the umbilical line. If it is heard below this line, it is an
indication of dilatation or of deep position of the whole stomach. Dil-
atation is very probable if the splashing sound is heard below the navel
in a fasting stomach. A good idea of the extent and location of the
splashing, and hence of the lower boundary, can be secured, if aus-
cultation is conducted when inflation is practised with air.
Furthermore, this sound is a sign of atony. If 50 to 100 grammes
of water be swallowed, no splashing sound is heard unless there is
atony of the stomach-walls ; but, if the atony is pronounced, a smaller
quantity will be sufficient to develop the sound. It is to be remem-
bered that the splashing sound of itself does not indicate disease. It
is significant only when taken with other signs, and also when it is
found after more than one examination.
II. Examination of the Gastric Contents. Either the con-
tents are secured with a stomach-tube or the vomitus is examined.
Mode of Procedure. 1. A test-breakfast (Ewald), or a test-dinner
(Leube), is administered, or the fasting stomach contents removed.
jEwald's iest-breahfast : It consists of one or two ounces (35 grammes)
of bread and a cup of tea (J litre), or the same amount of water.
Leube-Riegel test-dinner : A large plate of soup (400 c.c), a large por-
tion of beefsteak or other meat, some potatoes, and a roll are taken,
and examination is made three or four hours after the meal. (See
Boas' Meal. Lactic Acid.) 2. Remove the contents of the stomach
one hour after breakfast is taken, by aspiration or by expression.
Aspiration consists in the withdrawal of the stomach-contents by suc-
tion ; either with the ordinary stomach-pump, by means of a bottle
exhausted of air, as employed for paracentesis, and connected with the
stomach-sound, or by connecting the sound with a hand-ball aspirator
or Politzer bulb.
Expression consists in compression by the abdominal muscles, as if
straining in defecation. The patient takes a deep inspiration and then
contracts the muscles as above. If the tube is long enough it can be
bent, so as to assist expression with siphonage.
Aspiration is less disagreeable to the patient, and is necessary when
the stomach-contents are not fluid enough to flow easily.
Expression is not to be employed when there are old ulcers, ulcer-
ating carcinoma, phthisis with antecedent haemoptysis, or a disposition
to menorrhagia;
These methods supply the most reliable information of the condition
of the stomi :li and its secretions ; because, when once withdrawn, the
character of the secretions can be. ascertained accurately and the quan-
tity measured ; moreover, being able to choose the time of examination,
we can decide whether or not what is found corresponds with health, and
if not, in what particular it indicates disease. These methods permit a
diagnosis to be made before other methods supply sufficient data.
780 SPECIAL DIAGNOSIS.
A soft-rubber tube, with two good-sized openings near its distal ex-
tremity, should be selected. Stockton suggests a tracing of rings
around the tube one inch apart, beginning twenty inches from and
ending thirty inches from the lower extremity, for the purpose of
measuring the length of the tube inserted. In healthy adults the dis-
tance from the incisor teeth to the lower border of the stomach is about
twenty-two inches. In dilatation it may be from twenty-four to
thirty. The distance is partly determined by success in the siphon-
age. If the return flow of fluid does not take place, it is well either
to withdraw the tube or push it further on ; for, if too long, it may
curve above the level of the fluid, or, if too short, it may not reach
the fluid.
After the tube is moistened, oiled, or coated with the white of an
egg, the patient should be seated, and the tube at once passed to the
back of the pharynx, and, with or without guiding by the finger,
pushed toward the oesophagus. It is at once grasped by the oesopha-
gus or lower pharynx, and, if the patient is instructed to swallow and
to breathe slowly, it is rapidly carried downward by deglutition.
Mucus that accumulates in the mouth after the tube is passed should
be allowed to dribble outward and not be swallowed. It is often of
advantage to reassure the patient by having him pronounce the letter
" a " or some small syllable. It is not necessary to extend the head
backward. The tube is then attached to the apparatus used for para-
centesis, or to a tube entering a bottle in which a vacuum is created by
an ordinary rubber bulb apparatus ; or to the aspirator of Boas, which
is a modification of the ball-syringe. A valve is placed between the
stomach-sound and the syringe.
If a hard tube is used, it must be guided by the operator, who
should stand back of the patient, supporting the head, which should
not be thrown too far backward. The tube can be passed by the oper-
ator seated in front of the patient. This kind of tube is used with
the stomach-pump.
Normal Gastbic Contents. The amount of fluid, after digestion
of a test-breakfast has continued for one hour, is from 30 to 40 c.c.
After filtering the filtrate is clear, yellow, or yellowish-brown in color.
If the digestion is normal, the fluid should contain free hydrochloric
acid and no lactic acid. It should also contain pepsin, rennin (the
milk-curdling ferment), and organic acids. Albuminoids should be
converted into proteoses and peptone, and starches into achroodextrine,
dextrose, or maltose.
Physical and Chemical Examination. The steps taken are
as follows :
A. Physical examination :
1. The reaction.
2. The odor.
3. The character and quantity. Inspection.
B. Chemical examination.
It is to be observed that perfect familiarity with the products of
and the length of time required by normal digestion is very essential.
1. Reaction. The normal reaction of the contents of the stomach
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 781
is usually acid, from the hydrochloric acid of the gastric juice. It
may be alkaline in cases of hemorrhage, or in the vomiting known as
waterbrash.
2. Odor. The odor is sour normally, but it may be aromatic from
the presence of the fatty acids, fecal in obstruction of the bowels with
fecal vomiting, and, finally, may indicate the nature of poisonous in-
gesta — ammonia, phosphorus, carbolic acid. The dark, frothy mate-
rial from a dilated stomach is of a foul, yeasty odor.
3. Inspection of the Stomach-contents. By ordinary inspec-
tion the quantity and the character of the vomitus or stomach-contents
are noted. With the aid of the microscope the various micro-organ-
isms are sought for. In this manner most valuable information as to
the digestiye, motor, and absorptiye power is ascertained. Not only
do we learn whether digestion has taken place or not, but also the
variety of food that is undigested — albuminoids or hydrocarbons.
The Quantity. Fasting Stomach. If a person has taken no food or
drink between the evening meal and the following morning, the
stomach should not contain more than three and one-half fluidounces ;
more than this is abnormal.
The Character. By it we learn the digestive poiver. If undigested
food is found after digestion should be normally completed, there is
deficient digestive energy. No undigested food should be found longer
than six or seven hours after an ordinary meal of mixed foods.
By inspection of the gastric contents we learn much regarding the
motor poiver. Boas states that an abnormally great quantity of solid
matter and a small amount of chyme indicate an abnormal retention of
the latter, which is usually brought about by motor weakness (atony,
dilatation of the stomach), or dilatation in conjunction with insufficient
absorptive power. Sometimes, when there is a large residue in the
stomach, the contents separate into three layers. The uppermost is
mucus or undigested food ; the second, generally the thickest layer,
-consists of fluid ; and the lowest layer is chyme. Such a formation,
he says, points to abnormally long retention as the result of stenosis
and consecutive dilatation, or to motor weakness.
The stomach should be empty much sooner if only starches are
taken, as in Ewald's test-breakfast. One hour after the administra-
tion of a test-breakfast of 35 grammes of white bread and 300 grammes
of water there should remain 40 c.c. Hence, if after such a break-
fast there is found a much greater quantity, then motor or absorptive
insufficiency may be considered to exist. A filtrate of 100 to 300 c.c.
is very probably due to organic obstruction to the outflow, stenosis of
the pylorus, adhesions, or dislocation of the pylorus. Of course, to
make sure that the stomach contains nothing at the time of giving the
breakfast, it must first be emptied. The character of the food taken
is observed, as undigested particles may be seen in the contents.
We can discover by inspection if food is brought up by vomiting or
regurgitation. Regurgitation of food from the oesophagus can be told
from vomiting by the appearance of muscle-fibres, if meat has been
taken. If it is vomited, the fibre is in a state of disintegration ; if
not, it is whole.
782 SPECIAL DIAGNOSIS.
Mucus is found in small quantity normally, but is increased in
catarrhal affections of the mouth, throat, or stomach. When its source
is the mouth, saliva also is generally present. Mucus is recognized by
its stringy, tenacious character. Chemical diagnosis. Add the mucus,
gently shaking, to cold water ; pour off the supernatant water ; add
a little liquor potassse. The mucus is dissolved by the alkali. To
the solution acid acetic acid ; a precipitate is formed which is insol-
uble in an excess of acetic acicl. In this manner mucus is distin-
guished from the precipitate of syntonin, as the latter is soluble in
an excess. Pigmented mucus in vomitus is usually from the bronchial
tubes.
Bile and intestinal juice may be regurgitated into the stomach as the
result of violent emesis, or when the pylorus is much relaxed, or in
stenosis of the duodenum below the common duct ; bile is then present
in large quantity if the stomach is dilated. 1 Bile is recognized by the
usual tests (see under Examination of Urine), and intestinal juice by
its peculiar properties and the presence of leucin and tyrosin. Absence
of bile in the vomitus is an indication of pyloric stenosis.
Blood is found in ulcer ; cancer ; acute, especially toxic, gastritis ;
injuries to the mucous membrane from the use of the sound for expres-
sion, and violent retching. It is also common in cirrhosis of the liver,
and may occur in purpura, peliosis rheumatica, the hemorrhagic
diathesis, and in yellow fever. Blood mixed with gastric mucus may
come from the lung, the act of coughing having excited vomiting.
If the blood is unaltered, it can be distinguished from all other sub-
stances by microscopic examination. Occasionally the blood has the
appearance of coffee-grounds. The hemorrhage has taken place slowly
under these circumstances. In fact, the more rapid the bleeding the
brighter the red color of the blood. The hosmin test serves to distin-
guish it. The suspected material is filtered and a little of the filtrate
evaporated in a watch-glass ; when dry a small portion is mixed with
finely pulverized salt upon a glass slide ; it is then covered with a
cover-glass and one or two drops of glacial acetic acid allowed to flow
under the cover-glass. The acetic acid is evaporated by slowly heat-
ing the slip over a small flame, and when dry a few drops of water
are allowed to flow under the cover-glass, to dissolve the salt. If the
vomit contained blood, brown rhombic crystals of heeinin (hydrochlo-
rate of heemin) will appear under the microscope. As they are very
small, a magnification of about 300 diameters will be necessary to
bring them readily into view. The guaiacum test may be fallacious,
as the same color-reaction takes place when bile or saliva or a starch,
like potato, is in the test-liquid. It is performed as follows : Add two
or three drops of the tincture of guaiacum to a small portion of the
gastric contents in a test-tube and pour ozonic ether on the surface.
When the liquids meet a blue color develops. Bile may be distin-
guished from blood by Gmelin's test for the former — color-reaction
with nitric acid. If blood is present in the stomach-contents, it may
be detected by the test for iron. To the gastric contents, " coffee-
1 Hochhaus. Berlin, klin. Woch., 1891, No. 17.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 783
grounds," in a porcelain capsule, add a small quantity of potassium
chlorate and a few drops of a strong acid, HC1. Heat over a flame
and add a few drops of a 5 per cent, solution of potassium ferrocya-
nide. If iron is present, Prussian blue is formed.
Pas is rarely present in sufficient quantity to be detected by the
naked eye, but it sometimes occurs in phlegmonous gastritis and when
an abscess has ruptured into the stomach. In microscopic amounts
it may be found in severe catarrhal affections. Pus may be in
the vomitus and yet come from the lungs. It is usually a muco-
pus, and is told by the pigmented pellets or strings of mucopurulent
material.
Fecal matter is vomited in complete obstruction of the bowels, and,
according to Vierordt, in severe diffuse peritonitis. It is recognized
partly by its appearance and partly by its odor.
Worms are sometimes vomited ; the round worms not so very infre-
quently ; oxyurides and ankylostomata rarely.
Fig. 196.
U 'i
■ 3
Microscopical appearance of stomach-contents.
1, red blood -corpuscles ; 2, leucocytes; 3, squamous epithelium; 4, fat-globules; 5, starch gran-
ules; 5', starch changed by action of the gastric juice ; 6, muscular fibre ; 7, sarcinse ventriculi ;
8, fat-crystals ; 9, piece of orange ; 10, phosphatic crystal ; 11, yeast fungi ; 12, bacilli and micrococci-
Microscopical Examination. The illustration (Fig. 196) shows the
various matters which may be found in vomited matter. Briefly, they
are columnar and squamous epithelium ; white blood-corpuscles acted
on by gastric juice ; red blood-corpuscles. The corpuscles are usually
isolated. The red are rarely perfect, and in the white little more than
the nucleus remains. From the food we may also find muscle-fibres,
fatty globules, and fat-needles, clastic fibres and connective tissue,
starch-granules, and vegetable cells. Muscle-fibres are recognized by
their transverse striation. Fat-globules are soluble in ether, and are
recognized by their refracting powers. Starch-granules stain blue
with iodo-potassic-iodide solution.
In addition, fungi of many forms are found, as the mould-fungi ;
784 SPECIAL DIAGNOSIS.
the yeasts (torulse), and fission-fungi. The latter are recognized after
staining by the iodo-potassic-iodide solution, which colors them blue.
The most important fission-fungi are the sarcinse ventriculi. They
are of a dark gray tint, stain mahogany-brown to reddish-brown with
the above-mentioned solution, and resemble in shape corded bales of
goods. (See Bacteriological Diagnosis.) The torulce and sarcince are
present when fermentation is in progress, and hence indicate delayed
digestion from motor insufficiency or deficient digestive energy.
B. Chemical Examination. A chemical examination is made to
determine (1) the presence of free acids ; (2) the degree of total acidity
of the stomach-contents ; (3) the presence of free HC1 ; (4) the presence
of lactic acid ; (5) the presence of volatile acids ; (6) the presence of
products of digestion and the digestive power ; (7) the presence of
pepsin ; (8) the presence of rennin ; (9) the carbo-hydrates. Hydro-
chloric acid is the normal acid of the gastric juice. Normally lactic
acid is found during the first half-hour of digestion, when starches
have been taken. When only meats have been taken lactic acid is
not found early in digestion. The secretion of hydrochloric acid is not
delayed until then, but is at first combined, and cannot be detected
as free acid until half or three-quarters of an hour afterward.
1. Free Acids. The most sensitive test for free acids is Congo red.
Filter-paper soaked in a saturated solution of the dye and allowed to
dry is turned a deep blue if free acid is present. Prepared with a
weak solution, the filter-paper is turned to a light blue by HC1 and
violet by organic acids. Wolff l was able to detect one part of HC1
in 20,000 parts of water. When no reaction is obtained, therefore,
entire absence of acidity may be assumed.
Benzo-purpurin test-papers are made as follows : Soak strips of
filter-paper in a saturated solution of benzo-purpurin and dry. They
are purple. If hydrochloric acid is present they are turned dark blue.
The color is not removed by shaking with ether. If organic acids
(butyric or lactic) are present, it is turned brownish-black, but the
color is removed by shaking with ether. Von Jaksch states that if
hydrochloric acid and the organic acids are present a brownish-black
color is also produced, hence the dark blue and the volatile brownish-
black reactions only are important.
The presence of free acids, as indicated by the Congo red or benzo-
purpurin tests, shows that :
a. HC1 — inorganic acid — may be present alone.
6. Lactic, butyric, or acetic acid — organic acids — one or all, may be
present without HC1.
c. HC1 and one or more of the organic acids may be present together.
Free acidity may be due (1) to fixed acids— hydrochloric or lactic
acid, fixed acidity ; (2) to volatile acids — butyric or acetic acid, volatile
acidity.
2. The Total Acidity. This is determined by titration. The
stomach-contents must be well shaken ; if there is mucus in excess, it
must be strained off through coarse muslin. Fill a Mohr's burette
1 Trans. Philadelphia County Medical Society, 1889, vol. x. p. 305.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 785
with a decinormal solution of caustic soda. 1 To 10 c.c. of the filtered
gastric fluid add two drops of a saturated alcoholic solution of phe-
nolphthalein. Allow the caustic-soda solution to drop slowly from the
burette into the fluid, until a faint rose-red color is produced which does
not disappear on shaking. The color is produced by the action of
the alkali on the phenolphthalein. Four to 6 c.c. of the caustic soda
solution are required to neutralize the acid in normal digestion. The
degree of acidity is expressed in percentage. Thus if 4 c.c. neutralize
10 c.c, the total acidity will amount to 40 per cent., or if 6 c.c. are
required, to 60 per cent.
If more or less than the amount just indicated of the alkaline solu-
tion is required to neutralize the acid, the total acidity is increased or
diminished, and hence is abnormal.
Topfer's method : To 10 c.c. of stomach-contents in a beaker, add
3 to 4 drops of a 1 per cent, solution of sodium alizarin sulphonate,
then add a decinormal solution of sodium hydrate until a violet tint
appears corresponding to the hue produced by adding 4 drops of
alizarin solution to 5 c.c. of a 1 per cent, solution of sodium carbonate.
The solution reacts to all factors producing gastric acidity except com-
bined HO.
Martin recommends the following modification of the above : "To
20 c.c. of the stomach-contents add three or four drops of a saturated
alcoholic solution of phenolphthalein, and dilute with water to 300
c.c. Place 150 c.c. of this mixture in each of two flasks, and place
them side by side on a sheet of white paper. To one of the flasks add
decinormal solution of sodium hydrate until a red color appears ; the
exact time of appearance can be determined by comparison with the
liquid in the other flask. When a pinkish tinge appears the acid
liquid is neutralized. A control estimation may be made with the
second flask."
Ewald's method of expressing the total acidity is by a number.
The number is the same as the quantity of decinormal sodium hydrate
solution requisite to neutralize 100 c.c. of the gastric contents. Thus
if 50 c.c. of the soda solution neutralized 100 c.c. of the stomach-con-
tents, the acidity of the latter would be expressed by the figure 50.
The figures can be converted into terms of hydrochloric acid, as a deci-
normal solution of sodium hydrate is a liquid of a constant strength,
100 c.c. of which exactly neutralize 0.365 gramme of hydrochloric
acid. It may be expressed in terms of hydrochloric acid. If 50 c.c.
of decinormal sodium hydrate are required to neutralize 100 c.c. of the
stomach-contents, this would be equal to 0.18 gramme per cent, hydro-
chloric acid, as 3.65 grammes hydrochloric acid are neutralized by the
4 grammes of soda in a litre (1000 c.c.) of the decinormal solution.
3. Free Hydrochloric Acid. The gastric contents are now
filtered. Tropceolin 00 is declared by Boas to be an absolutely certain
test for HO. A saturated alcoholic solution is of an orange-yellow
1 Decinokmal solution of sodium hydrate is of the strength of 4 grammes of
pure sodium hydrate to the litre of distilled water. The sodium hydrate must be
pure and made from sodium. This weight of sodium hydrate (4 grammes) will exactly
neutralize 3.65 grammes of hydrochloric acid.
50
786 SPECIAL DIAGNOSIS.
color. Three or four drops of it are placed in a white porcelain dish
and spread upon the sides by rotating it. The same amount of the
fluid to be tested is then allowed to trickle down the sides of the dish
and intimately mixed with the tropseolin. (Or evaporate the dye to dry-
ness and then add the suspected liquid.) Upon heating the dish over
a small flame splendid lilac-blue to blue streaks, characteristic of HC1,
will appear if that acid is present. Xo organic acid gives the same
color.
Tropeeolin paper is turned brown by gastric juice containing HO,
the brown changing to blue upon the paper being heated. Organic
acids give a brown color also, but it disappears upon heating.
Tdpfer's test for the detection of free HC1 is as follows : Dimethyl-
amidoazobenzol is employed in a 0.5 per cent, solution of alcohol.
To a few cubic centimetres of filtered stomach-contents one to four
drops of the reagent are added in a test-tube or beaker. If hydro-
chloric acid is free a rose-red color is produced when the filtrate is
added to the reagent. The drug reacts to HC1 only when the latter
is in a free state. Its reaction is not interfered with by salts, peptone,
glucose, chloride of sodium, or starch. If organic acids are present
in a concentration of from 0.5 to 0.8 per cent, a reaction may be
brought about, providing albumin or peptone is present.
Phloroylucin vanillin, introduced by Giinzburg, is also a very sensi-
tive test for HC1. The following combination is said by Boas to be
more sensitive than the ordinary one, which contains only 30 grammes
of absolute alcohol :
Phloroglucin 2.0 (gr. xxx).
Vanillin 1.0 (gr. xv).
Alcohol (80 per cent ) .... 100.0 ffgiij).
Three drops are put into a porcelain dish and an equal quantity of
the stomach filtrate. Upon cautious heating over a small flame a beau-
tiful carmine surface is formed, especially at the edges. The same
color is not produced by inorgauic acids. Filter-paper soaked in it and
moistened with a few drops of stomach-filtrate, containing HC1,
changes on heating to a beautiful carmine, which is unaltered upon the
addition of ether. Giinzbun/s original test is employed with the same
solution, except that 30 parts of alcohol are used. " One drop of the
solution and one drop of the fluid to be examined are evaporated to
dryness on a water-bath. The appearance of a rose-red color indicates
the presence of hydrochloric acid.
Congo-red Test, Boas' method is a modification of that of Mintz.
Ten c.c. of the gastric fluid are shaken with 100 c.c. of ether until
organic acids are removed. The Congo-red test is then employed
until the grayish-blue discoloration cannot be secured.
Boas' Resorein Test. Dissolve 5 grammes (gr. lxxv) of resorcin
and 3 grammes (gr. xlv) of cane-sugar in 100 c.c. (f giijss) of weak
spirit, Apply the test in exactly the same way as Gunzburg's. A
similar rose-red coloration, if free hydrochloric acid be present, is pro-
duced. It is the cheapest solution that can be emploved.
Caution. In testing for the presence of HO it is better to give the
patient a meal which is known to be digestible within a certain time
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 787
by stomachs in a normal state, otherwise HC1 may appear to be absent,
because it is still combined with albuminoids. Ewald's test-breakfast
is the simplest. In one hour the contents of the stomach may be aspi-
rated and tested for HC1.
Amount of Free HOI. If by previous tests HC1 is found alone, its
percentage is easily calculated. To a measured quantity of the gastric
fluid add, drop by drop, from a burette a decinormal alkaline solution
until the acid is neutralized. This can be determined by checking
the titration from time to time, and examining with Giinzburg's reagent.
One c.c. of the alkaline solution is equivalent to 0.003646 HC1, the
limit of Giinzburg's reaction. Multiply the number of c.c. required
to neutralize 10 c.c. of the gastric solution by 0.003646, and again by
10, the result will be the percentage of acidity. If 6 c.c. are used, the
percentage will be 6 X 0.003646 X 10 = 0.218, within the normal
range, which is from 0.14 to 0.24 per cent. Giinzburg's test can be
used to estimate the quantity of HC1. This is applied by diluting the
stomach-contents until the test is not responded to. In health the
limit of response is found when one part of HC1 is found in 20,000
parts of the fluid. In abnormal conditions, when the gastric fluid is
diluted one-half, the proportion is 2 to 20,000, or 1 to 10,000. If the
fluid is diluted to ten times its original strength, it is 10 to 20,000, or
1 to 2000.
The following method is reliable and easy of employment. To two
or three drops of Topfer's solution of dimethylamidoazobenzol are added
10 c.c. of gastric contents, and a decinormal soda solution allowed to
flow in, drop by drop, until a yellow color takes the place of the red.
The number of c.c of solution of soda which will neutralize the free
HC1 in 100 c.c. of stomach-contents is multiplied by 0.00365. The
result is the percentage of HC1. If 4 c.c. of soda solution is required
to remove the red color, multiply 0.00365 by 40, the number equals
0.14 per cent, free hydrochloric acid.
4. Lactic Acid. If the stomach-contents are colorless, apply the
following tests ; if they are yellowish, make an ethereal extract, as
described below, and then use the tests. Its presence may be deter-
mined by Uffelmann's reagent : Mix one drop of pure carbolic acid
with fiye drops of a dilute solution of neutral ferric chloride. Add
sufficient water to render the whole of an amethyst-blue color. To
this add a few drops of the gastric fluid. A mere trace of lactic acid
will change the blue to a light yellow or greenish yellow. The test
for lactic acid is simulated when phosphates, glucose, or alcohol are
present in the gastric juice. The lactic acid should be removed by
extracting with ether, as follows : 50 c.c. of gastric contents are re-
duced to 10 c.c. by heat in an evaporating-dish over a water-bath.
After the concentrated solution cools add 50 c.c. of ether. The vola-
tile acids are driven off by heat, the lactic acid is dissolved by ether,
and hydrochloric acid remains in the residue. Apply the test for lactic
acid to the ethereal extract if it is acid. The following is more deli-
cate : Add one drop of liq. ferri perchloridi to 50 c.c. of water ; add
suspected solution ; the presence of lactic acid causes a yellow coloration.
Boas uses the following : When a substance containing lactic acid
788 SPECIAL DIAGNOSIS.
is heated with oxidizers, such as manganese dioxide and sulphuric acid,
the lactic acid is decomposed into formic acid and acetic aldehyde ; the
latter is detected by the formation of iodoform with an alkaline solu-
tion of iodine ; peptone and alcohol, which react similarly, are elimi-
nated by concentrating the filtrate to a syrup. As carbohydrates also
yield aldehyde when treated with oxidizers, a watery solution of an
ethereal extract of the condensed gastric filtrate of a trial-meal free from
lactic acid must be used.
Arnold (Joum. Am. lied. Assoc, Chicago, 1898, vol. viii. p. 21)
gives a new test for the detection of lactic acid in the stomach-con-
tents.
a. 0.2 c.c. saturated alcoholic solution of gentian-violet in 500 c.c.
of distilled water,
b. Tinctura ferri perchloridi (U. S. Pharm., 1890), 5 c.c. ; distilled
water, 20 c.c.
A drop of solution b, added to 1 c.c. of solution a in a porcelain
basin, gives a blue color, which changes to a green or yellow-green on
the addition of a few drops of filtered stomach-contents should lactic
acid be present.
5. The Volatile Acids. These acids are best detected by their
smell, their volatility, and their reaction.
Butyric acid is recognized by the pungent odor of rancid butter
given off when the stomach-contents are evaporated. It is recognized
by the following reaction : To a small quantity of the liquid add a
small quantity of alcohol and two drops of strong sulphuric acid ;
heat for a short time ; a characteristic smell of butyric ether, like that
of " pineapple rum," is given off.
Butyric acid is also detected by Uffelmann's reagent. A few c.c. of
the filtered gastric fluid are shaken with three or four times the amount
of ether. The ether is poured off when it rises on the top, and fresh
ether added and the washing repeated. After the third washing the
ether that cannot be poured off is evaporated by means of a water-
bath. Add a few drops of water to the residue and then an equal
amount of the reagent. The characteristic color is produced. It
strikes a tawny yellow color with a reddish tinge. As much as one
part of the reagent in 2000 is required.
In addition to Uffelmann's test the volatile acids may be detected
by boiling a few c.c. in a test-tube, over the mouth of which blue lit-
mus-paper is attached. If acid is present, its vapor will change the
blue to red. Acetic acid is recognized by its odor, particularly after
heating the solution. It may be detected as follows : Secure an
ethereal extract of the gastric contents (as above), evaporate in a water-
bath, and dissolve the residue in water. Neutralize the watery solu-
tion with sodium carbonate, and then add neutral ferric chloride solu-
tion. A blood-red color results if acetic acid is present.
Alcohol is detected by its odor and by Lieben's iodoform-test.
Distill the stomach-contents, add to a portion a small quantity of liquor
potass®, and then a few drops of iodine-iodide of potassium solution.
A precipitate of iodoform takes place slowly if alcohol is present. If
acetone is present, it forms rapidly.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 789
6. The Products of Digestiox. The ultimate products of diges-
tion are the proteoses and peptones. If they are present in the stomach-
contents, it shows that hydrochloric acid and pepsin must have been
secreted in the stomach. If vomiting occurs soon after food is taken,
or if there is obstruction at the lower end of the oesophagus, these
products are not present. Syntonin is a product of digestion which
precedes the two above given. To ascertain if digestion has taken
place, it is necessary only to test for syntonin and then employ the
biuret test. Syntonin is detected by neutralizing the gastric contents
with a solution of sodium hydrate. The precipitate is syntonin, which
is soluble in an excess of alkali, and may be again precipitated by an
alkali. After nitration and removal of the syntonin, proteoses and
peptone are detected by the biuret test.
7. Pepsix. If HC1 is present, add 5 c.c. of a gastric filtrate to a
small piece of egg-albumin. Allow digestion to take place for several
hours at 37° to 40° C. Non-digestion indicates absence of pepsin.
If HC1 is absent, pepsinogen is found alone. Add two drops of a
25 per cent. HC1 solution to 10 c.c. of the gastric contents. Add to
this solution a small portion of egg-albumin. If it is dissolved, pep-
sinogen was converted into pepsin by HC1.
8. Rexxix (the milk-curdling ferment). This may be detected as
follows : From 5 to 10 c.c. of cow's milk of neutral reaction is boiled and
added to neutralized and filtered gastric juice. Place the mixture on a
warm bath heated to 30° or 40° C. The casein of the milk is precipi-
tated in flakes in from twenty to thirty minutes if the ferment is present.
9. The Carbohydrates. Add a few drops of Lugol's solution to
the gastric contents. If starch is present, it turns blue. If erythrodex-
trin, it becomes purple. If the digestion has proceeded so far as to
change starch into dextrose, the iodine hue remains unchanged. The
starches should be completely digested an hour after they are taken
into the stomach, hence in health the iodine hue should not change after
this time.
III. The Digestive Power. Giinzburg has introduced the use
of iodide of potassium in the following way : From three to five grains
are placed in a rubber tube with extremely thin walls ; the ends of
the tube are then bent and brought into apposition with each other
and fastened in that position with three fibrin threads made firm by
preservation in alcohol. The whole packet is then pressed into an
empty gelatin capsule and given to a patient to swallow one-half hour
after a test-breakfast. The saliva is tested for iodine every fifteen
minutes. The more rapid the solution of the capsule and fibrin
threads the sooner the iodine can be absorbed and appear in the
saliva, and hence this rapidity is an index of the digestive energy.
The method is liable to fallacies. Solution of the fibrin may take
place in the intestine instead of the bowel, and the threads may be
loosened by the acids of fermentation instead of by digestion. Never-
theless, the test is a valuable one, especially when aspiration is inad-
missible.
The digestive power can be estimated by ascertaining (1) the pres-
ence of gastric juice and (2) its activity.
790 SPECIAL DIAGNOSIS.
1. The Gastric Juice. Wash out the fasting stomach with 400 c.c.
of lukewarm water ; test by litmus-paper for neutrality, then inject
50 c. c. of a 3 per cent, solution of soda. Allow the solution to remain
twelve minutes and then remove by washing out the stomach with
400 c.c. of water. If the HC1 secretion is normal, the soda solution
is neutralized. If it is deficient, the solution remains alkaline. The
presence of pepsin is then to be determined.
2. The Activity of the Gastric Juice. The white of one or two eggs
should be boiled in four ounces of water and then administered.
Remove the stomach-contents one-half hour later. The stomach should
be emptied by lavage beforehand. The residue removed will show
if digestion is complete, and proteoses and peptones may be tested for
by the biuret reaction.
Test for the Activity of the Gastric Juice and of the Movements by a
Test-meal. Ewald's test-breakfast must be employed if the patient
cannot bear more solid food, otherwise Leube's test-meal should be
used. If digestion is normal, the stomach-contents removed from five
to seven hours after a test-meal are neutral and contain a few flakes of
mucus. At the end of five hours the stomach-contents are acid and
contain peptone, some undigested muscle-fibres, and starch-grains. If
the stomach contains undigested food at the end of seven hours, the
contents are acid and contain peptones, indicating delay in digestion.
IV. The Motor Power. Ewald and Sievers have suggested the
use of salol ; fifteen grains are given, and normally salicylic acid
should be detected in the urine in from forty to sixty minutes, or in
seventy-five minutes at the latest. If it is deferred still longer, motor
insufficiency is indicated. The sign is of value only when the excre-
tion is delayed. Urine containing salicylic acid gives a dark, brown-
ish-red color upon the addition of a drop of tincture of the chloride of
iron.
Klemperer's oil-test is more accurate, although disagreeable. One
hundred grammes of oil are placed in the stomach by the stomach-
tube. In two hours the stomach-contents are removed by aspirating,
previously adding a little water. The amount of oil is dissolved by
ether, the solution evaporated, and the residuum of oil weighed. Sev-
enty-five to eighty per cent, of the oil should be discharged in two
hours.
V. The Absorptive Power. Penzoldt and Faber recommend the
administration of three grains of chemically pure iodide of potassium
— i. e., free from iodic acid — a short time before dinner. Any frag-
ments of free iodine adhering to the iodide of potash are first carefully
washed away. The saliva is tested for iodine with starch-paper and
fuming nitric acid. If absorption is active, a violet color is obtained
in from six and one-half to eleven minutes, and a blue color in from
seven and one-half to fifteen minutes. Zweifel directs that 3 grains
(0.2 gramme) of iodide of potassium be administered in a gelatin cap-
sule, and 3| oz. of water (100 c.c.) taken ; iodine is detected in about
eight minutes in the saliva. The character of the food taken is said
to have considerable influence in retarding the appearance of the reac-
tion, so that the blue reaction may not appear for forty-five minutes.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 791
Boas states that in dilatation of the stomach the reaction may be de-
layed to two hours, and in cancer as long as eighty-two minutes.
Both motor and absorptive power are recognized also by digestive delay.
Clinical Value of a Chemical Examination of the ^ r omitus or Stomach-
contents. It cannot be gainsaid that the chemical examination of the
stomach-contents is of the utmost clinical value. It is just as certain,
however, that the results attained by such examination should not be
final in the formation of a diagnosis ; that alone they do not meet the
expectations of clinicians. This is particularly so when we attempt to
deduce a scientific therapeusis from such examination. To rely upon
the results of such examination alone would lead to failure. The diag-
nosis, and, therefore, the rational therapeusis, must rest not alone upon
a chemical examination, but also upon other methods of examination
of stomach-contents, the physical examination of the stomach, the his-
tory and progress of the case, and the subjective symptoms. In short,
a general view must be taken, and all methods of inquiry employed.
Diseases of the stomach require for their correct estimation broader
lines of investigation than almost any other organ of the body. More-
over, the practitioner must not be discouraged if he cannot employ
chemical methods with the skill of the laboratory expert. The simple
methods detailed above can be conducted by any educated physician.
For practical purposes, it is only necessary to determine the total acid-
ity, the presence of free acids, the presence of free HC1, the presence
of lactic acid and of the volatile acids.
Finally, the clinician must not be discouraged if the stomach-
contents cannot be secured, on account of the contraindications pre-
viously detailed. An approximate diagnosis — probably not so precise
or final — can usually be made by means of a physical examination of
the stomach and a consideration of the symptoms.
The results of the chemical examination have the clinical value
estimated herewith. In the first place, we find whether the acidity
is increased or diminished.
1. Diminished acidity, or anacidity, means deficiency in the amount
of HC1 secreted. Diminished acidity may be due to functional or
organic disease of the stomach. It occurs in fever, in chlorosis, and
pernicious anaemia, chronic wasting diseases, including tuberculosis,
and acute infectious diseases from functional disturbance of nervous or
hgemic origin. It occurs in chronic dyspepsia from irregularities in
diet. It is also deficient in congestion, acute catarrh or atrophy of the
mucous membranes, and in carcinoma, which apparently modifies gas-
tric secretion.
2. Increased acidity may be due to an increase of hydrochloric acid
— hyperacidity, or to an increase of the organic acids — increased acidity.
a. Hypersecretion of HC1 takes place in the early stages of gastric
irritation — dyspepsia. It may be increased in gastric ulcer, b. In-
creased acidity (organic acids) may be due to excess of (1) lactic acid ;
(2) of butyric acid, and (3) of acetic acid. Excess of lactic acid is due
to fermentation of carbohydrates from the growth of the bacillus acidi
lactici or bacillus lactis aerogenes ; of butyric acid, to butyric acid
fermentation ; of acetic acid, to alcoholic fermentation of the above-
792 SPECIAL DIAGNOSIS.
mentioned class of foods. Alcoholic fermentation is often due to the sar-
cinse. In short, these acids result from bacterial fermentation, a process
which takes place only when there is delayed motor power, or when
the normal antiseptic — the HC1 — is absent or diminished. Hence, we
find these acids in weakness of the muscles, as in dilatation, in organic
obstruction of the pylorus, and in cancer of the stomach ; while the
bacteria are found on microscopical examination.
3. Free hydrochloric acid is diminished in acute and chronic catarrh
of the stomach (gastritis), in chronic dyspepsia, in ulcer of the stomach
and duodenum, in gastric atrophy, in dilatation, in gastric carcinoma
(early stage), and from all general causes which lessen the total acid-
ity, including diabetes and Addison's disease. Of course, deficiency
of hydrochloric acid means deficiency of functional activity, and goes
hand-in-hand with diminished motor and absorptive power. The acid
is increased in the early stages of irritative dyspepsia and in ulcer of
the stomach, and at different periods in the gastric neuroses. The
most common causes of increase of HC1 are the gastric neuroses.
Hydrochloric acid is absent entirely in advanced chronic gastritis and
in the gastric neuroses. In the former there are evidences of fermen-
tation. HC1 is often absent in cancer, but unless constantly absent,
and two or more other facts of value can be secured, the diagnosis
cannot be made on the chemical examination alone.
4. Lactic acid. Its presence points to fermentation, hence it is asso-
ciated with lesions that are accompanied by bacterial fermentation.
It is present in carcinoma, as pointed out by Boas. Fermentation
is not the only condition in which it occurs. It is nearly always found
after a meal of meat, and is known as sarcolactic acid. It may occur in
chronic catarrhal gastritis. In cancer of the stomach lactic acid is the
most common objective sign. Its absence does not exclude carcinoma.
It may be detected before a tumor is palpable. Therefore, if lactic
acid is present and free HC1 absent, cancer can be pretty safely diag-
nosticated, particularly if stagnation of stomach-contents is also pres-
ent. Boas recommends a meal which will not yield sarcolactic acid.
It consists of one to two litres of oatmeal gruel, to which a little salt
may be added. It should be removed by expression one hour after it
has been taken. It is well to remove all food by lavage six hours
before the test-meal is given.
The clinical value of the remaining chemical tests and investigations
need not be explained. They indicate inability of the gastric function
to accomplish digestion, but do not point to any special gastric affec-
tion. They are of value in distinguishing between gastric neuroses and
an organic disease. In both there are pronounced gastric symptoms ;
if the examination shows normal digestive powers, a neurosis is indi-
cated.
Gastric Hemorrhage. Hemorrhage of the stomach, ho?.mateme-
sis, or vomiting of blood, is due to an organic lesion, or the effects of
acute irritant poisoning. The blood is vomited. Care must be taken
to see that the blood is not from the upper air-passages, and previously
swallowed. If hemorrhage is profuse, the blood may cause irritation
of the larynx, and provoke paroxysms of coughing. It is often diffi-
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 793
cult, therefore, to distinguish between hemorrhage from the lungs and
hemorrhage from the stomach.
H-EITATEMESIS.
1. Previous history points to gastric,
hepatic, or splenic disease.
2. The blood is brought up by vomiting,
prior to which the patient may experience
HiEMOPTYSIS.
1. Cough or signs of some pulmonary
or cardiac disease precedes, in many cases,
the hemorrhage.
2. The blood is coughed up, and is usu-
ally preceded by a sensation of tickling in
a feeling of giddiness or faintness. ; the throat. If vomiting occurs, it follows
! the coughing.
3. The blood is usually clotted, mixed 3. The blood is frothy, bright red in
with particles of food, and has an acid re- ; color, alkaline in reaction. If clotted, it is
action. It may be dark, grumous, and rarely in such large coagula, and muco-
fluid. pus may be mixed with it.
4. Subsequent to the attack the patient ! 4. The cough persists, physical signs of
passes tarry stools, and signs of disease of ! local disease in the chest may usually be
the abdominal viscera may be detected. | detected, and the sputa may be blood-
| stained for many days. ( Osler. )
The hemorrhage may continue within the stomach without exciting
vomiting. The general symptoms of hemorrhage may appear, first, as
pallor, dimness of vision, giddiness, or faintness. The blood which
conies from the stomach is usually acted upon by the gastric juice, and
is dark, clotted, and partly digested. It is often mixed with food.
Its reaction is acid. In large hemorrhages the blood may be fluid
and of a scarlet color ; but if retained for any length of time, it is
coagulated. The vomited matter has the appearance of coffee-grounds,
when there is a small amount of blood. When large in amount and
digested, it appears like tar.
Vomiting is usually followed by movements of the bowels. The
matter discharged is of characteristic appearance. It is black or tarry.
It is distinguished from hemorrhage of the intestinal canal below the
duodenum by the color of the blood. In intestinal hemorrhage the
blood is dark red, and not necessarily tarry. The dark stools must not
be confounded with the same character of stools seen when iron or
bismuth is taken. In rare instances a hemorrhage into the stomach
may take place from disease of the lower part of the oesophagus.
Causes. 1. General diseases, from changes in the blood, cause gas-
tric hemorrhage, as scurvy, purpura, hemorrhagic smallpox, yellow
fever, acute yellow atrophy of the liver, and severe anaemia, leukaemia,
Hodgkin's disease, and pernicious anaemia. 2. Ulcer of the stomach.
3. Cancer of the stomach. 4. Ulcer of the duodenum. 5. Portal
congestion, as in cirrhosis of the liver, and other forms of chronic
hepatic disease. 6. Disease of the spleen. 7. Congestion due to dis-
ease of the heart. 8. In chronic Bright' s disease with atheroma. 9.
Rupture in aneurism. 10. Vicarious menstruation. 11. Cohen asserts
that it occurs in vasomotor ataxia.
Profuse and sudden hemorrhage, in the absence of well-marked
symptoms of disease, is in nearly all cases due, either to latent ulcer,
or to congestion of the stomach from early cirrhosis of the liver.
General Examination. The objective examination has thus far
been confined to a study of the stomach. The student will infer from
the previous chapters that in order that on the one hand the possible
794 SPECIAL DIAGNOSIS.
cause of the gastric disorder may be determined, or, on the other, the
effect of gastric disorder upon the other organs ascertained, they must
be examined carefully. Moreover, valuable data in the recognition of
gastric affections and the diagnosis of the various forms are secured by
such examination. The general appearance of the patient, the state of
nutrition, and the degree of strength furnish suggestive facts in the
diagnosis. As well said by Stockton :
" The preoccupied and dejected manner observed in those suffering
from continued gastric flatulency ; the restless, discomposed behavior,
the stooped posture and half -surprised expression often seen, in the
victims of gastralgia ; the emaciated, weak, and cachectic appearance
frequently accompanying chronic food stagnation, are good examples
of the value of the general appearance in the diagnosis."
It must be remembered that any local source of irritation distant
from the stomach, as the eyes, the nose and pharynx, the uterus and
ovaries, and the rectum, may be the primary cause of gastric disorder.
The study of the hepatic and intestinal functions assist in the diag-
nosis. Examination of the urine and the blood may enable us to
determine the nature of a gastric morbid process. Even the study of
the skin is of importance.
" A sallow, earthy-colored skin, showing improper secretion ; a dry,
harsh skin, with too rapid loss of epithelium, showing poor nutrition ;
a skin showing oedema, poor capillary circulation, lividity, or acne ;
certain forms of eczema, excess of pigment, or syphilides may afford
important information as to the digestion, inasmuch as some of these
may be the results and others accompaniments of gastric disturbance "
(Stockton).
The Blood. Examination of the blood enables us to determine
the degree of anaemia Avhich may be the cause of digestive failure.
The examination must be exhaustive. If a leucocytosis is present, the
gastric neuroses may be excluded. In carcinoma there is not only a
severe secondary anaemia, but also poikilocytosis and a multinuclear
leucocytosis. Such changes are without doubt the result of interference
with the digestion because of motor inactivity. Moreover, certain
gastric diseases have specific effects upon the blood. Gastric ulcer
may be distinguished from gastric carcinoma, by the fact that digestive
leucocytosis occurs in the former while it is absent in the latter.
The Urine. No study of a gastric disorder is complete without
an exhaustive examination of the urine. For diagnostic, but chiefly
for therapeutic purposes, the presence of renal insufficiency, hyper-
lithuria, indicanuria, glycosuria, peptonuria, and albuminuria must be
tested for.
The Reaction. The reaction of the urine is modified by the state of
the stomach. In health the urine is alkaline after a full meal of ordi-
nary character. When HC1 is absent from gastric contents, this normal
alkalinity does not occur. Alkalinity is rarely seen in gastric carci-
noma.
The Chlorides. The chlorides are lessened when a small amount of
food is taken ; a similar cause lessens the amount of urea. Both are
decreased in carcinoma and in benign diseases of the stomach. But
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 795
the chlorides are diminished in carcinoma without a proportionate
lessening of the urea. It is this disproportion which is of diagnostic
value, as pointed out by Nothnagel, in carcinoma ventriculi.
Diseases of the Stomach Characterized by Fever, with Pain and
Vomiting.
Acute Gastritis. The simple variety of acute gastritis varies
according to the cause, from a slight attack of vomiting after indiscre-
tion in diet, with ordinary symptoms of indigestion, to the more severe
forms ushered in by chill and attended with fever.
In the mild forms there is a sense of fulness and discomfort in the
epigastrium, attended with nausea. The appetite is lost, and there
may be disgust for food, and the flow of saliva is increased. There is
undue acidity. On examination the epigastrium is found to be tender.
The onset of the attack is attended with giddiness, flashes of light
before the eyes, frontal headache, and some prostration. The pulse is
increased in frequency. When this nausea is most pronounced the
face is pale and the extremities cold. Vomiting then occurs, the
matter ejected consisting of ingesta only slightly changed, with mucus
and watery fluid. It is very bitter. It is often colored green from
bile-pigment. Another attack of vomiting may be sufficient to give
relief, or it may be repeated for twenty-four to forty-eight hours every
hour or two. After the stomach is relieved of food, mucus and bile
alone are vomited.
Examination of Stomach-contents. The reaction of the vomited
matter is neutral or faintly acid. No free hydrochloric acid is present,
but later lactic and fatty acids are found. Pepsin is diminished in
quantity.
Twelve to twenty-four hours after the gastric symptoms intestinal
symptoms may arise. Borborygmi and colicky pains are complained
of, followed by diarrhoea, with some tenesmus.
Herpes labialis may occur, and some writers speak of a peculiar
odor which is exhaled from the skin. The more severe cases are
ushered in with chill followed by fever. The local symptoms are
much aggravated. The tongue is furred, and the breath foul. The
vomiting is frequent and severe. The skin is livid and the pulse be-
comes rapid.
Diagnosis. In the acute cases attended by fever it may be mistaken
for meningitis, peritonitis, or hepatitis. The same gastric symptoms
may usher in an attack of pneumonia. The possibilities of a mistake
are to be borne in mind, and in all cases of vomiting with fever due
regard must be paid to the possibility of the gastric symptoms being
symptomatic only. It must be borne in mind that the same group
of symptoms that belong to gastritis accompanies the exanthematous
diseases, and diphtheria, dysentery, pyaemia, and puerperal fever.
They may be of reflex origin, or due to the action of fever, poison, or
ptomaines on the stomach. Ewald calls it sympathetic gastritis when
the symptoms are the same as in the simple variety, masked, however,
796 SPECIAL DIAGNOSIS.
by the primary disease. Sometimes, however, as in the eruptive
fevers, attention is directed to the state of the stomach, to the exclusion
of other conditions. And often, to the surprise of the student, an erup-
tion or inflammation ensues, which indicates the true nature of the case.
In cases of gastritis, therefore, endeavor to find a local cause for the
symptoms. If there is no history of indiscretions in diet, of exposure,
of exhaustion, or mental shock, on account of which digestion might
be arrested, then inquire for a history of exposure to contagious dis-
eases and look for the earlier evidences of exanthemata. If the result
of the examination is still unsatisfactory, examine the condition of
each individual organ, particularly bearing in mind meningitis, pneu-
monia, peritonitis, nephritis, and general infections.
Mycotic and diphtheritic gastritis occur secondarily to typhoid fever,
pneumonia, pyaemia, smallpox, and sometimes diphtheria. The mucous
membrane may be covered with patches in areas or throughout its
whole extent.
Some special micro-organisms irritate the gastric mucosa, as the
anthrax bacillus and the sarcinse and yeast fungi in cancer and dilata-
tion of the stomach. Rarely tuberculous inflammation with ulceration
takes place, and other micro-organisms have been described. Klebs
found the bacillus gastricus with numerous spores in the tubules, as
a consequence of which a gastritis was set up.
The mucous membrane itself escapes infection from micro-organisms,
because of the character of its secretion. The acid gastric juice is
antagonistic to and causes the death of micro-organisms. Tuberculo-
sis, for instance, rarely attacks the stomach for this reason.
Phlegmonous Gasteitis. This is a very rare affection, in which
the inflammation is seated in the submucosa and leads to perforation.
The onset is sudden. The chief local symptom is intense pain in the
epigastrium, with a burning sensation. There are great acidity, dry
tongue, and absolute anorexia. The fever is high and characterized
by delirium. Chills usually accompany it. The pulse is small, rapid,
and irregular. The matters vomited are first mucus, then pus. The
patient is extremely restless and anxious, even delirious, and early
passes into coma. Death takes place from collapse. It is impossible
to make an absolute diagnosis, as local peritonitis and abscess of the
liver are characterized by the same symptoms. In abscess a tumor
may form in the epigastrium. It may occur idiopathically, but it fre-
quently occurs in septicaemia, and follows trauma.
Toxic Gasteitis. This form of gastritis is allied to the former in
the severity of general symptoms. It is the result of the swallowing of
irritating poisons, of which phosphorus, arsenic, bichloride of mercury,
and caustic acids and alkalies are the most common. It is attended by
inflammation of the mouth, oesophagus, and stomach. There are sali-
vation and dysphagia, and constant vomiting of blood, often with shreds
of mucous membrane. The patient is restless, and may have convul-
sions ; collapse readily develops. In mild cases, in which the local
effects of the corrosive substance have been mitigated by proper anti-
dotes, sloughs occur, leaving behind ulcers on the mucous membrane,
which, after healing, result in deformity or stenosis of the oesophagus.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 797
Some cases are attended by other symptoms peculiar to the special
poison. Thus with arsenic there are choleraic symptoms ; in phos-
phorus-poisoning the symptoms come on late after its ingestion, and
are attended by jaundice and symptoms of acute yellow atrophy.
Diseases of the Stomach Characterized by Indigestion.
Functional Disorders of the Stomach. The Neuroses. Func-
tional disturbances of the stomach are due to impairment of the motor
power of the stomach, impairment of the secretory function and of the
sensory function. The following table of Ewald, as given by that
distinguished authority, is a classification of the various neuroses mid-
way between the symptomatic and the etiological :
The Neuroses of the Stomach.
1. Conditions of Irritation.
a. Sensory. b. Secretory. c. Motor.
Hyperesthesia. Hyperacidity. Eructation.
Nausea. Hypersecretion. Pyrosis.
Hyperorexia. Vomiting.
Anorexia ex hyperesthesia. Colic.
Parorexia. Tormina ventriculi.
Gastralgia.
2. Conditions of Depression.
Polyphagia. Anacidity. Atony.
Anaesthesia. Insufficiency of the pylorus and
cardia.
3. Mixed Form.
Gastro -intestinal neurasthenia (dyspepsia nervosa).
4. Keflexes from Other Organs upon the Gastric Nerves.
Reflexes from the brain, eyes, spinal cord, kidneys, liver, sexual organs, and
intestines manifest themselves in the forms mentioned in 1 and 2.
It must not be supposed that each of the above-named symptoms
occur in an individual, or that functional disturbances may be limited
to alterations of the sensory and secretory or the motor apparatus, re-
spectively. They do not occur, as Ewald states, as distinct indepen-
dent diseases, but usually in groups, " either appearing simultaneously
or closely following one another during the course of the malady, pass-
ing before us like an ever-changing scene." They may arise directly
from disease of the stomach, or reflexly from disease of other organs,
as the brain, the spinal cord, uterus, kidneys, liver, eyes, and nose.
Etiology. Gastric neuroses are of most frequent occurrence in
women, especially during the years from puberty to the menopause.
The accidents of childbirth are predisposing factors. In both sexes
they are of most frequent occurrence after the age of twenty years,
because individuals are subjected to causes which lead to neuroses at
this period of life. The gastric neuroses occur in all conditions of
patients. They are more likely to occur in those who are poorly nourished
or anaemic ; although persons who are distinctly robust may also suffer.
While more common in the residents of cities, they may occur in
farmers and others accustomed to an open-air life. Although we are
798 SPECIAL DIAGNOSIS.
oftenest called upon to treat them among the better classes, neverthe-
less a large number of cases are seen among the poor. To analyze
more closely the predisposing causes, we have to study individually
all conditions and circumstances in life which lead to wear and tear,
as in business or social affairs. The causes which Beard and others
have forcibly pointed out as factors in the production of neurasthenia
are especially prevalent in this country.
In men, excessive devotion to business, or dissipation ; in women,
excesses in social life, or the restraint of home cares, with, unhappily,
too often, the irritation of marital relations, are the predisposing
factors which lead to the development of this class of cases. Often
patients in the large cities are subject to the neuroses in the spring
after the dissipations of the winter. Behind this excess there is, no
doubt, in the majority of cases, a nervous temperament that is respon-
sible for the bringing out of the symptoms, particularly if, combined
with this temperament, the patients live in an unhygienic way in
regard to exercise, ventilation of their dwelling-places, and drainage,
combined with improper diet.
Symptoms. With the gastric neuroses other symptoms of neurasthe-
nia are present, and the patient may seek advice for these symptoms,
such as headaches of various kinds, changes in the mental condition,
vertigo, insomnia, neuralgias, and all forms of paresthesia. Intimately
connected with the neurasthenic state is that of hysteria, and therefore
in gastric neuroses hysterical manifestations are most common. It may
be impossible completely to define the border-line between neurasthe-
nia and hysteria, and the gastric symptoms of the former are the gas-
tric symptoms of the latter. While, therefore, general neurasthenic
symptoms are prominent, in order to reach a diagnosis upon which
proper lines of treatment can be based, the condition of the individual
must be viewed as a whole, and no one symptom or group of symptoms
exaggerated in our minds.
Varieties. Ewald has divided the neuroses into those which arise
from («) irritation, those which arise from (b) depression, and (c) those
in which both are combined — mixed neuroses.
(a) 1. Sensory Neuroses of Irritation. Hypek.esthesia. The
first result of irritation is hyperesthesia of the stomach, which is indi-
cated by a feeling of fulness and tension, and of nausea. The sensation
is allied to the normal, and is also seen in chronic gastritis, as well as
in hysteria, meningeal irritation, cerebral tumors, and other diseases
of the nervous system. The increased irritability is such that the
gentlest irritant excites discomfort or a painful sensation. There is a
continuous sensation of heat or cold, of gnawing, or pulling, or burning
in the organ. The local sensation reflexly influences the physical life
of the patient, so that hypochondriasis in some form attends it. The
sensations may be relieved by food, to become worse if the stomach is
emptied, although in the larger number of cases the trouble is aggra-
vated during digestion. The sensations are likely to be aggravated by
fasting a longer period than usual, or by restriction of the diet. Ex-
cesses may aggravate them, and, on the other hand, they are said to
follow debilitating states. Some foods, such as shell-fish, crabs and
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 799
lobsters, or oysters, and strawberries, are likely to increase the peculiar
sensations in the epigastrium, exciting mild depression, or burning, or
even nausea. The excitation from these foods is usually due to pecu-
liar idiosyncrasies of the individual. On account of the same idiosyn-
crasies, pruritus, erythema, and urticaria occur, with headache and
some fever.
Deviations from the Sense of Hunger. Hyperorexia.
When hunger is exaggerated it is known as boulimia, or hyperorexia.
It may be temporary or permanent. When permanent it is obstinate,
weakening, and exceedingly unpleasant. It may occur alone or be a
symptom of various diseases of the nervous system, as manifest disease
of the brain, neurasthenia, hysteria, and psychoses. It complicates
such disorders as diabetes, and may be of temporary duration in con-
valescence from acute disease. The disorder accompanies migraine, or
hypochondriasis, and exophthalmic goitre. Analogous to it is perver-
sion of the appetite, as seen in pregnancy, in children, and in mental
disorders.
Anorexia. Loss of appetite, or repugnance to food. In the first
instance, there is simply loss of appetite ; in the second, there is repug-
nance toward food, or nausea at the sight of it. Loss of appetite
accompanies dyspepsia in all forms. In the gastric neuroses it occurs
spontaneously, or is due to hyperesthesia of the stomach, and therefore
may arise from central or peripheral conditions of irritation. It is
•commonly seen following central nerve perturbation. The patient is
hungry, and sits down to the meal fully prepared to satisfy himself.
The first mouthful is at once followed by anorexia, which may almost
amount to nausea. On account of these symptoms the patient eats less
and less of solid food, which soon results in disturbance of nutrition
affecting the higher centres. On the other hand, profound mental dis-
turbance may be an exciting cause, so that after the death of a friend,
or shock of any kind, the patient is unable to take food. Loss of appe-
tite may be the only manifestation of the gastric neurosis, but because
nutrition is so seriously interfered with, it soon results in other local
or general symptoms. Fen wick points out that its relationship to ema-
ciation and enfeeble rnent is such that grave organic diseases may be
simulated. Thus it may be mistaken for phthisis, and a general ex-
amination alone is sufficient to distinguish it.
Gastralgia. Pain in the stomach occurs in organic disease, as in
ulcer or cancer, or forms of gastritis. It also attends a gastric neurosis,
and may be the only symptom of this neurasthenic state. Such pain
is functional, and is found in anaemic, neurotic women. It may, how-
ever, occur in all classes. It is characterized by sudden pain in the
epigastrium, usually without regularity, though at times it may be dis-
tinctly periodic. There may not be any definite relationship between
the attack of pain and the taking of food, though it is most apt to
occur when the stomach is empty. Some kinds of food may aggravate
it, though, in general, eating relieves the pain. If the epigastrium is
examined, it will be found to be free from tenderness, and indeed
pressure with the palm of the hand may give relief. The pain is of
an agonizing character, sometimes sharply localized, or again diffuse.
800 • SPECIAL DIAGNOSIS.
It may even resemble the girdle-sensation. On account of the severity
of the pain the patient may be compelled to double himself up to relax
the abdominal muscles. The breath is short, and speaking is done in
a whisper. The attack is attended by more or less collapse, and the
patient may complain of the sensation of impending death. There is
pallor of the face, which is distorted with pain, and the brow is covered
with perspiration. The pain may radiate along the spinal nerves in
close situation to the stomach, and there is often vigorous pulsation of
the abdominal aorta.
The attack may last but a few minutes or continue for hours. It
sometimes terminates suddenly with vomiting, or is relieved as soon
as food is taken. After the attack the patient is exhausted and re-
laxed, and passes an abundance of urine of low specific gravity.
The gastralgias that are due to disease of the central nervous system
are often most puzzling. Rosenthal has written exhaustively on this
subject. Types of gastralgia of this character are seen in the gastrie
crises of tabes, first described by Charcot. Recent observers have
found that it is due to sclerotic degeneration of the vagus nucleus.
The patient is suddenly seized with severe pains, which may begin in
the groin and ascend along both sides of the abdomen to the epigas-
trium, to which point they are fixed. Pain in the shoulders occurs at
the same time. The pains are characteristic of lumbar ataxia in their
lightning-like rapidity. With the pain the heart's action is increased
in rapidity and force. There is no rise in temperature. At the same
time there is uninterrupted and painful vomiting, which is attended by
nausea and vertigo. The gastric pain may continue uninterruptedly
for two or three days. It belongs to the pre-ataxic period, so-called,
but is almost sure to continue throughout the whole course of the dis-
ease. The nature of the stomach-contents bears no relation to the
pain. The frequency of the attacks is variable. They may recur at long
periods, or as frequently as once a month or once a week. Another
special characteristic is the sudden relief that is given without cause.
Neurasthenic Gastralg-ia. Neurasthenic gastralgia occurs in
patients who are suffering from neurasthenia, and is divided by Rosen-
thal into two forms, the one irritative, the other depressant ; these are
related by transitional forms. The early symptoms of neurasthenia
(q. v.), particularly in the irritative form, with painful points in the
nape of the neck and between the scapulas, or often lower down on the
vertebras, with neuralgias and paresthesia in the upper and lower ex-
tremities, are attended by periodical gastralgia. The gastralgia is
characterized by a boring sensation which, during the attack, radiates
over the lower ribs to the median line. It is accompanied by vaso-
motor symptoms and symptoms of cerebral anamiia. In the depressant
form the patient complains of weight and fulness, or a dragging sensa-
tion after eating, which is constant instead of paroxysmal. The neu-
ralgic pains are not so marked, motor exhaustion is not so prominent,
and the pain in the back is not so intense as in other varieties. In
both instances on deep pressure over the region of the nerve-plexuses
which follow the bloodvessels in the abdomen, there is sharp and un-
pleasant pain radiating to the epigastrium. Burkart considers these
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 801
painful points to be present in all cases, Avhile Richter believes that
pressure over the stomach and abdomen is not painful. With such
pain there is usually increased pulsation of the abdominal aorta, partic-
ularly during the time of the paroxysm. In neurasthenic gastralgias
there is increased sensitiveness to the electrical current and increased
irritability of the sensory nerves of the trunk, which may also be ex-
tended to the limbs.
Neurasthenic gastralgia must be distinguished from the gastralgia
of organic disease and the gastralgia of hysteria. The gastralgia of
organic disease is recognized by observing the condition of the stomach
when fasting and by studying the secretion. In organic disease there
is retarded digestion ; in gastric neuroses digestion is completed in the
normal limit of time — seven hours. Hysterical gastralgias are recog-
nized by the presence of the usual symptoms of hysteria, in which the
psychical factors occupy a prominent place, associated with convul-
sions, paralyses, pupillary inequalities, hemianesthesia, and electrical
sensibility. Most characteristic, however, is the alternation of hysteri-
cal gastralgias with neuralgia, or neuroses in other organs.
(a) 2. Secretory Neuroses of Irritation. Hyperacidity and
Hypersecretion. Hyperacidity is the increase of the normal
amount of hydrochloric acid secreted, due to a neurosis of the secretory
function. Hyperacidity begins when the amount of acid in the fluid
withdrawn from the stomach in the usual way is between 60 and 70
per cent. It must not be forgotten that it is a symptom of gastric
ulcer, but it exists as a neurosis independent of any organic lesion of
the stomach. It has been observed in nervous diseases, as hysteria
and melancholia, and as a reflex symptom in gallstones and renal
calculus.
Hypersecretion occurs in two forms, the periodical and constant.
The acid is not necessarily increased. The periodical occurs after eat-
ing ; it has no direct connection with food. It is seen in neurasthenia
and locomotor ataxia. In chronic hypersecretion the gastric juice,
which is usually hyperacid, is in excess, so that the fasting stomach
may contain large quantities, even to a pint and a, half, without food
and only slightly tinged by bile. In chronic hypersecretion the diges-
tion of starches is delayed, but that of albuminoids is very prompt.
After an abundant meal consisting of meat and starches the meat dis-
appears entirely. Hypersecretion occurs in about half of all the stom-
ach disorders, according to Riegel. It is more common in men than
in women. The acid fluid causes the hyperresthetic conditions in the
gastric region previously described. Pain and eructation, heartburn
or gastralgia, vomiting of sour masses, occur with the digestive dis-
turbances of chronic gastritis. The tongue is usually clean and the
appetite increased rather than diminished. As a result, atony of the
muscular coat takes place, followed by gastrectasia. The neurosis is
then converted into an organic lesion, and the symptoms <>f dilatation
arise.
Reickman's disease is a hypersecretion of the gastric juice, and there
are two forms — the acute, which is generally of nervous origin, and
the chronic. The latter is seen in emaciated persons ; the stomach is
.11
802 SPECIAL DIAGNOSIS.
dilated, and succussion-splash is readily obtained. The diagnosis is
made in part by examination of the gastric contents, which are re-
moved five to six hours after the meal. The quantity will be found
large. On standing, the material becomes separated into three layers
— an upper, frothy layer ; a middle, turbid, yellowish layer, and a
lower, consisting of starchy matter. In order to determine that hyper-
secretion exists, the stomach-contents are removed in the evening, and
the viscus washed out thoroughly until the water is no longer acid in
reaction. The patient receives no food until the next morning, when,
after the proper interval, the contents of the stomach are again evacu-
ated. From 30 to 600 c.c. (1 to 19 ounces) of fluid will now be
obtained, which, on examination, proves to be active gastric juice. '
The disease is chronic.
In order to make a diagnosis the secretions must be secured while
fasting. The patients usually improve on albuminous food, which
differentiates it from gastralgia and pyrosis of acid fermentation.
Alkalies give temporary relief.
Gastroxynsis is a gastric neurosis in which, after mental overexertion
or profound emotional disturbance, there is sudden vomiting of acid
fluid, continuing for a considerable time. It is closely allied to
migraine.
(a) 3. Motor Neuroses of Irritation. Eructations. Eructations
and belching are phenomena of the gastric neuroses of motor origin.
They usually occur in hysterical subjects rather than in neurasthenics.
In the latter they are associated with other sensations, particularly op-
pression and tension in the epigastrium. In hysteria they occur alone.
There is increase in the contractility of the stomach, the pyloric
sphincter contracts powerfully, and the stomach is distended ; gas is
expelled at the cardiac end of the stomach. They may be due to
paralysis of the cardiac end of the stomach rather than to contraction
of the pyloric end. They occur involuntarily generally. They must
not be confounded with the pseudohysterical vomiting which Bristowe
has described. In the latter instance the gas is raised from the oesoph-
agus by contraction of the muscles of the neck. Hysterical eructation
is very frequently of oesophageal origin. The belching is loud and
may occur in paroxysms. The gas is odorless, and hence is distin-
guished from the gas of dyspepsia and fermentation ; it is in all proba-
bility the result of the swallowing of air.
Pyrosis. Pyrosis, or heartburn, is the raising of sour masses from
the stomach. The stomach-contents are not necessarily hyperacid.
If acid, as in the normal gastric juice, or hyperacid, the regurgitation
causes severe acrid and burning sensations. It is probably due to
heightened contractility of the muscular coat of the stomach with
pyloric contraction, which overcomes the weaker cardia.
Pneumatosis. Excess of gas in the stomach. When the stomach
is overdistended the diaphragm is pushed up, pressing on the heart.
The patients are seized with severe dyspnoea. At first inspiration is
difficult, and finally both inspiration and expiration become difficult.
Palpitation of the heart and pulsation of the peripheral arteries take
place. There is fulness of the head and a sensation of impending
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 803
death. The patient may become unconscious. Relief can only be
afforded by belching, when the attack rapidly subsides. Introducing
a stomach tube gives immediate relief.
Nervous Vomiting. (See Subjective Symptoms and Gastroxyn-
sis).
Tormina Ventriculi. Peristaltic Unrest. Characterized by
borborygmi and gurgling, which begin immediately after eating, are
heard at a considerable distance, and are a source of great annoyance.
It is a common symptom of the gastric neuroses.
Rumination {Merycismus). Rumination is a rare condition in
which the patients regurgitate and chew the cud like ruminants.
(6) 1. Secretory Neuroses of Depression. An acidity. An-
acidity of the gastric juice as a neurosis is found in hysterical persons
and in neurasthenics. (See chemical examination Absence of Hydro-
chloric Acid).
(b) 2. Sensory Neuroses of Depression. Anaesthesia. In con-
ditions of depression polyphagia, or the want of a feeling of satiation
occurs ; if gluttony is excluded, it is a morbid condition of extreme
rarity.
(b) 3. Motor Neuroses of Depression. Atony, or Atonic Dys-
pepsia. It accompanies gastritis ; it also occurs as a primary neurosis.
The innervation of the nerve-centres regulating peristalsis is disor-
dered. The primary disorder may be local or central. The movement
of the chyme is tardy or insufficient. Atony should be applied to the
disease of the motor function only, or, as Rosenbach states it, to insuf-
ficiency of the stomach. The symptoms develop gradually. At first
oppression during digestion occurs, with swelling and fulness of the
stomach.
There is mental and physical torpor during the time of the digestive
act. The symptoms become aggravated, and eructations occur, vomit-
ing begins, and gradually the fermentative symptoms become most
pronounced. At this period it is putrid, or fermentative dyspepsia.
By the usual tests the motor power of the stomach is found to be
diminished. The secretions are also scanty.
Relaxation at Orifices. Relaxation of the Cardiac and Pyloric
Ends of the Stomach from, Conditions Resembling Paralysis. When
the cardiac end is relaxed eructations and regurgitations occur. If
large quantities of the material from the stomach are regurgitated and
expectorated, the condition is pathological. It may lead to serious
changes in nutrition. It may exist for years without bad results. It
must not be confounded with the regurgitation from diverticula of the
oesophagus. In the latter regurgitation is produced at will.
(c) Mixed Neuroses. Nervous Dyspepsia. According to Ewald,
this is the true gastric neurasthenia, which combines all forms of gas-
tric neuroses. The clinical picture is made up of a combination of
various neurosal symptoms. Leube considers nervous dyspepsia a
group of symptoms of a cerebral nature due to abnormal irritability
of the sensory nerves of the stomach during the normal digestive
processes, the symptoms of which are hyperesthesia and nausea, hy-
jjerorexia, anorexia, parorexia, and gastralgia. He thinks the true
804 SPECIAL DIAGNOSIS.
peptic activity of the stomach is unchanged. Although the anatomical
or physiological explanation of the condition is difficult, the clinical
symptoms are those of irritation of paralysis, the manifestations of
which are intermingled, sometimes one and sometimes the other being
most prominent. (See table, page 797.)
The one characteristic feature is that the symptoms are mild. With
severe forms of gastralgia nervous vomiting and boulimia do not occur.
Symptoms of intestinal indigestion are usually associated in a mild
degree. Constipation is of the most common occurrence, although in
some cases there is diarrhoea. In other cases the intestinal iu digestion
is much aggravated, with mild gastric disturbances and anorexia, repug-
nance toward taking food, furred tongue and mild nausea, constipation
and colicky paiu, either diffuse or in separate painful spots. . The
abdomen is distended and tympanitic, sometimes to a marked degree.
It is called flatulent dyspepsia. Along with the gastric and intestinal
symptoms, the general nervous symptoms to which the term neuras-
thenia is applied are present. These nervous manifestations sometimes
precede the local gastric symptoms, but as the latter develop the former
become more aggravated. The dyspeptic conditions, as Ewald puts
it, are on a neurotic basis, or are such as may occur in the form of reflex
neuroses in chlorosis, menstrual disorders, uterine and ovarian disease,
and intense physical or psychical excitement. As far as Ave know there
are no great alterations in the chemical fimctions when anatomical and
pathological changes are absent. An indigestion of short duration, a
mild catarrh, recurring hyperemia, have been the primary cause of
nervous symptoms in the digestive organs.
Diagnosis. There are no characteristic symptoms, and the student
must bear in mind that it may be necessary to make several examina-
tions and listen to the story of the subjective symptoms frequently
before a conclusion can be arrived at. This is all the more necessary
because of the frequency in which organic lesions and neurasthenic con-
ditions are present at the same time. The course of the disease must
be observed for a long time, all possible causal factors investigated, and
all the general signs of neurasthenia carefully considered. In addition,
it may be necessary to use therapeutic tests. If the possible organic
diseases are not relieved by such measures, there must be a deeper basis
for the gastric symptoms. Just as in neurasthenia and in neurasthenic
states elsewhere, the peculiarities, idiosyncrasies, and all the associations
in the life of the individual must be considered in connection with the
general and local symptoms of the neurasthenic state. Great stress must
be placed upon the study of individual symptoms, their mutual rela-
tionship, and their changeable occurrence. In gastric neurasthenia
gastralgia is more diffuse than the pain of ulcer or cancer of the stom-
achy It is not so much dependent upon food as either of the others,
particularly ulceration. In gastric neurasthenia vomiting is rare. The
v. uniting is composed of mucus mixed with bile and food in various
stages of digestion. It is never bloody, nor does it contain decomposed
masses. Hysterical vomiting occurs with ease and regularity compared
with the vomiting of neurasthenia. The vomiting in neurasthenia is
bitter, due to the presence of peptones. In gastric neurasthenia the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 805
stools are changeable in character. They do not contain undigested
remnants of food, or mucus, or blood. The form of the feces is variable.
Differential Diagnosis. Neoplasms, ulcers, strictures, and dilatation are
distinguished by physical signs or characteristic symptoms. In gastric
neurasthenia the stomach should be empty seven hours after taking a
meal. The results of the chemical examination are not sufficiently
definite for diagnostic purposes, for at times the same chemical changes
are present, as in ulcer, carcinoma, and chronic catarrh. The diag-
nosis must be based largely, as previously intimated, upon prolonged
observation and a carefully taken history, and upon the general condi-
tion of the patient. The cases must not be mistaken for costal neural-
gia, although it is not usually easy to be led astray. Keflex gastric
neuroses are seen, as indigestion, gastralgia, or vomiting. The types
are interchangeable, although vomiting occurs in the more acute reflexes,
indigestion in the more chronic. The cerebral disorders which give
rise to vomiting are meningitis, abscess, and tumor. The vomiting
may be transitory, or may be persistent. There is usually hypersecre-
tion of the gastric juice. The vomiting may usher in the disease or
develop during its course. If vomiting is of long standing its possibly
reflex origin should always be investigated. (See Vomiting.)
Gastralgia is sometimes a reflex from lesions in the cervical and
dorsal portions of the cord ; not only in the posterior columns, but also
in disseminated sclerosis. Vomiting occurs, and the attack is known
as a gastric crisis.
Chronic dyspepsia is a frequent reflex disorder of diseases of the
sexual organs, as amenorrhoea and dysmenorrhea, in the climacteric
period, and in chronic inflammations of the uterus. In malpositions
and tumors, and in pelvic exudations with traction, in ulcers, in ova-
rian tumors, the so-called dyspepsia uterina of Kisch is common.
Chronic Gastritis. Causes. 1. Previous attacks of acute gastritis.
2. The local irritation of badly cooked or poorly masticated food,
and of alcoholic and other beverages.
3. The local irritation of urea in chronic Bright' s disease, and of
products of putrefaction in constipation.
4. In anaemia chronic gastritis is of frequent occurrence, and in
venous congestions from any cause, but particularly from disease of
the heart or diseases which interfere with the portal circulation. It
occurs secondarily to diabetes, gout, rheumatism, nephritis, and tuber-
culosis.
5. It is a constant attendant upon local disease of the stomach, as
cancer, dilatation, and ulcer, and of local disturbance of the circulation.
The symptoms are those of chronic indigestion. There is a dry,
pasty, or salty taste in the mouth, especially in the morning. The
tongue is coated over its entire surface, or has red patches at the base ;
its papilla? arc always swollen and its edges marked by the teeth.
Aphtha? recur frequently. The lips are dry and often chapped.
The appetite is poor or capricious. Although there is no great
thirst, the patients crave fluids with their meals, and acid drinks are
grateful. After eating there is a feeling of oppression and disten-
tion in the epigastrium, frequently followed by belching. The gaseous
806 SPECIAL DIAGNOSIS.
eructations are odorless or foul, and rancid regurgitation with pyrosis
is frequent. The acidity is due to fatty acids and not to hydrochloric
acid, as in hypersecretion. Vomiting is invariably present, but occurs
irregularly. It is usually preceded by nausea. The most character-
istic form is that in which mucus is vomited in the morning on rising.
Constipation usually exists ; it may alternate with diarrhoea. There
are flatulency and rumbling in the intestines.
General Symptoms. The nervous symptoms are the most pronounced.
The mental activity is diminished, there is a feeling of languor or
torpor, especially after eating. Headache is frequent after eating, and
the patient may become morose and hypochondriacal. Attacks of ver-
tigo are common. Itching of the skin and coldness of the extremities
are not rare. Sleep is deeper and longer than is natural, but is dis-
turbed by dreams, and is not refreshing. Yawning is frequent. Phar-
yngitis usually attends the attack, with hacking cough and expectora-
tion, or hawking of mucus.
The pulse may be weak and irregular, and at times there is an even-
ing rise of temperature. The urine is scanty, high-colored, and usually
loaded with urates.
Three forms are seen : (1) Simple chronic gastritis; (2) chronic
mucous gastritis ; the term " chronic catarrh of the stomach " is applied
to both conditions. If the condition lasts a long time, it results in (3)
atony, with dilatation of the stomach, or with atrophy. Atrophy, or
atrophic gastritis, is secondary to the chronic form, or to stenosis of the
oesophagus, or to cancer. The symptoms are those of pernicious anae-
mia. Cirrhosis of the stomach is also a sequence of gastritis. It is
rare, and the symptoms are not characteristic of a spinal lesion. They
are those of the primary disease.
Examination of the Stomach-contents. In simple gastritis the stom-
ach, after digestion is completed, contains a small amount of slimy
fluid. Hydrochloric acid is diminished in quantity after a test-break-
fast ; lactic acid and the fatty acids are present, as previously noted.
Pepsin and the milk-curdling ferment are absent or diminished. In
mucous gastritis there is subacidity. It differs from the simple form
in the excess of mucus only. In atrophy the hydrochloric acid and
pepsin are diminished, or absent altogether after the test-breakfast.
The fasting stomach is empty. There are no fermentation acids.
Atrophy must be distinguished from cancer and subacid neuroses.
The latter occur in younger individuals than those subject to atrophy.
A bloody tinge in the stomach-contents, or hemorrhage, may be the
only distinguishing mark of cancer. It is often impossible to make
a diagnosis.
Diagnosis. The diagnostic features of chronic gastritis are : First,
long duration ; second, persistence of local symptoms ; third, recur-
rence of local symptoms after food, the symptoms being aggravated by
stimulants, or stimulating food ; fourth, moderate pain ; fifth, absence
of cachexia ; sixth, absence of tumor ; seventh, flatulency. Hemor-
rhage is rare, and there may or may not be vomiting, while the quan-
tity of hydrochloric acid is variable. Finally, the cause is usually
definite.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 807
Dilatation of the Stomach (Gastr ectasia). (See Plate XXXVIII.,
Fig\ 1.) It is caused by obstruction at the pyloric orifice, either from
cancer, the cicatrix of an ulcer, or fibrous stricture. It follows atony
and degeneration of the walls of the stomach which occur in the course
of chronic gastritis. It may attend paralysis of the stomach. Excessive
eating or drinking are the only probable causes independent of organic
disease. Hence, we have (1) obstructive and (2) atonic dilatation.
The dilatation may be acute. The term acute paralytic distention is
also applied to this condition. The cases are extremely rare. There
is sudden enlargement of the upper portion of the abdomen, with
pressure upon the surrounding structures. The heart is dislocated and
its action much interfered with ; collapse follows and may end in
death. At first there may be some belching, but the patient is soon
unable to remove the gas, and suffers from extreme discomfort, palpi-
tation, and dyspnoea. The vomiting may occur at once or later. It
is persistent and excessive. On physical examination the stomach
yields the same physical signs as in chronic dilatation.
Chronic dilatation develops slowly. The symptoms of it are super-
imposed upon the causal disease. There is marked dyspepsia, with
flatulency, pyrosis, and other symptoms of fermentation. The tongue
is pale and furred, or red, smooth, and shiny ; or it may be soft and
flabby. If frequent vomiting has attended the causal disease, it now
occurs at longer intervals ; the amount is excessive, greater than the
normal stomach would hold, and is made up of partially digested and
fermented food and large amounts of mucus. The stomach-contents
contain sarcinse, torulse, and other products of fermentation. Hydro-
chloric acid is usually absent, but there is a large excess of lactic
and fatty acids. The patient loses flesh and strength ; becomes irri-
table, depressed, and more or less melancholy. The patient is subject
to vertigo and to attacks of nocturnal asthma. The nervous symptoms
of chronic gastritis are also present.
Sleeplessness is quite common. In some cases there is excessive
thirst because of the small amount of nutriment and fluid absorbed.
Cardiac palpitation and irregularity are common, and dyspnoea may
occur on account of the distention. Tetany has been observed in cases
of dilatation, especially after lavage.
Physical Examination. The diagnosis is not complete without physi-
cal examination. On inspection the abdomen is large and prominent,
and the outline of the stomach can sometimes be seen. Peristaltic
movements of the organ are often seen. The movement is from left
to right. The heart is lifted upward. On palpation the peristalsis can
be felt, and with one hand on the stomach, tapping with the other, a
splashing sound can be detected. Or the hand may be placed over the
stomach (patient standing) and the body quickly shaken. On palpa-
tion the striking or pushing hand should be compressed over the false
ribs. A tumor can sometimes be felt in the region of the pylorus, or
below the umbilicus. On percussion, when the stomach contains gas,
a tympanitic note is heard. After drinking water dulness may be de-
tected between gastric and intestinal tympany if the patient stands up.
The dull note disappears when he resumes the recumbent posture.
808 SPECIAL DIAGNOSIS.
Before taking water tympany is not so marked in the upright as in
the recumbent posture, because the stomach is dragged back or down.
The tympany extends high up in the chest on the left side, so that
Traube's half-moon space is exaggerated. It may extend as high as
the fourth interspace on the left side. Cardiac dulness is increased
and the apex of the heart is lifted upward and to the left. In the
axillary region the tympany may extend as high as the sixth rib.
There is usually atrophy of the spleen, so that unless very careful
light percussion is performed the splenic dulness cannot be brought
out. The lower limit extends below the transverse umbilical line, and
may even extend midway to the pubis. If there is gastroptosis, the
half -moon space becomes dull on percussion, the stomach tympany fall-
ing to a lower level. On auscultation succussion can easily be elicited.
Sometimes the sound is sizzling, as if there was effervescence. Heart-
sounds may be transmitted clear and metallic over the tympanitic
stomach. With auscultatory percussion the border of the stomach can
often be defined accurately. Percussion must be commenced far away
from the stomach-limit and conducted toward it. (See Examination
of the Abdomen.)
Stenosis of the Pylorus. Usually, obstruction is caused by malig-
nant disease. Hypertrophic stenosis occurs in rare instances and leads
to dilatation, as indicated above. The condition may be congenital or
acquired.
Acquired stenosis may be the result of chronic gastritis, or develop
independently, sometimes as part of a general proliferation of connec-
tive tissue. (See case of author, Path. Soc. Trans., vol. xi. 1881-83,
p. 216.) If, to the physical signs of tumor of the pylorus, be added
the signs and symptoms of dilatation, we have the clinical picture of
hypertrophic stenosis of the pylorus. It is extremely rare to find
complete obstruction.
Congenital hypertrophic stenosis, as Metzler and Caudley point
out, has for its characteristic features : (1) Vomiting, occurring with-
out apparent cause and persisting in spite of treatment ; (2) the ab-
sence of bile from the vomited matter ; (3) obstinate constipation ; (4)
marasmus ; (5) the presence of a tumor in the region of the pylorus ;
(6) the absence of abdominal distention except from dilatation of the
stomach itself in some instances ; and (7) the absence of signs or
symptoms of gastritis and of the more common forms of intestinal
obstruction. Diagnosis depends entirely on the characteristic symp-
toms arising during the first few weeks of life and the presence of a
tumor.
Diseases of the Stomach Characterized by Pain and Vomiting.
Cancer of the Stomach. The clinical symptoms are varied. Gas-
tric cancer may occur without any symptoms whatever, and be discov-
ered after death from other causes. On the other hand, general maras-
mus and cachexia may be present, without local symptoms. In some
cases the gastric symptoms are slight, and obscured by the symptoms
of secondary growth in the liver or peritoneum.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 809
Typical cases are those which occur late in life, with symptoms of
chronic gastritis. These symptoms may continue for months before
anything- further is observed. Gradually the uneasiness and discom-
fort after eating increase to actual pain. Loss of appetite is marked,
and in spite of careful treatment there is loss of flesh and strength.
The usual vomiting of chronic gastritis gradually becomes more fre-
quent. The general appearance of the vomitus is at first like that of
chronic gastritis. Soon it becomes streaked with blood, or a moder-
ately large hemorrhage may take place. The vomited matter is dark
in color, like coffee-grounds in appearance. The relation of vomiting
to the time of taking meals depends upon the seat of the disease. If
at the cardiac end of the stomach, the vomiting may take place at
once. If in the greater curvature, within twenty minutes or one
hour and a half after taking food. If at the pyloric orifice, the vomit-
ing is delayed several hours. ■ As the disease advances, and obstruc-
tion becomes more complete at the cardiac orifice, food is immediately
regurgitated, unless secondary dilatation of the oesophagus takes place.
When there is gastric dilatation the vomiting may take place at longer
intervals and be characteristic of the vomitus of dilatation. Constipa-
tion is the rule.
Tumor. After the symptoms of chronic gastritis have continued for
some time without relief a tumor may be detected, depending upon its
situation and size. (See Tumors of Abdomen.) If the growth is situ-
ated at the cardiac orifice of the stomach, it is often impossible to
detect it. If at the pyloric orifice, the tumor is found to the right of
the median line above the umbilicus, but may be forced down by
the weight of the stomach and felt at the umbilicus. (See Plate
XXXVIII., Fig. 2.) When dilatation follows pyloric tumor it may
be still lower down, as in a case of the writer's, in which it was found two
inches below and to the right of the umbilicus. In tumor of the greater
curvature the mass is detected below the margin of the ribs on the left
side, and may be as low down as the umbilicus. If the greater curvature
is involved, the organ usually atrophies, and hence the physical signs
indicating the lower border of the stomach are higher up than in health.
It is necessary to exclude tumors due to other causes. This is some-
times difficult — indeed, as far as the location and physical characters
are concerned, often impossible. The most pronounced diagnostic
feature of tumor of the pylorus is the occurrence of secondary dilata-
tion of the stomach. For a differential diagnosis of tumors in this
region, see Palpation of Abdomen.
Symptoms due to Metastasis. The liver is the most frequent seat of
secondary growths. The organ enlarges, and its surface is covered
over with nodules. (See Plate XXXVIII. , Fig. 2.) Jaundice occurs
in rare instances. The enlarged liver may cover the stomach and hide
the local mass. The inguinal glands enlarge. At times there is en-
largement of the supraclavicular glands, suggestive also of intra-abdom-
inal carcinoma, from other causes.
The general symptoms are those of emaciation and cachexia. The
emaciation is extreme, and in some cases may be out of proportion to
the local symptoms.
810 SPECIAL DIAGNOSIS.
The symptoms of cachexia are those of emaciation and anaemia.
The ancemia becomes profound. The pallor of the face is striking,
often it is of a yellowish and straw-colored hue. It must not be con-
founded with jaundice — examination of the conjunctiva? is usually
sufficient to distinguish the two. The skin is flabby, and the subcu-
taneous fat is entirely lost ; the emaciation is not so marked as in cancer
of the oesophagus, except when there is complete cardiac stricture.
The nutrition of the skin suffers, boils are common, and ulcers may
occur. Subcutaneous hemorrhages are seen in the terminal stages on
the backs of the hands, on the dorsum of the feet, on the legs and
arms. There is slight cedenia of the ankles.
General atrophy of the internal organs takes place, so that the heart
becomes small ; it loses its strength, the patient becomes weaker and
weaker, the pulse rapid and feeble.
If fever occurs in the course of the disease, it is usually due to sec-
ondary accidents, as suppuration in a tumor, or perforation with septic
peritonitis. The usual course of the temperature is normal until the
later stages, when it is subnormal.
Examination of the Stomach-contents. Hydrochloric acid may or
may not be absent, depending upon the amount of gastric catarrh.
Lactic acid, on the other hand, is commonly present even in the earli-
est stages, and when associated with absent HC1 is very diagnostic.
Boas' test-breakfast must be given. For an accurate diagnosis re-
peated examinations must be made. Other general and local condi-
tions, as fevers on the one hand, or dilatation on the other, are attended
by absence of hydrochloric acid at times. In carcinoma it is the per-
sistence of the absence which is diagnostic. Pepsin and the milk-
curdling ferment are not changed.
The Urine. Indican in increased amount, acetone and diacetic acids
may be present in the urine ; otherwise there is no change.
Diagnosis. In the diagnosis of gastric cancer the following must be
borne in mind : 1. The age of the patient. 2. The occurrence of
causeless dyspepsia without relief. 3. Rapid loss of flesh and strength,
with cachexia. 4. The occurrence of pain in the epigastrium, contin-
uous, increased by food, but not relieved by vomiting, as in ulcer,
and not distinctly localized. 5. Tumor — hard, circumscribed, fol-
lowed by the physical signs of dilatation, if in the pylorus. 6. Vom-
iting is necessarilv associated with the taking of food, in which frag;-
ments of cancer may be found ; blood-cells are common ; they may be
detected on microscopical examination, or by the test for heemin. 7.
Examination of stomach-contents. («■) Except in dilatation the fasting
stomach is empty ; (6) hydrochloric acid is often absent, whereas lactic
acid is present ; (c) delayed absorption is present, indicated by motor
tests. 8. Hemorrhage. In small amounts, usually of characteristic,
coffee-ground appearance. 9. Metastases— above the left clavicle ; in
the liver ; in the inguinal glands ; rarely in the lungs and peritoneum.
10. Eichhorst speaks of persistent itching of the skin and insomnia as
characteristic symptoms. 11. Finally, the comparatively short dura-
tion of the case. Rarely does it extend over a period of two years.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 811
Differential Diagnosis of Gastric Cancer, Gastric Ulcer, and
Chronic Gastritis. (Welch.)
Gastric Cancer.
1. Tumor is present in three-
fourths of the cases.
2. Rare under forty years of
Gastric Ulcer.
Tumor rare.
Chronic Catarrhal Gastritis.
No tumor.
May occur at any age after
childhood. Over one-half of
the cases under forty years
of age.
May occur at any age.
3. Average duration about one Duration indefinite; may he Duration indefinite,
year, rarely over two years. ; for several years.
4. Gastric hemorrhage fre-
quent, but rarely profuse ;
most common in the ca-
chectic stage.
Gastric hemorrhage less fre-
quent than in cancer, but
oftener profuse ; not uncom-
mon when the general
health is but little im-
paired.
Gastric hemorrhage rare.
5. Vomiting often has the pe- Vomiting rarely referable to Vomiting may or may not be
culiarities of that of dila- dilatation of the stomach, present,
tation of the stomach. and then only in a late stage
I of the disease.
Free hydrochloric acid usu-
ally absent from the gastric
contents in cancerous dila-
tation of the stomach ; lac-
tic acid much increased.
Free hydrochloric acid usu-
ally present in the gastric
contents.
7. Cancerous fragments may Absent.
be found in the washings
from the stomach or in the
vomit (rare).
8. Secondary cancers may be Absent,
recognized in the liver, the
peritoneum, the lymphatic
glands. and, rarely, in other
parts of the body.
9. Loss of flesh and strength
and development of ca-
chexia usually more mark-
ed and more rapid than in
ulcer or in gastritis, and
less explicable by the gas-
tric symptoms.
10. Epigastric pain is often
more continuous, less de-
pendent upon taking food,
less relieved by vomiting,
and less localized than in
ulcer.
11. Causation not known.
Cachectic appearance usually
less marked and of later
occurrence than in cancer,
and more manifestly depen-
dent upon the gastric dis-
orders.
Pain is often paroxysmal,
more influenced by taking
food, oftener relieved by
vomiting, and more sharply
localized than in cancer.
Causation not known.
Free hydrochloric acid may be
present or absent.
Absent.
Absent.
When uncomplicated, usually no
appearance of cachexia.
The pain or distress induced by
taking food is usually less severe
than in cancer or ulcer. Fixed
points of tenderness usually ab-
sent.
Often referable to some known
cause, such as abuse of alcohol,
gormandizing, and certain dis-
eases, as phthisis, Bright's dis-
ease, cirrhosis of the liver, etc.
May be a history of previous simi-
lar attacks. More amenable to
regulation of diet than is cancer.
12. No improvement, or only Sometimes a history of one or
temporary improvement, more previous similar at-
in the course of the dis- tacks. The course may be
ease. irregular and intermittent.
] Usually marked improve-
ment by regulation of diet.
Cases of cancer of the stomach may present only symptoms of anae-
mia. In this manner the disease has been confounded with pernicious
ancemia. The blood is never reduced in cancer to the degree it is in
pernicious anamiia, nor does it present the characteristics found in
anaemia.
Ulcer of the Stomach. Simple round ulcer of the stomach may
occur at any age, but is most common in young anaemic women. It
812 SPECIAL DIAGNOSIS.
may be the result of an erosion of hemorrhagic infarcts by the gastric
juice. Stockton believes it to be a neuropathic change.
The Symptoms. The symptoms are variable. The cases have
been divided by Welch into four classes : (1) Those in which there are
no symptoms whatever, the ulcer having been found after death from
other diseases ; (2) no symptoms until the sudden occurrence of hemor-
rhage, or perforation ; (3) the symptoms of chronic gastritis or gastral-
gia only ; (4) typical cases, with the characteristic symptoms, pain,
hemorrhage, and vomiting. The symptoms of gastric ulcer may develop
suddenly.
Pain, The pain is localized ; it is usually confined to a small area
in the epigastrium. It may be seated behind the cartilage of the sixth
and seventh ribs, or may be complained of in the back, between the
eighth and ninth dorsal vertebra?, extending as low down as the first
and second lumbar. It is of a burning or gnawing character, is in-
creased by food, and comes on in from two to ten minutes after the
ingestion of food. It is relieved by vomiting, or after the act of diges-
tion is completed ; but a persistent, dull pain or a feeling of soreness
remains. In addition to the ordinary pains, there may be attacks of
gastralgia. The pain is increased by pressure. It may be modified
by the position of the patient. It may be relieved by lying on the
back when the ulcer is in the anterior wall ; or relieved by lying on
the abdomen when in the posterior wall.
Vomiting. Vomiting occurs shortly after the ingestion of food. It
is not attended by retching. The vomited matter may contain blood.
The vomited matter and the contents of the stomach contain hydro-
chloric acid, which may be in excess. Eichhorst thinks it is always in
excess.
Hemorrhage. Blood in the vomitus gives it a brown or reddish
color. It may be detected by the usual methods. Hemorrhage may
occur, however, independently of the act of vomiting. It varies in
amount from half a pint to a quart. It may be so severe as to cause
collapse. Sometimes, instead of being discharged as a profuse hemor-
rhage, the blood may gradually ooze from the ulcer and collect in the
stomach before being vomited. It is then altered by the acid gastric
juice. Sometimes the blood is not vomited, but passed by stool, which
is then tarry. Tarry stools also follow the vomiting of blood. In the
course of ulcer a hemorrhage may be so severe that death takes place
before vomiting occurs. The stomach is then found to be filled with
blood.
The stomach bougie should not be used ; the nature of the contents
must be determined by an examination of the vomited matter.
The General Symptoms. If the cases are of long standing, the
face is anxious and the lines are sharpened. If there is much hemor-
rhage, anaemia ensues. There is not much wasting and no fever.
Chronic dyspepsia and constipation may be present during the intervals
in which the severe symptoms are in abeyance. The period of abey-
ance varies, and the symptoms may come on without cause, as in gas-
tric crises, during which time the vomiting may persist for two or three
days. I saw a young girl of twenty years with most severe gastric
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 813
hemorrhage and classical symptoms of ulcer. With careful treatment
she improved. After marriage she remained well until pregnancy.
During the first periods of this condition vomiting was extreme ; it
then subsided, whereupon, without warning, a gastric crisis took place.
The vomiting of blood continued for many days, and the symptoms of
gastric ulcer remained for a month.
One of the characteristic features of the disease is the recurrence of
symptoms after a long period of abeyance. A patient under my care
during the last ten years has had three undoubted attacks. It is pos-
sible that during each period ulcers healed, to be followed after a time
by the occurrence of new ulcers.
Diagnosis. The diagnostic features are : 1. The age. 2. The long
duration. 3. The occurrence of emaciation up to a certain point only ;
most of the patients are under-weight and have a gaunt look, particu-
larly males. 4. The characteristic pain. 5. The vomiting. 6. The
hemorrhage. 7. The periods of relief from symptoms. 8. The absence
of marked nervous symptoms which attend gastric neuroses. 9. The
absence of dilatation of the stomach. 10. The hyperacidity of the
gastric juice.
The Accidents of Ulcer of the Stomach. 1. The occurrence of perfo-
ration. Sudden severe pain, with collapse. The pain is usually in
the epigastrium, but may be in the back as high as the seventh or
eighth dorsal vertebra.
2. Hemorrhage, which may cause death immediately, with either
vomiting of blood or retention in the stomach.
3. With healing of the ulcer, stenosis at the pyloric orifice may take
place, with subsequent dilatation of the stomach.
Diseases of the Intestines.
The intestine is a canal of varying dimensions, the physiological
office of which is to propel material received from the stomach, and to
permit of the digestion and absorption of that which is to serve for the
nutrition of the body. The canal is richly supplied with bloodvessels
and lymphatics. It is made up of mucous membrane, muscle, and
peritoneum. For the purpose of digestion, fluids are secreted, either
from the intestinal glands or large neighboring glands which discharge
into the canal.
Diseases which affect the canal impair or cause an abeyance of the
physiological offices. As these offices — absorption and digestion — are
essential to nutrition, it is not surprising that the body-weight and
strength are impaired. We know too little about the function of diges-
tion to utilize such knowledge in diagnosis. Intestinal digestion is
also dependent upon the healthy performance of the functions of the
liver and pancreas. It is difficult to draw fine lines of distinction even
in health, and intestinal pathology is closely interwoven with hepatic
and pancreatic pathology.
Alterations of the function of the intestine as a canal give rise to dis-
tinctive symptoms. Either its movements are too frequent and rapid,
causing diarrhoea, or too sluggish, causing constijjiition. Obstruction of
814 SPECIAL DIAGNOSIS.
the canal leads to symptoms common to such a condition (see Morbid
Process), modified by the physiological duties and the anatomical
structure of the canal.
The morbid processes are hyperemias, inflammations, degenera-
tions, and new growths. The symptoms that attend these processes
are not different from the symptoms that attend such processes in
similar structures elsewhere. It must not be forgotten that the function
of the canal is influenced by each process. On account of the process
we may have pain and fever ; on account of the impaired function,
pain, flatulency, diarrhoea, or constipation, change in the character of
the stools, and impaired nutrition. Some of the above morbid processes
may lead to the mechanical condition, obstruction.
The morbid alterations of the intestinal tract are ascertained by
data obtained by inquiry and by observation. The data obtained by
inquiry include the subjective symptoms — pain, and discomfort from
flatulency. By observation the general condition of the patient, the
presence of tenderness, alterations in the size and shape of the abdo-
men, and other physical phenomena are observed. The feces are care-
fully studied, with the object of determining modifications of the
function of the bowel, the presence of ingredients due to some morbid
process, as serum, blood, pus, or mucus, or of extraneous matter, as
worms or foreign substances. The feces are studied by the naked eye,
by the microscope, and by bacteriological methods.
One symptom may be the chief manifestation of a disease, as pain
of lead-colic, diarrhoea of several morbid disorders, constipation of
others. In the discussion of the special symptoms a consideration of
the diseases of which the symptom is the main expression will be
taken up.
Parasites. The intestine is the recipient of material for nutrition.
Parasitic forms of animal life, or their ova or spores, may enter the in-
testine with the food. They either remain in the intestinal tract or
wander into other structures. They include animal and vegetable
parasites, such as forms of protozoa, vermes, and fungi. While the
canal is open to infection by various micro-organisms, it is the natural
habitat of others, which may become deleterious agencies when the
conditions of their environment are changed. Thus the bacillus coli
communis is, in man, with normal epithelial structure and normal
secretions, an innocuous parasite which, when inflammation sets in,
may become nocuous.
The symptoms produced by the protozoa and fungi, or by their prod-
ucts, the ptomaines, are of an infectious or toxic nature. Inflamma-
tion is produced locally.
The symptoms of worms, if retained in the intestinal canal, are : (1)
Reflex in nature ; (2) symptoms due to catarrhal inflammation ; (3)
symptoms due to action of the parasite on the blood — anaemia ; (4)
symptoms due to wandering of the parasite, as in trichinosis. (See
Feces.)
Symptoms of the Tcen'm and Bothriocephali. There may be no symp-
toms save discharge of the parasite or portions of it by the rectum.
In others the symptoms of intestinal dyspepsia or intestinal catarrh
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 815
are observed. Headache, giddiness, lassitude, and itching at the nose
and at the anus are said to be present. The patient becomes hypo-
chondriacal. Convulsive disorders occur. Hysteria, forms of epilepsy,
grinding of the teeth at night, and restlessness attend the habitation of
the parasite in the intestine. In all convulsive disorders the possi-
bility of worms as a cause must be remembered.
Symptoms of Asearides. (1) Gastro-intestinal catarrh ; (2) symp-
toms of obstruction (rare) ; (3) symptoms due to wandering — as to the
hepatic duct to the stomach, or to the vagina ; (4) nervous symptoms
of reflex origin ; (5) the worm or its ova in the feces.
Symptoms of Oxyuris Vermicular is. (1) Gastro-intestinal dyspepsia
or catarrh ; (2) itching or heat at the anus, worse in bed ; (3) vesical
and rectal tenesmus ; (4) erythema about the anus ; (5) priapism ; (6)
vulvitis and vaginitis ; (7) the worms in the feces.
The Strongylus. The symptoms are local, with the symptoms of
profound anaemia. The discovery of the ova in the feces distinguishes
this form of anaemia from other varieties.
The symptoms due to the presence of the trichina spiralis and filaria
will be discussed in appropriate sections. (See Blood and Infectious
Diseases.)
The Intestines in other Diseases. The relationship of intes-
tinal disorders to affections of other viscera will be discussed with each
symptom. It must not be forgotten that derangement of this tract
may have its origin in local causes or in causes remote from the intes-
tinal tract, or in some general condition of the individual. Thus diar-
rhoea may be due to inflammation which is primarily local, or which
may be secondary to infection. Nothing is more common than to see
diarrhoea in a general infection, such as septicaemia. In exophthalmic
goitre the diarrhoea is not due to a local cause, but to some as yet un-
known nerve disorder. Constipation may be due to central brain dis-
ease, to a general condition like diabetes, or be of local origin.
It must be remembered that the diagnosis of an intestinal lesion
is never complete without determining its causes. Thus enteritis and
ulceration occur in typhoid fever, in cholera, and in other infectious
disorders, all of which are to be passed in review in making up a diag-
nosis. Diarrhoea is a symptom in Bright' s disease, and the causal rela-
tionship must always be borne in mind.
Differential Diagnosis. Intestinal disease or disorders are not usually
confounded with disease of other structures. It is worthy of remark,
as a fact which is sometimes overlooked, that symptoms of intestinal
obstruction are frequently due to peritonitis. Tumors of the intestine
must be distinguished from tumors of the peritoneum, the stomach,
pancreas, and liver, and the uterus and ovaries. The history, the seat
and physical character of the tumor, and the associate symptoms point
to the true condition.
Arteries of the Intestine. The intestines are supplied by the mesen-
teric arteries. Its branches may become the seat of emboli.' The
symptoms are sudden pain, intestinal hemorrhage, and discharge of a
portion of intestine. The patients are the subjects of atheroma or heart
disease.
816 SPECIAL DIAGNOSIS.
The Subjective Symptoms.
The Data Obtained by Inquiry. Pain. Colic. Colic is the term
applied to paroxysmal pain in the abdomen. It is characterized by
suddenness of onset and by alteration of intestinal function. It attends
all forms of inflammation of the intestinal tract. It is applied to a
peculiar affection known as lead-colic, due to local effects of lead. The
term colic is also applied to painful affections of the hepatic ducts,
pancreatic ducts, the ureters, and the uterus. Intestinal colic is the
form at present referred to. In addition to the inflammation of the
intestinal tract, it may be due to indigestion with flatulency. AVhen it
occurs suddenly without local cause it is known as enter algia.
Ixtestinal Colic. The colic of intestinal indigestion occurs sud-
denly, or it may be preceded by signs of intestinal indigestion. The
pain is chiefly in the umbilical region and radiates from that point.
It is relieved by moderate pressure or warmth. The patient is rest-
less and irritable. The face is anxious. The pain causes him to
roll about and double up. There is a cold sweat, and the pulse is
small and hard. Prostration or collapse rapidly ensues. Nausea and
vomiting follow the pain, and there are gaseous eructations. Disten-
tion. The abdomen is distended and tympanitic on percussion. The
pain may be relieved by the passing of flatus. Cramps. Spasm of
the muscles of the calves is common. The cramps are very painful ;
the muscles become knotted. The hands and feet are also cramped.
The pain is said to be due to spasm of the intestine, and is known also
as spasmodic colic. It is certainly due to distention or to irritation.
If the intestinal colic is due to indigestible food, it may have been pre-
ceded by an attack of acute indigestion, and the griping pains may
have developed at long intervals, with gastric and intestinal flatulency.
Vomiting may precede or attend the attack, and diarrhoea follow. If
the colic is due to gas alone, there is great tympanites. If it is due
to feces, it has been preceded by a history of constipation, and there
may be fecal masses detected in the rectum or along the colon.
Fever. The presence of fever is against intestinal colic, and points
to inflammation in some portion of the abdomen ; moreover, in inflam-
mation the pain is constant, but localized and aggravated by pressure.
The skin is hot and dry.
Diagnosis. The sudden severe pain, often relieved on the discharge
of gas, with gastro-intestinal disorder, tympanites, the occurrence of
cramps in the extremities, and the localization of pain to the umbili-
cus, all point to the true nature of the affection. A history of indis-
cretion in diet, or exposure, aids in the diagnosis. In colic the pain
may come on suddenly, or increase gradually from a sense of discom-
fort or soreness. The pain at its height is described as agonizing, and
of a boring or shooting character, abating for a time and then in-
creasing, until the patient rolls and twists in agony and breaks out into
a cold sweat. The pain may shoot from the seat of greatest intensity
to the shoulders, back, chest, or iliac region.
It must be distinguished from enteralgia. The latter comes on
slowly and lasts for hours or days. The pain is situated around the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 817
umbilicus, and is relieved by deep pressure, although the skin may be
hyperaesthetic. Sometimes the abdomen is retracted ; there are no
signs of indigestion, and flatulency and borborygmi are absent.
Lead Colic. If the enteralgia is due to lead, there is a history of
exposure to that metal. The blue-line on the gums, with obstinate
constipation but no vomiting, and the occurrence of neuritis due to
saturnine-poisoning, point to the true nature of the case.
Hepatic Colic. In hepatic colic the pain is situated in the region
of the liver, and may radiate to the shoulder or back. It is sometimes
fixed in the right parasternal line about the cartilages of the sixth and
seventh ribs. The attack is attended by vomiting, usually of bilious
fluid. It occurs in women most frequently ; the patients are almost
always over forty years of age. It may be followed by jaundice. There
is local tenderness, and there may be some swelling in the region pre-
viously mentioned. The bowels are constipated, and after the attack
may contain gallstones.
Renal Colic. In renal colic pain begins in the kidney and then
extends along the ureter. It is always more localized to the right or
left of the median line in the abdomen. It is more frequently in the
lower portion of either of the upper quadrants, three inches to either
side of the median line, depending upon the kidney affected. From
this region the point of maximum intensity and of local tenderness
moves to the lower quadrant toward the median line in the oblique
direction, rarely getting an inch below the transverse umbilical line.
The pain then extends to the region above the pubes and down the
thighs. From the first there is increased frequency of micturition.
The urine is scanty, high-colored, and may contain blood. With the
free micturition relief follows.
Local Peritonitis. Pain over the liver, spleen, and kidneys is gener-
ally due to involvement of the peritoneal coverings of these organs,
and partakes of the character of local peritonitis. It may, however,
be due to malignant, ulcerative, or inflammatory disease, and the diag-
nosis must be made by noting the character of the pain, its intensity,
duration, seat, and the other general and local symptoms with which
it is associated.
Rectal Pain. Pain in defecation may be due to piles, internal or
external, or to fissure, or may be the result simply of the passage of
an unusually large, hard mass. Pain from fissure is most acute and
spasmodic, and persists for some time after defecation. Fibroid stric-
ture of the rectum causes more pressure and straining at stool than
real pain ; but cancer is apt to be extremely painful.
Uterine Colic. In uterine colic the pain is situated in the pelvis.
There is some abnormality of discharge, and a history of uterine dis-
ease. Care must be taken not to confound the sudden pain of extra-
uterine pregnancy with intestinal colic or other forms of abdominal
pain. In extra-uterine pregnancy the pain is in the lower quadrants of
the abdomen to the right or left of the median line. It is sudden and
intense, attended by more or less collapse. It may be attended by
all the symptoms of internal hemorrhage. It may cause vomiting.
The history of cessation of menses, or other signs of pregnancy, of
52
818 SPECIAL DIAGNOSIS.
discharge of decidua, with the local signs on physical examination?
indicate the true nature of the pain.
Pancreatic Pain. In disease of the pancreas, either from the passage
of calculi (extremely rare) or because of pancreatic hemorrhage, there
may be sudden severe pain. The pain is localized to the region below
the sternum. It may be severe in the back and extend up the thorax.
It occurs in paroxysms, and is attended by great anxiety and collapse.
Gastric Pain. Intestinal colic must be differentiated from pain
of gastric ulcer, gastric cancer, and gastralgia. The characteristics of
pain in these affections have been discussed. When perforation occurs
in gastric ulcer the pain is usually seated in the epigastrium, but may be
complained of in the back as high as the mid-scapular region. It is
sudden and severe, preceded by a history of ulcer and attended by
collapse. There are no evidences of indigestion. Perforation of the
biliary passages is attended by pain in the hepatic region. The pain
is sudden and is usually preceded by symptoms due to derangement of
the biliary passages from obstruction by gallstones.
Appendicitis. Intestinal colic must not be confounded, although
it frequently has been, with the pains that attend appendicitis. This
is particularly the case with relapsing appendicitis. In this form only
mild fever attends the attack. The patient is seized with severe pain,
which may be described as occurring in the lower right quadrant, but
is sometimes complained of about the umbilicus. It frequently follows
indiscretion in diet, and may be attended by vomiting, and is likewise
usually relieved by eructation, but not by the passage of gas, a point
of great importance in the diagnosis. The attack occurs mostly in
young subjects, and lasts from twelve to twenty -four hours. It may
be so severe as to cause collapse. If fever attends it, and there is
a mass present, the diagnosis is much easier. In the relapsing as well
as the true form there is tenderness at McBurney's point. (See Ap-
pendicitis.)
Peritonitis. Intestinal colic must not be confounded with peri-
tonitis, which may follow in any of the above conditions, or develops at
other points in the abdomen. The purulent peritonitis that succeeds
pyosalpinx may be attended by severe pain without much reaction.
The pain, however, although complained of about the umbilicus, can be
localized by pressure in the lower quadrant and in the pelvis. It may
disappear after eight or ten hours, to be followed by a recurrence.
The recurrence of pain is usually attended by fever. In the first
twenty-four hours the bowels are loose, or at least readily moved. If
the peritonitis continues beyond this period, it is often impossible to
move the bowels.
Intestinal Obstruction. Intestinal colic must not be confounded
with organic disease of the bowels with resulting obstruction. In
these affections there are sudden constipation and rapid prostration.
The vomiting, if present, persists and soon becomes stercoraceous. In
intussusception the stools are characteristic. Strangulation, or ileus, is
associated with a history of previous peritonitis or the presence of hernia.
In the latter there may be signs at the hernial points. In the obstruc-
tion from external pressure the presence of tumors has been known
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 819
previously or can be recognized. In fecal obstruction, or the obstruc-
tion by gallstones, the local signs may be pronounced, and the pain is
usually in the ileo-caecal region. The affection is acute. Pain that
extends over a long period of time, that is not due to an acute process,
or attended by sevire acute symptoms, has been considered elsewhere.
(See Abdomen.)
Rheumatism and Neuralgia. Intestinal colic may be mistaken for
rheumatism of the abdominal walls. In the latter there may be a
history of exposure. The muscles are extremely tender. There are
no gastro-intestinal symptoms, the urine is loaded with uric acid and
urates, and there may be muscular pain in other situations, or a pro-
nounced history of previous attacks of rheumatism. In lumbo-abdom-
inal neuralgia the pain may simulate intestinal colic. Pressure-points,
where the respective nerves have their exit through the fascia, are
detected.
Pain in Vertebral Disease. Just here may be considered the
pain about the navel, which occurs in paroxysms, due to disease of the
vertebra?. There may be caries from tuberculous disease or from
pressure of an aneurism or malignant growths. Examination of the
vertebra? may determine its nature.
Diarrhoea. Diarrhoea is a symptom of disorder of the intestine,
which in turn is itself the cause of symptoms, just as jaundice, a symp-
tom of hepatic disorder, is the cause of various symptoms. In diar-
rhoea there is increased frequency of the movements of the bowels.
This is due to increased peristalsis of the intestine, which occurs from
a number of causes. Not all increased peristalsis results in diarrhoea.
(A) Nervous diarrhoea. Increased peristalsis may be due to some im-
pression upon the nervous mechanism of the intestine. This may
explain the diarrhoea of emotion, or that which occurs from other
psychical influences. (B) Catarrhal diarrhcea. In the larger number
of cases the diarrhoea is due to catarrhal inflammation of the intestinal
tract. The causes of the catarrhal inflammation are many, and have
been divided into primary and secondary causes. Primary catarrh is
due to the direct influence of causal factors upon the mucous mem-
brane. (1) It is seen after cold or exposure ; (2) it occurs from the
direct irritation of undigested food, and (3) from the action of irri-
tants, as of bacteria or the products of bacteria. Catarrhal inflamma-
tion due to micro-organisms is the most frequent form that occurs in
children.
Secondary catarrhs follow other lesions of more pronounced charac-
ter, as ulcers. The catarrh, and hence the diarrhoea, that attends the
ulceration of typhoid fever, the ulceration of dysentery, or that occurs
in Bright's disease, and the diarrhoea that attends carcinoma or other
organic disease of the bowel, is of this nature. In addition, a catarrh
of the bowels arises from venous stasis in the mucous membrane, with
chronic congestion. This occurs in organic heart disease with conges-
tion of the liver.
Diarrhoea is a symptom of the action of certain poisons, such as
mercury, arsenic, and other corrosive agents. The diarrhoea which
820 SPECIAL DIAGNOSIS.
occurs from the irritant action of food-products and in cholera infantum
is due to a toxic ptomaine.
Diarrhoea sometimes fulfils a vicarious office. This is the case with
the diarrhoea which comes on in cases of chronic Bright' s disease, and
in acute Bright' s disease before the supervention of uraemia. When
diarrhoea occurs in a person with pallor, dimness of vision, and oedema
the urine should always be examined.
The Symptoms of Diarrhoea. The Motions. Increased move-
ments of the bowels. The frequency of the movements varies with the
cause. In the diarrhoea of nervous origin, usually after five or six
movements have occurred, the patient is relieved, because by this time
the cause for the nervousness has disappeared. In catarrhal diarrhoea
the number varies from half a dozen in twenty-four hours to the same
number in an hour. Inoleed, in some severe cases the evacuations
may be almost constant.
Character of the movements. The movements may be (1) fecal, with
a small amount of water. They are light in color, softer than natural,
but yet retain their form. They are the kind of movements seen in
simple catarrh.
2. The fecal matter is mixeol with undigested food. The feces are
in scybalous masses, and the watery element is increased. They are
the stools of the so-called dyspeptic diarrhoea.
3. Along with the feces more or less mucus is seen. The amount of
mucus depends upon the seat as well as the intensity of the inflamma-
tion. Inflammations of the large intestine are attended with mucous
discharge. It may be mixed with and stained by feces so that it can
be recognized only by close inspection. In milder degrees of catarrh
it is seen on the surface of the fecal masses.
4. The feces disappear almost entirely, anol instead the evacuations
are watery. The watery evacuations may be discolored, as in the pea-
soup evacuations of typhoid fever, or they may be almost clear water,
as in the rice-water discharges of cholera.
5. The evacuations may contain blood. Bloody discharge usually
accompanies the discharge of mucus ; when the catarrh is in the loAver
bowel blood may occur independently of the mucus. If with the
mucus, it tinges it in reddish specks, or small amounts of free blood
are seen. The blood may be bright in color, and then usually comes
from the rectum. It must be remembered that the blood may be from
hemorrhoids, or fissure, which is unduly irritated by the diarrhoea. It
is then bright red and unmixed with the movement, and from its
position can readily be seen to have followed it. On the other hand,
it may be due to cirrhosis of the liver, with venous congestion. It
may be due to the ulceration of typhoid fever, and the intense inflam-
mation of enteritis. It is a symptom of carcinoma of the bowel, and
is of frequent occurrence, almost pathognomonic, in intussusception.
It must be remembered that blood of this character is discharged from
the bowel independently of diseases of that tube, as in purpura, scurvy,
and other blood diseases. (See Arteries of the Intestines, page 815.)
If mixed with the movement, the blood may be black, as in all forms
of melcena, or it may be dark red in color. The black blood usually
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 821
comes from the stomach or the first part of the duodenum, and may
be the result of ulceration, or even from the swallowing of blood.
Microscopical and Bacteriological Examination. (See Feces.) In
simple catarrhal inflammation of the tubules, on microscopical examina-
tion, but little is found except an excess of epithelium from the mucous
lining. In more intense inflammations, in addition to epithelium, we
find pus and blood and mucus. Micro-organisms are found, the kind
depending upon the cause of the diarrhoea. In health, Booker has
found at least forty varieties of micro-organisms, many of which, in
all probability, are not pathogenic. In health, the bacillus coli com-
munis and the bacterium lactis aeriformis are found. In the diarrhoea
of children both forms are present in excessive numbers, because con-
ditions favoring their growth arise, and in all probability are the cause
of the irritation of the bowel. In that form of inflammation of the
bowel known as dysentery, in addition to the bacteria that attend in-
flammation, the amoeba coli is often present. It has been found that
dysentery may be due to a number of causes, but that the so-called
tropical dysentery is due to the protozoa first described by Kartulis,
in Egypt, and in this country by Osier. (See Feces.)
Pain. The symptoms that attend increased movement of the bowels
depend upon the cause and also have direct relationship to the fre-
quency of the evacuation. The most frequent symptoms are pain,
flatulent distention, with borborygmi and tenesmus. The pain depends
largely upon the cause. If the irritant is a product of indigestion, or
a bulky mass, pain is more or less severe. It is situated in the centre
of the abdomen, and may extend all over it. Pain occurs before the
evacuation ; it is sharp, lancinating, and is usually relieved by the
movement. If the inflammation is in the large intestine, the pain may
be complained of in the course of the large bowel or be more intense
over the caecum and the sigmoid flexure. The rectum may be the
seat of pain or of painful sensations. This has been described as a
feeling of a hot ball in the lower pelvis.
Flatulent Distention. The flatulent distention is not very great
generally. The abdomen is distended, tympanitic on percussion, and
tender on palpation, both of which may be more marked in the middle
of the abdomen if enteritis alone is present, or it may extend along
the course of the colon, as in the so-called entero-colitis of children.
With the distention there are borborygmi. The rumbling usually
subsides after the evacuation.
Tenesmus occurs in all forms of diarrhoea if the evacuations have
been frequent. After the discharge of the contents of the bowel, par-
ticularly if from the rectum, the tenesmus is much more severe, and may
be of constant occurrence. In the severe cases the tenesmus may be
almost continual. On account of it prolapse of the bowel is apt to ensue.
General Symptoms. The general symptoms that attend diarrhoea
depend upon the cause. In simple diarrhoea there might be slight
feverishness only, with a little weakness. En diarrhoea, with excessive
movements, with mucus, with or without blood, the fever is marked
and may rise as high as 103°. The fever that attends dysentery is
high, and usually rises rapidly at the beginning.
822 SPECIAL DIAGNOSIS.
Prostration. More or less prostration attends all cases. It is, how-
ever, more marked when there are frequent watery evacuations. In
its most pronounced degree it is seen in cholera and cholera infantum.
Collapse rapidly ensues under these circumstances, on account of the
depleting effects of the excessive watery discharge. In catarrh of the
intestines secondary to typhoid fever and other conditions the general
symptoms depend upon the primary disease.
Chronic Diarrhcea. Chronic diarrhoea may be due to chronic
inflammation of the bowels, as in chronic intestinal catarrh. It may
be secondary to the ulceration of dysentery, tuberculosis, syphilis, or
cancer. It is the common diarrhoea of amyloid disease. In chronic
diarrhoea the number of the stools varies, but seldom amounts to more
than ten to fifteen in a day. In chronic intestinal catarrh three or four
movements occur in the twenty-four hours. They usually occur in
the morning, the first evacuation taking place immediately on rising
and the remainder during the morning hours. They are more com-
mon in women than in men, and are readily excited by exhaustion or
nervous influence, as grief, emotion, or excitement of any kind. The
stools are fecal and watery, and contain some mucus. The mucus
usually coats the surface of the feces. The color of the feces is not
changed. The patients usually suffer fom intestinal dyspepsia, or they
are subject to some gastric neurosis. They are not under weight, and
except for the inconvenience of the morning hours, could attend to the
ordinary demands of life. They are more nervous than most people,
and are liable to attacks of hemicrania.
Membranous Diarrhcea. In a number of cases the discharge
from the bowels resembles membrane. The disease is also called
membranous enteritis. The discharge contains much mucus, and may
be quite watery. After the feces have been passed membrane is dis-
charged. This may be in shreds or large masses, and may also be
like a cast of the bowel. The patients are usually women who are
hysterical and have some menstrual disorder. Pain may precede the
discharge, and continue until there is complete relief.
Constipation. Constipation may be due to a number of causes. It
may be due to alteration or diminution in the secretions of the intesti-
nal tract, as is seen in all fevers, except when they are attended by
specific intestinal catarrh, as in typhoid fever. Such diminution of
secretion occurs in the summer, when there is more free perspiration
than in other seasons, and is present in affections attended by excess
of perspiration, or exhaustive diuresis. Constipation, therefore, is a
common symptom of diabetes.
In addition to alteration of the secretion, diminution in the sensi-
bility of the nerves may exist. This is the one chief cause of habitual
constipation that is so prevalent. On account of carelessness the
patient loses the habit of having a regular movement of the bowel
each day, and in consequence the usual stimulus is removed. Consti-
pation also occurs from weakness of the muscles.
The three conditions — diminution or alterations in the secretions,
debility of the muscles, and impairment of the sensibility of the ner-
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 823
vous mechanism — are combined influences, on account of which consti-
pation is so prevalent in persons of sedentary habits and in persons
living upon improper diet. General diseases and local disorders which
influence either of the above elements cause constipation. Thus in
anaemia and chlorosis, in neurasthenia and hysteria, constipation is a
common condition. Its occurrence in fevers has been mentioned. In
the convalescence from exhausting disease and prolonged confinement
to bed constipation is apt to ensue.
Local Causes. Atony of the abdominal muscles or of the bowel
is the cause. Atony is most strikingly seen in peritonitis and typh-
litis, in both of which a paretic state of the bowels develops. It is
seen in the aged and in cachexia along with atony of other muscles.
Obstruction of the bowels, acute or chronic, usually causes constipation
(q. v.). If the obstruction is not complete, there may be diarrhoea on
account of catarrhal inflammation. Constipation often occurs on ac-
count of pain, particularly pain seated in the rectum. The pain is
such that the patient shrinks from an evacuation. Frequent postpone-
ment soon causes constipation. The pain may be due to fissures, to
hemorrhoids, or to fistula. Constipation occurs also from local dis-
eases in other portions of the body, influencing, in all probability, the
nervous mechanism by which peristaltic action is excited. In acute
and chronic disease of the brain and cord, as meningitis and myelitis,
constipation is a usual attendant. It also occurs in tetanus. If the
bowel is deprived of fecal matter, evacuations cease ; constipation is,
therefore, a common sign of stricture of the pylorus and of stricture or
cancer of the oesophagus.
Symptoms of Constipation. Constipation is characterized by diminu-
tion in the frequency of the bowel-movements. The frequency of the
movements varies in health. Some persons are comfortable with an
evacuation taking place once a week, or at most every third or fourth
day. There are cases on record in which the evacuations took place
but once a month. Cases of this class are usually due to muscular
paralysis of the bowels, with secondary dilatation. The accumulation
of feces is removed by a sharp attack of diarrhoea, attended by much
pain. The diarrhoea sometimes continues for twenty-four hours. When
it sets in fever may be present until there is thorough evacuation.
Local Symptoms. Usually the symptoms that attend constipation
are local, being due to the discomfort of the accumulation of feces.
The local symptoms may be limited to the rectum or extend through-
out the abdomen. In the rectum there is a sensation as of the pres-
ence of a mass, which may cause some pain. The abdomen is dis-
tended; there is considerable rumbling, and sometimes peristaltic
waves are seen. The accumulation of the fecal mass in the bowels
may set up tormina and tenesmus, and portions of the mass may be
discharged from time to time. In other words, a diarrhoea may occur,
the diarrhoea of constipation, or spurious diarrhoea. The stools are
small, composed of hard scybalous masses, generally coated with
mucus, and streaked with blood. The evacuation does not give relief,
and the desire for a movement may be more or less continuous.
On examination in constipation with fecal accumulations the outline
824 SPECIAL DIAGNOSIS.
of the colon may be marked out by palpation and percussion of the
distended abdomen. In its course masses are felt varying in size from
a marble to a base-ball, and in consistence they may be soft to the
palpating finger ; they are never indurated like a calcareous mass, as
gallstones or a mass due to malignant disease. (See Fecal Tumor.)
General Symptoms. While in many instances the general symptoms
are of no consequence, in others the patients are nervous and may be
in more or less impaired health, on account of the secondary effects
upon the stomach. Digestion is impaired and the form of indigestion
is that which attends neurasthenia.
The patients are of spare habit, usually of dark or muddy complex-
ion. They may be depressed. There is inaptitude for mental exer-
tion ; they are more or less hypochondriacal. The tongue is constantly
furred, the appetite variable ; there are weight and fulness after eating,
and generally some flatulency.
The Secondary Effects of Constipation. The effects of constipation
upon the intestines are various and sometimes disastrous. They are
dilatation and ulceration. The former may become enormous, as in
cases reported by Formad and Osier. The dilatation may be so great
as to distend the entire abdomen. The ulceration may be localized to
the rectum, or caecum, or extend throughout the entire large intestine.
On palpation the course of the colon is tender, and fecal masses may
be outlined that are painful, because of their pressure upon the ad-
jacent ulcer. In the rectum the ulcer may be deep, and be followed
by peri-rectal abscess.
Stercoral typhlitis. In the caecum the accumulation may cause a large
boggy swelling, extending in the course of the csecum, which is tender
on pressure and dull on percussion.
Fecal impaction, with secondary ulceration, is of frequent occurrence
in typhoid fever. This must be borne in mind, for often serious gen-
eral and local symptoms arise because it is overlooked. Recently I
saw a case with diarrhoea of constipation, with some fever, which per-
sisted for weeks after the usual course of typhoid fever. It was
thought the patient had tuberculosis, or that the typhoid process was
abnormally prolonged. Examination disclosed ulceration into the
vagina, and the feces were constantly discharged from this orifice. It
had been thought that the discharges of feces were due to diarrhoea.
Of course, fever attended the process, and rendered the case all the
more obscure.
In this connection must be mentioned the constipation that occurs
on account of lead-poisoning, and the exhibition of drugs, as opium, or
astringents. The constipation of lead-poisoning is usually attended
by colic, and the blue-line on the gums is seen, while wrist-drop or
other manifestations of lead may be present.
Intestinal Hemorrhage. The causes are general and local. The
general causes are those that accompany hemorrhage in other localities.
(See Gastric Hemorrhage.) The local causes, when the hemorrhage is
small, are : inflammation of the bowel ; traumatic injury to the bowel
from hernia, feces, and parasites, and foreign bodies swallowed, or from
corrosive poison ; tumors of the bowel, as in cancer, invagination, and
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 825
ulcers. When the hemorrhage is large the causes are the congestion
attending portal obstruction and liver disease, or disease of the heart
with secondary obstruction ; aneurism of the superior mesenteric artery,
or aneurism rupturing into the intestine, and, occasionally, embolism
of the artery ; the ulceration from typhoid fever, from dysentery, and
from syphilis. It may occur in pyaemia and septicaemia, or the acute
exanthematous diseases.
The symptoms may be those of hemorrhage alone : collapse, pallor,
failure of sight, tinnitus, vertigo, small pulse, and general restlessness.
The hemorrhage must be copious under these circumstances, and is
due (1) to an ulcer, as in typhoid fever ; (2) to portal obstruction ; (3)
to an aneurism ; (4) to purpura or haemophilia.
A second group of symptoms is connected with the appearance of
the discharges from the bowels. The stools are bloody ; if the hemor-
rhage is low down, they are bright red and usually mixed with feces.
If high up, they are tarry. The latter condition is known as melaena.
(See Feces.) The passage of the stools is preceded by colicky pains,
or there may be some rumbling. The diagnosis must be directed to-
ward determining the cause of the hemorrhage, as well as its seat ; the
history, the associate diseases, or symptoms, aid in determining the
cause. Examination of the rectum may afford a clue to its origin.
The Objective Symptoms.
The Data Obtained by Observation. Physical Signs. (See
The Abdomen.) Inspection. Local and general enlargements of the
abdomen have been discussed in the preceding pages. Movements of
the intestines are seen in obstruction due to increased peristalsis. The
intestine above the point of obstruction may swell into a well-defined
tumor which becomes hard and dull, and tympanitic on percussion.
Palpation. Tenderness, peristalsis, peritoneal friction, the bubbling
of gas through a constriction of the bowel, and tumors, are recognized
by palpation. It is necessary often to place the patient on all-fours
or in a knee-chest position.
Percussion. The normal note is tympanitic. Local areas of dulness
may be due to intestinal tumor. Light percussion should be employed.
A dull tympany indicates a solid mass surrounded by the distended
intestines. The outline of the large intestine can be ascertained by
filling it with water.
The Feces. General Considerations and Macroscopical
Appearances. The number of stools in health varies chiefly with
the individual and the character of the food taken. After infancy,
one passage in twenty-four hours is the rule, but it is natural for some
persons to have two or three, and for others to have but one passage
in two, three, or four days. Such a condition is termed constipation,
while pathological constipation is properly called obstipation. The
opposite condition is known as diarrhoea. The amount and character
of food and drink ingested influence the number of stools. Exercise
also plays a role ; increased or diminished peristalsis, from whatever
cause, will induce diarrhoea or constipation, respectively. In disease
826 SPECIAL DIAGNOSIS.
the greatest extremes are met with — from the non-passage of feces
for days, as in obstruction, to an almost continuous discharge, as in
some forms of intestinal inflammation. It is well to remember that
diarrhoea may be the symptom of obstipation, as when impacted feces
in typhoid causes looseness of the bowels.
The amount of feces varies with the quantity and nature of food. If
most of the food is digested there will be but little left to form feces.
In any disease that prevents the absorption of digested food or causes
an increase in the fluid contents of the intestine, as cholera, the amount
of feces will be increased. In health about 140 to 200 grammes are
voided in twenty-four hours.
The form and consistence of healthy stools vary somewhat. They
are commonly cylindrical and firm or mushy. When they remain long
in the intestinal canal, and the water is extracted, they become hard
and may form balls, or flattened masses known as scybala. These are
frequently seen in convalescing typhoid patients. On the other hand,
the feces may be without form, and are then liquid, either watery, as
in cholera, or purulent or bloody. Many diseases cause such a con-
dition.
The odor of feces is sometimes more or less characteristic of certain
conditions. Thus the stools of nursing infants have a sour smell,
while in infantile diarrhoea, and when fermentation takes place, they
have an odor of sebacic acid. When urine is mixed with the passage
the odor will be ammoniacal ; with blood present it often has a stale
odor.
The reaction is not constant. Thus in intestinal catarrh, with acid
fermentation, it will be acid, or in alkaline fermentation it will be
alkaline. The color of the stool varies too much to be of special diag-
nostic value. In health it is light to dark brown, due chiefly to the
presence of hydro-bilirubin, a product of decomposition of bile-pig-
ment, which is never normally found unaltered in the feces. It is
influenced greatly by food and medicines. When certain berries, as
huckleberries, are eaten, or certain medicines taken — iron and bismuth
— they make the passages black. Calomel causes green stools, on
account of the biliverdin discharged. Green stools may also receive
their color from the presence of a bacillus which produces a green dye.
Santonin, rhubarb, and senna cause yellow, and hsematoxylon red
stools. The last fact is important, as parents or nurses should always
be warned to expect red passages when hsematoxylon is given.
The feces may be red or reddish from the presence of unaltered
blood ; or black, when the blood has undergone changes ; the so-called
" tarry stools " are of this character. With a decrease in the amount
of bile the stools become less colored, and if the bile is cut off they
become clayey. This color may, in some cases, be due to the presence
of fat left undigested because of the lack of bile. On the other hand,
if from disorders of the stomach and intestine the contents pass through
too rapidly, the feces may contain unaltered bile, unchanged bile-pig-
ment, giving a green or yellow color, and showing the bile-reaction.
The constituents of feces that can be recognized by the naked eye are
numerous. Seeds, stones, skins of fruit and berries, and the fibres of
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 827
vegetables are often seen in healthy stools. In the passages of chil-
dren and weak-minded individuals foreign substances of all descrip-
tions may be present. Foreign bodies and partially digested portions
of food may be mistaken for parasites. Portions of tumors from the
digestive tract may appear in the feces.
In certain diseases of the stomach and small intestine, and in those
who eat very fast and do not properly masticate their food, undigested
and unchanged particles of food may be seen in the stools.
Shreds of mucous membrane of varying size are passed with the
feces. Von Jaksch saw such a shred 5 cm. long and 3 cm. broad in a
case of cholelithiasis. Various sized pieces of membrane, consisting
of transformed mucus, are passed in membranous enteritis.
Particles resembling sago-grains, perhaps the result of over-indul-
gence in farinaceous food, have been met with.
Gallstones in the feces have great clinical value. They may escape,
detection if not properly sought for. When suspected, each passage
should be passed through a linen sieve, the fecal masses being softened
with water. They may be found as small, crumbling masses, composed
chiefly of cholesterin (intrahepatic calculi), or as hard, irregular,
smoothly worn, shining, many-sided, hard stones, sometimes as large
as an egg, usually the size of a pea. Enteroliths are occasionally seen.
They are said to originate in the appendix.
Blood may be present in the feces in varying proportions and con-
ditions. When found unaltered on the surface of scybalous masses, it
is from the rectum or large intestine, and probably the result of trau-
matism. Hemorrhoids, if bleeding, may cause such an appearance, or
may cause very free hemorrhage. Severe hemorrhage may come from
ulceration of the rectum or colon, due to malignant disease or severe
inflammation. The blood may be intimately mixed with the feces,
and have its origin in the large intestine, but much more commonly it
indicates a source in the stomach or small intestine. Under such cir-
cumstances it is nearly always more or less changed by the intestinal
juices, and is brownish-red or black (the tarry stool mentioned above),
or has the appearance of coffee-grounds. The brighter the color of
the blood the nearer is the source of hemorrhage to the anus. The
more retarded the passage the greater the change ; while, if quickly
expelled, blood from the small intestine may be passed unchanged, as
in the hemorrhage of typhoid fever. The microscope detects blood
when the naked eye fails to detect it. It is to be remembered that
certain drugs, as already stated, may color the feces red, and simulate
blood.
Mucus may be present in the passages in health, but when in any
marked quantity there is a catarrh of the mucous membrane of the
intestines. When hard scybala are covered with mucus, or the mucus
is seen in shreds, the large intestine is the seat of a catarrh ; although
mucus may be mixed with thin stools, as in dysentery. Usually, how-
ever, when the mucus is finely divided and mixed with the feces, it
comes from the small intestine. Mucous shreds have already been
mentioned. In cholera the particles of mucus look like boiled rice,
hence the term " rice-water stool."
828
SPECIAL DIAGNOSIS.
Fatty stools, to the naked eye, appear greasy or even clayey, when
there is much fat, even though bile-pigment may be present.
Pus may be present in large quantities from rupture of an abscess
into the intestinal tract, or when there are ulcerations from various
conditions, producing pus in considerable quantities.
Microscopical Examination of the Feces. Many animal
parasites ai"e not microscopic, but it is convenient to consider them in
the following paragraphs. A small portion of the solid feces to be
examined is placed on a slide, moistened with a \ per cent, salt solu-
tion, and a cover-slip applied ; or if liquid, various drops are to be
examined. The different constituents found will vary with the food
taken as well as with disease.
A. Constituents Derived from Food. There may be portions
of digested or undigested food. In general it may be said that the
presence of large pieces of unchanged food, or many small particles of
undigested or only partially digested food, indicates defective digestion
in the stomach or small intestine. If unchanged bile is present, some
particles w T ill be colored yellow, another indication of disordered func-
tion.
From the food we may see muscle and elastic fibres, more or less,
according to the quantity of meat eaten by the patient. The former
are recognized by their transverse striation ; the latter, by their double
contour and curling ends. Fat may be present as fatty globules or
in the form of needles, fatty crystals. Much fatty food increases
their number, and they are seen plentifully in alcoholic poisoning,
in jaundice, in pancreatic diseases, tuberculosis of intestines, diseases
of the mesenteric glands, and enteritis. The crystals may be trans-
Fig. 197.
Collective view of the feces. (Eye-piece III., objective 8A, Reichert.) a. Muscle-fibres. 6. Con-
nective tissue, c. Epithelium, d. White blood-corpuscles, e. Spiral cells, f-i. Various vegetable
cells, k. Triple phosphate crystals in a mass of various micro-organisms. I. Diatoms. (Von
Jaksch.)
formed into fat-drops by the addition of acid and heat. When meat
is eaten freely, areolar tissue may be present, but its presence otherwise
points to defective digestion. Various forms of vegetable cells are
commonly seen, in which granules of starch may be contained, or the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 829
starch particle may be free. Undigested milk occurs in the stools of
children and when diarrhoea prevails ; a substance, probably casein,
has been described by Xothnagel as occurring in the feces of persons
who have intestinal disturbances.
In persons living on vegetables most of the above constituents will
be absent, and in infants who partake only of milk, the derivatives of
meat are absent, while there will be an excess of fatty crystals and fat-
globules and coagulated products.
B. Constituents from the Alimentary Tract. Epithelium. In
every normal stool will be found epithelium of the squamous variety.
Occasionally the columnar form is seen, and modified epithelial cells
are very common. In intestinal catarrh their number is greatly in-
creased.
Red Blood-corpuscles. In the majority of blood-stained stools red
blood-cells are not found ; in their stead will be seen masses of free
blood-coloring matter and rhombic crystals of hseniatoidin. Red cells
are seen in dysenteries, in bloody stools in which the blood comes from
near the anus, as in hemorrhoids, and when blood is discharged with
the feces soon after the occurrence of the bleeding. If there is any
doubt as to the presence of blood, when the corpuscle cannot be found,
a true decision can be reached by examining for hsemiu-crystals, ac-
cording to Teichmann's method. A portion of feces is dried and pow-
dered, placed on a slide with a grain of common salt, and covered by
a cover-slip. A few drops of glacial acetic acid are directed beneath
the slip, the slide is heated just to boiling, and if blood has been pres-
ent, reddish-brown rhombic crystals of hsemin will soon be found.
Leucocytes. Leucocytes are frequently seen in healthy stools. ^ In mi
pus is present or discharged into the intestinal canal they are found in
great numbers, as in ulceration of the intestine and in abscess.
Molecular debris, or detritus, occurs in all feces as part of the waste-
products.
Crystals. Fat-crystals, are the most important. They have been
quite fully considered above. There seems to be little doubt that the
crystalline needles found in the feces are salts and fatty acids, and not
tyrosin.
( 'harcot-Leyden crystals, similar to those already described (see Spu-
tum), have occasionally been met with in the stools of typhoid fever
patients, in dysentery, intestinal tuberculosis, and ankylostomiasis.
Ha in of oi'I iii-crystals occur as reddish-brown, hard, needle-shaped
bodies, usually in clusters, and free or enclosed in masses of mucin or
a substance resembling it. They have been found in the feces of
breast-fed infants, in cases of chronic intestinal catarrh, and, by Y<>n
Jaksch, in the stools of a case of nephriti>.
Crystals of various salts of calcium, of triple phosphate and eho/cxt'-rin
will often be recognized, but they have no diagnostic value. When
bismuth is being administered, black rhombic crystals of the sulphide
of bismuth will be recognized.
C. Parasites. (A) Animal and (B) vegetable parasites flourish in
the intestinal tract, and the presence of some of these in the feces is
of the greatest clinical importance.
830
SPECIAL DIAGNOSIS.
A. Animal Parasites. Following Leuckart's classification, we
will consider these parasites under the secondary heads :
I. Protozoa. 1. Rhizopoda. This variety is made important be-
cause the amoeba dysenterise or amoeba coli belongs to it.
(a) Amoeba Dy sentence. Amoeba Coll. This protozoon has been
found so many times by various observers in different parts of the
world that it can now be considered to be the causative factor of so-
called tropical dysentery. The subject has received special study in
our own country by Osier/ Stengel, 2 Dock, 3 and Councilman and
Lafleur. 4 The work of Councilman and Lafleur is at the present time
the best that has been published in any country ; and to it the reader
is particularly referred. The following notes are based on this book.
The amcebse dysenterise vary in size from 0.012 to 0.035 mm. They
are found most plentifully in the small gelatinous masses often to be
seen in the feces. They vary in number in different cases, and in the
same case at different times. The severer the lesions the more numer-
ous are the amoeba?. When not active they are round or oblong, and
highly refractive. They contain one or more vacuoles of varying size.
Occasionally the division into an ectosarc and endosarc is easily made
out. When thus inactive they may be confounded with swollen con-
nective-tissue cells and compound granular bodies found in feces. The
active amoebae have, however, a characteristic movement. This consists
of progression and of thrusting-out and retraction of pseudopodia. Their
activity varies greatly. It is best seen w T hen the body-heat is main-
tained. The stools should be passed into a clean and warm pan, and
examined immediately, or kept warm until examined, and a warm
Fig. 198.
Amceba coli. (Hallopeau.)
stage should be used with the microscope. The division into ectosarc
and endosarc is usually clear during activity. The ectosarc is com-
posed of a hyaline homogeneous mass, as are the pseudopodia, while the
1 Johns Hopkins Hospital Bulletin, May, 1890, vol. i., No. 5.
2 Phila. Med. News, 1890. * Texas Med. Journal, April, 1891.
1 Johns Hopkins Hospital Reports, vol. ii., Nos. 7, 8, 9.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 831
endosarc is made up, not of granular matter, but of a dense homo-
geneous mass enclosing vacuoles and a nucleus. The vacuoles may
vary in size as well as in number. There may be one or two large
ones, or the entire endosarc may appear as made up entirely of small
vacuoles. The nucleus is sometimes plainly seen as a small rounded
body, but is more often difficult to distinguish from the vacuoles.
Dried cover-slip preparations may be stained with the various aniline
dyes, but the results are not satisfactory.
The amoeba? will often be found to enclose bodies such as red blood-
corpuscles, pus-cells, blood-coloring matter, bacilli and micrococci.
In examining the feces for amoebae dysenteriae the suggestion given
above concerning the warm bed-pan and warm stage to the microscope,
and, above all, the immediate examination of the stool, should be ad-
hered to. The small gelatinous masses should be selected when present.
A r arious magnifying powers should be used, including the y 1 ^ oil-immer-
sion lens.
(6) Monadines, pear-shaped, with a long slender process, are seen
alive in only perfectly fresh stools. They are not found constantly in
any one disease.
2. Sporozoa. Under this head belongs the coccidium perforans of
Leuckart. They are short, elliptical bodies, which infest the intesti-
nal mucous membrane, and may damage it badly; they are often dis-
charged in large numbers.
3. Infusoria, (a) Cercomonas Intestinalis. This is a pear-shaped
body, nucleated, with eight tentacles of varying length. It is found
in the feces of persons suffering from various diseases, as cholera and
typhoid fever, and probably of itself causes diarrhoea.
(6) Trichomonas intestinalis. Larger than the cercomonas, and cov-
ered with ciliae at the club end. It is not diagnostic and is not
common.
(c) Paramecium coli. Larger than the preceding, 1 mm. long —
oval, covered everywhere with ciliae ; may be found in diarrhceic stools.
II. Vermes. These are much more generally known and are of
much more clinical value than the preceding.
They have important clinical value, as the presence of some of them
in the intestinal canal gives rise to many untoward symptoms. They
will be considered under (A) Platodes and (B) Annelides.
A. Platodes. 1. Tapeworm — Cestodes. These parasites infest
the small intestine only, to the walls of which they cling by the head.
The head and neck are small ; the joints are flat and form long ribbons.
The distal joints continually drop off and can easily be recognized in
the stools by the naked eye, and the eggs by the use of the micro-
scope. The feces are best washed in water and broken up to obtain
the eggs. As the lower joints are lost new ones take their place from
above. The more important are as follows :
a. Tenia solium (Fig. 199) reaches a length of two to three metres.
The head is the size of a pin-head. The neck is 2.5 cm. long, as thick
as a thread, and without joints. The segments forming the body are
short and broad near the neck, but as they increase in size there is
more growth in length than in width. The average dimensions are 9
832
SPECIAL DIAGNOSIS.
to 10 mm. by 6 or 7 mm. The head appears dark, the body white.
The joints are easily detected in the feces by the naked eye. Under
the microscope the head is seen to be spheroidal, with four pigmented
sucking-disks surrounding at the base a rostellum, which is a " crown
of hooks " — chitin hooks- — about twenty-four in number. In the ripe
segments, or proglottides, is seen the longitudinal uterus with about
twelve horizontal ramifications to a segment. The eggs are round or
oval, 0.035 mm. long, with a thick, striated shell when ripe, and con-
tain hooklets.
Fig. 199.
Fig. 200.
Head of T. solium, x 45. (Leuckart.)
Ova of T. solium, a, with yolk, b, without
yolk, as in mature segments. The hard brown
shell is indicated. (Leuckart.)
b. Tcenia mediocanettata, or saginata. This worm is four or five
metres long. The head is slightly larger than that of the T. solium,
and more pigmented, and the segments are longer, fatter, and darker.
The head is supplied with four powerful sucking-cups, but has no
rostellum or hooklets. The uterus in the ripe segment is much more
finely branched than in the solium, and these segments have indepen-
dent movement. The eggs are very similar to those of the T. solium,
but may be rather larger.
c. Tcenia nana. In length the T. nana is only 10 to 15 mm., and
0.5 mm. in breadth. The round head is but 0.3 mm. in diameter.
The segments are all short, and at the lower end of the body are four
times as wide as they are long. The head is found to have four round
suckers at the base of a rostellum that can be inverted. At the base
of the rostellum are about twenty-two hooklets. The uterus is oblong
and filled with eggs. The eggs have a double membrane.
d. Tcenia cucwmerina. This parasite is found to be 5 to 20 cm.
long and about 2 mm. wide. The head is placed at the thinner end,
and under the microscope are to be seen some sixty hooklets regularly
distributed about the rostellum, and four sucking-cups. The lower
segments are decidedly larger than the upper — 6 by 7 mm. "When
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 833
ripe they become reddish, and contain cocoon-like bodies, in which
are six to twelve eggs.
e. Bothriocephalus latus. This is the largest of the worms, meas-
uring 7 or 8 metres. The head is somewhat drawn out, and on either
side is a long, narrow sucker. There are neither hooks nor rostellum.
The proglottides are short near the head, but become square further
down. The uterus appears as a rosette, peculiar to this worm. The
eggs are oval, and measure 7 mm. by 0.045 mm., have a shell covering,
with an opening like a lid at one end. Ripe segments are thrown off
in bunches, not singly.
It will not be necessary to describe certain other varieties that are
rarely met with.
2. Trematodes, or flukes, a. Distoma hepaticum measures 28 mm.
by 10 mm., and is shaped like a leaf. A short head is situated at the
broad end and has one sucker ; on the under surface is another sucker,
and between the two is the opening of the uterus, a highly convoluted
arrangement. The eggs are brown, oval, about 0.12 mm. long, and
have a lid at one end. It is not often seen.
b. Distoma lanceolatum. This round-shaped worm is about 8 mm.
long and 3 mm. broad, and in other respects resembles the preceding.
The eggs are more rounded and contain minute embryos. Like the
D. hepaticum, it is rarely seeu.
c. Distoma crassum is the largest — 4 to 8 cm. long. These flukes
are endemic in parts of Japan. In general these animals occupy the
bile-passages or upper part of the small intestine.
B. Axxelides. 1. Round Worms — Nematodes. A. Ascarides. a.
Ascaris lumbrieoides. This is the parasite usually referred to by the
term round worm. It resembles the common earth-worm in shape
and color. The male worm is about 250 mm. long, and the female
400 mm. The head is made up of three prominent lips, and is sup-
plied with microscopical teeth. The vulva of the female is in the pos-
terior third of the body. The eggs are rounded, brownish, 0.06 mm.
in diameter, and covered, when fresh, by a rough albuminous coat over
a hard shell. This worm has the small intestine for its habitat. It
may pass with the stools or work its way into the stomach and be
vomited (the writer has had them thus vomited during the etherization
of a child of ten years). They have been the cause of jaundice by
crawling into the ductus choledochus, and may infest the larger hepatic
ducts. Enormous numbers may be present in the intestine at one
time.
b. Oxyuris vermicularis. The thread-worm, or seat-worm, inhabits
the large intestine, and is often present in the stool as a white, thread-
like body ; the male 5 mm. and the female 10 mm. long They often
wander out of the anus and into the vagina. The head has a number
of small lips, and is covered with a thick skin. The female has one
vagina and two uteri. The eggs are unsymmetrical, have a laminated
shell and a diameter of about 4 mm.
B. Strong y tides. Anhylostomum duodenatc. This is a round worm,
reaching a length of 6 to 10 mm. in the male and 10 to 18 mm. in
the female, and can, therefore, be seen easily, though the eggs are
53
834 SPECIAL DIAGNOSIS.
much more frequently found in the stool than is the worm itself. With
the eggs there may be present in the stools large numbers of Charcot-
Leyden crystals. The head is prominent, especially in the male. Four
hook-like teeth surround the mouth, and by these the animal attaches
itself to the intestinal wall. The tail of the male is expanded and that
of the female pointed. The vulva is in the posterior third. The eggs
are oval, about 0.05 mm. in diameter, and contain one to four cells —
embryonic globules, which rapidly develop in a warm place outside
the body, and may thus be recognized. The worm infests the small
intestine, especially the jejunum. It often causes serious symptoms —
bloody stools and intense anseniia.
c. Triehotrachelides. a. Tricocephalus dispar. The whip-worm is
4 to 5 cm. in length, the female being longer than the male. It is
recognized by the contrasting form of the anterior and posterior por-
tions. The former is thin and threadlike, the latter expanded and
broad, and in the male curled up. The eggs are brownish, about 0.05
mm. long and half as broad, and have a button-like projection at either
end ; they are to be recognized in the stools, where large ones may be
present. There may be only a few or thousands of the forms present
in the body. They live chiefly in the caecum and large intestine.
They have been thought to cause beri-beri by some writers.
b. Trichina spiralis. It is the adult trichinae which exist in the
intestine and are found very infrequently in the feces. These produce
the embryos, which become muscle trichinae. The adult male is 1.5
mm. long and the female twice that length. The former has two pro-
jections from the hinder end, between which are four papillae. The
female has a tubular uterus and a tubular ovary in the posterior half
of the body.
D. Rhabdonema. Strongylides. Under rhabdonema intestinale
we now include two small nematodes, which were termed anguillula
mtestinalis and A. stercoralis, and which are probably one and the
same. They are found in the stools of cases of endemic diarrhoea of
hot countries. Usually the young embryos, which have developed in
the intestinal canal, are dejected with the stools. These sexually
mature embryos are 0.8 to 1.2 mm long, male and female respectively.
They are round and have a cone-shaped head. There are two jaws
and two teeth in each. The adult worm is about 2.2 mm. long and
0.04 mm. thick. The mouth has three lips. The vulva is at the be-
ginning of the posterior third. The eggs might be easily confounded
with those of the ankylostomum duodenale, but are somewhat more
pointed, and larger. The rhabdonema infests the small intestine, and
is frequently found in connection with ankylostoma.
Echinococcus hooklets and portions of the striated cyst-wall have
been found in the feces. The rupture of a hydatid cyst into the in-
testine may be discovered when the above structures are found, point-
ing to a cyst in the abdominal cavity.
B. Vegetable Parasites. We find both (I) pathogenic and
(II) non-pathogenic vegetable parasites in the feces. The latter we
have classed as (1) moulds, (2) yeasts, and (3) fission-fungi.
1. Moulds. The only mould found in the stools is the thrush
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 835
fungus, when children are the subjects of thrush in the mouth. It is
of very rare occurrence in the feces, and has no special clinical import.
2. Yeasts. In all feces, in health or disease, yeast fungi exist.
They are most numerous in acid stools. They are round or ovoid, and
usually occur in groups. They stain dark brown with a solution of
iodine and iodide of potash, while apparently similar cells become
violet or blue with the same dye.
3. Fission-fungi. Bacteria are found in greatest numbers in the
feces, chiefly as bacilli, micrococci, and spirilla. They may be grouped
as torulae or sarcinse. They present active movement, and may be
separate or in colonies. The bacillus coli communis (B. termo) is the
most frequent form met with, both in health and disease. It is not
yet determined what relations it holds to normal and abnormal condi-
tions, or what is the true relationship between it and certain other bac-
teria. B. subtilis is another bacterium found both in health and
disease. As above stated, there are various organisms which stain
brown with iodo-potassic-iodide solution, and others which become
blue with the same dye. Von Jaksch has studied these latter closely.
They take various forms, as long or short rods, and take different
shades of blue or violet. One of them is the Clostridium butyricum
of Nothnagel. It occurs as large round cells, like yeast fungi, and
stains like the tubercle bacilli with the Ziehl-Neelsen fluid. Von
Jaksch finds these fungi in greater abundance in intestinal catarrh.
They are present in both acid and alkaline stools.
Bacillus coli communis has been found in the blood, various
organs, feces of cholera patients, in healthy feces, in the air, and in
putrefying infusions ; it can also be found in the peritoneal exudate
in most cases of peritonitis.
Morphology. A bacillus, 4 to Q/m by 2 to 3//, with rounded ends,
sometimes in cultures a short oval. Five or more flagella have been
observed attached to the organism.
Biological Properties. Aerobic ; facultative anaerobic ; non-liquefy-
ing ; slightly non-motile.
Growth. On gelatin plates the colonies vary very much. The deep
colonies are transparent, straw color to dark brown, or may be granu-
lar and opaque. The surface-colonies are large and spherical, centre
dark brown, edges transparent. In stab-cultures the surface-growth
is thin and dry. There is abundant growth along punctures, which
is white by reflected, but amber by transmitted light ; sometimes
moss-like tufts are seen. On potato a soft, shining, brownish-yellow
layer grows. Stains with anilines, but not by Gram's method. In-
jected in guinea-pigs it produces fever, diarrhcea, and collapse. In-
jected into the abdomen of rabbits it causes a typical peritonitis.
Pathogenic Fungi. Spirillum Choler.e Asiatics. See page
338.
Spirillum Cholera Nostras. Morphology. Longer and thicker
than the spirillum of Asiatic cholera ; central part thicker than ends.
Stains as the true cholera spirillum.
Biological Properties. Culture. A thick, stocking-like funnel of
liquefaction instead of a fine, straight funnel. (See Fig. 87, page 340.)
836 SPECIAL DIAGNOSIS.
Typhoid Fever Bacillus. This bacillus is present in the stools
of typhoid fever patients, but cannot be directly differentiated by
microscopic examination alone, either when stamed or unstained. It
is necessary for its detection to make pure cultures according to bac-
teriological methods. The bacillus is about as long as the tubercle
bacillus, but much thicker, being one-third as thick as it is long.
The ends are rounded. It is best stained by concentrated aqueous
solutions of methylene-blue, the dried preparations on the cover-slip
being prepared as above. (See Plate III., Fig. 6, b ; and Typhoid
Fever).
Tubercle Bacillus. The bacillus of tuberculosis is frequently
found in the feces of persons suffering from intestinal tuberculosis and
occasionally in the feces of cases of pulmonary tuberculosis, when
sputum has been swallowed. When tubercle bacilli are constantly
found in the feces, and in large quantities, it points to the former
condition almost to a certainty. They are detected by methods em-
ployed in the examination of sputum.
Bacilli op Booker. No less than nine bacilli have been described
by Booker. They have been found by him in cases of diarrhoea in
children. Seven of them resemble very closely the bacillus coli com-
munis. Bacillus A is a bacillus with rounded ends, 3-4// by 0.7/i.
It is aerobic and facultative anaerobic, liquefying, and motile. Colo-
nies on agar and potato are dirty brown. On gelatin they liquefy too
soon to show characteristic form. The bacillus is found in the stools
of cholera infantum.
Chemical Examination. The chemical examination of the feces
is of but slight clinical value. Mucin and albumin are normally pres-
ent ; peptones in different diseases (Von Jaksch). Among the acids
to be found are bile-acids, volatile and fatty acids, formic, acetic,
butyric, and propionic acids ; while phenol, indol, skatol, cholesterin,
and fats are always present, according to the same author. They will
not aid in diagnosis.
The normal coloring-matter of the feces is urobilin ; its presence is
shown by the proper tests. As before stated, bile-pigment never
occurs in the feces in health ; it is present when there is catarrh of the
small intestine. Blood-pigment is usually in the form of hsematin.
As might be expected, ptomaines have been obtained from the feces
of certain diseases caused by fungi.
Diseases Characterized by Pain and Flatulence.
Intestinal Indigestion. Intestinal indigestion is said to be due to
alterations in or diminution of the bile, the pancreatic, or the intestinal
secretion. It is almost always attended by gastric indigestion, and
may not readily be distinguished from it.
Acute Intestinal Indigestion. Acute intestinal indigestion is
due to the irritation of food not properly digested in the stomach. It
is attended with colic, flatulency, and borborygmi. Some fever may
develop, and diarrhoea may ensue. In the mild forms the tongue is
coated, there are loss of appetite and some general pains. There is
DTSEASES OF STOMACH, INTESTINES AND PERITONEUM. 837
epigastric distress or pain in the right upper quadrant. Flatulency
and constipation occur. The stools are often clay-colored, or may
not be changed. Slight jaundice occurs, and there is an abundance of
lithates in the urine. Accompanying gastric indigestion modifies the
symptoms slightly.
The symptoms are more marked and pronounced in chronic intestinal
indigestion. The local symptoms are as follows : Pain which begins
from two to six hours after eating. It may be complained of in the
region of the liver or below the sternum. It is usually seated in the
umbilical region. It is dull and continues two or three hours, or until
the next meal is taken. There is some tenderness. With the pain
there are tympanites, borborygmi, and a sense of fulness in the abdo-
men ; the bowels are constipated, and the stools are hard and dry.
The constipation alternates with diarrhoea, and undigested particles of
food are passed. The appetite is not lost, but is variable. Hemor-
rhoids are often present.
The general symptoms are marked, and are referred to the nervous
system and the condition of the blood. There are great depression and
hypochondriasis. The patients sleep badly, suffer from bad dreams and
tinnitus aurium ; there are spots before the eyes and more or less constant
headache. They complain of pain in the back and limbs, and hyper-
esthesia and anaesthesia are present. There is inaptitude for mental
exertion. Frequently the patient has sudden attacks, apparently due
to toxins, as sudden fainting followed by collapse, or vertigo. During
these attacks there are great palpitation and tachycardia. The ex-
tremities are cold, and there are cold sweats over the body. Inde-
pendently of the attacks, the patient is subject to palpitation and some
dyspnoea. The urine is always high-colored, acid in reaction, and full
of urates and uric acid. Oxalate of lime may be present, and the
albuminuria of uric acid occurs, due to the irritation. The patient
earl}' becomes anamiic, because of the auto-intoxication and poor
assimilation. There is some emaciation ; in some cases the emaciation
is rapid. The complexion is sallow. If there is an abundance of
oxalates, the patient complains of weight and heaviness about the loins.
The stools may contain fat, indicating probable pancreatic disease, if
fatty food has been ingested. On the other hand, with loss of appetite,
furred tongue, frontal headache, and drowsiness, the stools may be
clay-colored and the bowels costive ; apparently the bile is at fault.
Diseases Characterized by Pain and Diarrhoea.
Acute Intestinal Catarrh. Cause. Exposure to cold or the direct
irritation of mechanical or chemical substances within the intestine.
Irritating food that is not digested, or that cannot be digested because
of the quantity ; spoiled meats and unripe fruit usually excite an
attack. Water saturated with impurities, or such as the individual is
not accustomed to, may excite an attack. Strangers in a new locality
are frequently subject to a diarrhoea until accustomed to the drinking-
water, which in the native does not excite catarrh. Toxic substances,
as poisons or drugs, or toxic substances the result of putrefaction, as
838 SPECIAL DIAGNOSIS.
ptomaines, are frequent exciting causes. Extension of inflammation
from neighboring structures by infection, as in peritonitis, sets up a
catarrh. Local diseases of the intestine, as ileus, intussusception, her-
nia, and ulcers of all forms, are attended by catarrh of the intestine.
It also occurs in cachectic states of the system, as cancer, anaemia, and
B right's disease. In disease of the heart and bloodvessels, or of the
liver and spleen, where the disturbance of the circulation causes a con-
gestion, catarrhal inflammation occurs. It is of common occurrence
in the infectious diseases, and particularly in septicaemia and pyaemia.
Symptoms. Diarrhoea is the chief symptom, varying with the cause
and the extent of the catarrhal inflammation. The stools differ in fre-
quency and in color, as has been previously indicated in the various
types. They contain undigested matter ; sometimes worms. Colicky
pains about the umbilicus, with borborygmi and frequent desire to go
to stool, attend each evacuation. The fever is of the remittent type,
and is attended with some prostration. The urine is scanty and high-
colored. The symptoms vary somewhat with the location of the in-
flammation, although the exact locality cannot be distinctly defined.
The symptoms of proctitis, pain with tormina and tenesmus, do, how-
ever, enable the localization to be made to that portion of the bowel.
These are more common than in inflammation apparently limited to
the small intestine, while in colitis the violence of the rectal symptoms
stands between enteritis and proctitis.
The diagnosis of acute intestinal catarrh is not difficult. It is more
difficult to determine the actual cause. If the attack occurs suddenly
after the eating of improper food, or the drinking of impure water, the
irritation is probably due to that cause, and may be determined by the
nature of the feces. If they contain undigested food, the diarrhoea is
probably due to indigestion. Catarrh from cold usually follows ex-
posure, and is generally not very severe. To estimate the cause from
poison or drugs the condition of the rest of the intestinal tract must be
investigated and other symptoms of the effects of drugs must be in-
quired for. In arsenical poisoning there is always vomiting and the
discharges are of a choleraic nature. Collapse rapidly ensues. The
other symptoms of arsenical poisoning must be inquired for and the
history of exposure, if possible, ascertained. The intestinal catarrh
due to infectious diseases is attended by the symptoms due to the
respective affections, each of which is usually readily recognized. It
may be necessary to resort to a bacteriological examination of the feces.
The intestinal catarrh which occurs on account of local disease of the
bowel, as hernia, stricture, etc., is preceded or attended by the local
symptoms of these diseases. In like manner we judge of the nature
of the diarrhoea that occurs in the course of tuberculosis or syphilis,
and in the course of organic heart disease or of liver disease. In each
instance the possible influence of morbid processes present in other
structures must be very carefully estimated.
The Vaeieties of Acute Intestinal Catarrh. Divisions
have been made in accordance with the symptoms which distinguish
the various localities of the intestine in which the inflammation is most
marked.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 839
Catarrh of the Duodenum. This partakes of the nature and has the
symptoms of gastro-intestinal catarrh in a mild degree, and is charac-
terized by the occurrence of jaundice due to catarrhal inflammation of
the biliary passages.
The Small Intestine. Colicky pains and rumbling are experienced.
There is usually gastritis at the same time. The feces are mixed with
mucus. Over the right lower quadrant there is tenderness on pressure.
Ccecum. Pain in the right lower quadrant with tumor, dulness on
percussion, and tenderness are present. (See Typhlitis.)
Colitis. The large intestine is most frequently affected. Pain and
tenderness occur along the course of the bowel. The evacuations
contain mucus ; there is tenesmus. The association with gastro-
enteroptosis and with neurasthenia must be borne in mind.
The Rectum. Proctitis gives rise frequently to small stools, tenes-
mus, pain in the left lower quadrant, with tenderness about the anus,
and spasms of the sphincter. There are considerable mucus and blood
in the passages.
Cholera Infantum. This affection occurs in children during the
hot season. It is promoted by bad hygienic surroundings, and is due
to improper milk or food. At first there is catarrhal diarrhoea. This
may continue for twenty-four hours, then vomiting and diarrhoea
ensue. The stools are liquid and large in amount. At first they may
contain milk-curds. The vomiting is excited by anything taken into
the mouth, or by odors, or by movement of the little patient. The
watery discharges are almost constant. They may be preceded by
greenish or yellowish-green stools for twenty-four hours. Stools are
acid in reaction, and their odor is sour. At first there is colicky pain,
but when the watery discharges begin there is only a little tenesmus.
The stools irritate the skin and cause eczema. The rectum may be-
come prolapsed. The abdomen is at first distended with gas, but soon
becomes retracted.
In a short time, twenty-four hours or even less, collapse ensues.
Previous to the collapse the skin is hot and dry ; the patient is restless.
The thirst is intense, the mouth dry. The body-temperature is 103° to
104°. With collapse the extremities become cold, the skin cool. The
axillary temperature is lowered and the rectal temperature increased to
105° to 106°. The restlessness continues, the fontanelles become de-
pressed, the eyes sunken, the face pinched, the brows drawn. The urine
diminishes in amount or may disappear entirely. Brain symptoms
ensue. So-called hydrocephaloid symptoms follow — rolling of the head,
strabismus, turning in of the thumbs, and, later, convulsions. Stupor
followed by coma develops in the fatal cases. If the patient does not
die in collapse, marasmus develops ; ulceration of the cornea may take
place ; there are oedema and blood extravasation under the skin. The
child emaciates and withers. On account of the weak heart and ex-
haustion pulmonary atelectasis or bronchopneumonia may occur.. The
age, the season, the presence of catarrh, with collapse and other symp-
toms, render the diagnosis easy.
Cholera Morbus. The attack is characterized by sudden vomiting,
followed in a short time by purging. The vomiting may be preceded
840 SPECIAL DIAGNOSIS.
"by pain, or both may occur at the same time. At first the pain is
seated in the epigastrium and subsequently about the navel. It is
very severe and paroxysmal in character, compelling the patient to
double up if lying in bed. A cold perspiration breaks out on the fore-
head, the extremities become cold, the face anxious ; the pulse becomes
rapid. At first the patient vomits undigested food, then watery,
greenish-colored fluid. The latter is bitter. Purging sets in at once,
or within an hour. The bowel-movements follow an attack of pain.
The first passage is fecal, and may contain undigested food ; the subse-
quent passages are watery and profuse. There are severe attacks of
burning and tenesmus ; the abdomen is tender around the navel and
in the epigastrium. After an evacuation there is slight relief, but soon
another paroxysm of pain comes on. The vomiting is excessive, and
retching may be present in the intervals. Ice, or water, or anything
taken into the stomach excites pain and causes the vomiting. The
attack subsides in twelve to twenty-four hours, and is followed by ex-
haustion. In rare cases collapse ensues, and in others it is followed
by gastro-intestinal catarrh.
Cholera Nostras. The symptoms are those of severe gastro-enter-
itis. There are sudden vomiting and diarrhoea. It usually begins in
the night. The vomiting is not different from that of cholera morbus.
The watery and brownish-colored stools become colorless and have the
appearance of rice-water. Pain attends the attack, rapid prostration
ensues, the extremities become cold, and collapse takes place. With
the collapse there are cramps in the legs. Other muscles of the body
may become cramped. The disease occurs in epidemics during the hot
season, and may be mistaken for cholera. It can be distinguished from
the milder forms of cholera which precede the occurrence of the epi-
demic only by the absence of the comma-bacillus. The bacillus of
cholera nostras is found in the stools. (See Feces.)
Entero-colitis. In entero-colitis the more intense inflammation
succeeds a mild intestinal catarrh. There are increased languor, great
fretfulness, and fever. The early catarrh is attended by green acid
stools, with lumps of casein. The tongue is furred and moist at first. It
soon becomes red and dry ; vomiting ensues. The stools are offensive
and increase in frequency, and, in addition to the appearance first indi-
cated, contain mucus and blood. Death may take place within the .
first week, on account of exhaustion from the vomiting and diarrhoea.
If the disease is protracted, it is attended by great wasting, symp-
toms of hydrocephalus, skin eruptions, hypostatic pneumonia, and ex-
tremely weak, feeble circulation.
Chronic Intestinal Catarrh. It usually follows an acute attack, or
may be chronic from the start. It may follow gastric hyperacid-
ity and dilatation of the stomach. It arises secondarily to portal con-
gestion in disease of the liver and in chronic disease of the heart or of
the lungs. It occur in malaria and in the scorbutic cachexia.
The symptom is diarrhoea alternating with constipation, or diarrhoea
alone. Stools may contain undigested food, or pus, mucus, and blood
in small amounts. Diarrhoea may be present in the morning only
under these circumstances. If the feces are examined, the eggs of
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 841
parasites, or infusoria may be found. The local abdominal symp-
toms of rumbling, flatulency, and tormina are present. There are
reflex symptoms of cardiac palpitation and dyspnoea (asthma). Rush
of blood to the head may occur. Often these symptoms are relieved
by the passage of flatus. Chronic catarrhal gastritis usually accom-
panies the intestinal catarrh. The general symptoms of anaemia,
emaciation, and neurasthenia are present. Hemorrhoids are common.
Amyloid Degeneration of the Intestines. The symptoms are
those of diarrhoea, persistent but mild in character, associated with
symptoms of amyloid disease in other organs. With enlargement of
the liver and spleen changes in the urine due to amyloid disease are
present. The occurrence of these symptoms in a patient with syphilis,
or especially in a child with bone disease or tuberculosis, points to the
nature of the case.
Ulceration of the Intestines. Duodenal Ulcee. Ulcer of the
duodenum usually occurs in young subjects in whom there are symp-
toms of chlorosis or anaemia. The causes are the same as those of
gastric ulcer. It may follow boils, erysipelas, or pemphigus, and
differs in one etiological respect from ulcer of the stomach, in that it
occurs more frequently in the male sex. The symptoms are obscure,
and may be wanting entirely, the patient probably complaining only
of intestinal indigestion. In other cases they are like those of gastric
ulcer. In typical cases the symptoms are those of pain situated below
the xiphoid or to the right of the median line in the region of the
pylorus. The pain occurs after eating, and may be relieved by vomit-
ing. There is localized tenderness on pressure. Hemorrhage may
take place from the stomach, or blood be found in the stools alone. It
differs from gastric ulcer only in the possible difference in location of
the pain, the occurrence of intestinal indigestion and hemorrhage, and
the fact that the pain comes on one to two hours after eating.
Duodenal ulcer is diagnosticated by the occurrence of melaena, which
may be excessive and cause syncope and vomiting with no blood in the
vomitus ; by pain, which may be in the right hypochondrium or be-
tween the navel and the right costal border ; by gastralgic attacks ; by
dyspepsia, with constipation.
General Ulceration. Ulceration of the intestine may be due
to a specific infection, and hence be symptomatic of typhoid fever,
syphilis, and tuberculosis. It is always present in the first mentioned,
and of frequent occurrence in the latter. Follicular ulceration occurs
in entero-colitis in children. Ulcers due to the pressure of feces occur
in typhlitis and chronic constipation. The sacculi of the colon become
filled with scybalous masses, the pressure of which produces ulcers.
Tenderness is experienced along the course of the colon, particularly
on palpation of the fecal masses, which may be felt through the
abdominal wall. A chronic ulcerative colitis is the form that succeeds
the diarrhoeas which occur during camp-life, or that are set up in com-
munities where people are crowded and live under bad hygienic cir-
cumstances. It is the form that attends scurvy, and is frequently seen
in chronic Bright's disease. It may be succeeded by dilatation of the
colon, by hypertrophy of the muscular walls, or by contraction of the
842 SPECIAL DIAGNOSIS.
bowel. The persistent diarrhoea leads to profound emaciation, extreme
prostration, sallow complexion, with markedly impaired nutrition of
the skin. Such forms of diarrhoea were seen during the late war, par-
ticularly in soldiers held in captivity. The diarrhoea may first be of a
lienteric character, and later alternate with constipation. Stools con-
tain blood and mucus.
Ulcers of the intestinal tract may occur from other causes, and diar-
rhoea may be the predominant symptom. They may be due to cancer ;
the malignant nodules may ulcerate within the lumen of the bowel.
The bowel may be perforated from the exterior, on account of suppura-
tion somewhere along its course, as in appendicitis, pancreatitis, or
tuberculous peritonitis.
Symptoms. The symptoms of intestinal ulcer are usually those of
diarrhoea. Ulceration, however, may be present without any symp-
toms whatsoever, particularly if the small intestine is affected. One
or two small ulcers, on the other hand, in the lower portion of the
colon, may set up continuous diarrhoea. The stools are composed of
feces, mucus, pus. shreds of tissue, and blood. If pus is discharged in
large amounts, an abscess has probably opened into the bowel. Mod-
erate discharge of pus usually follows ulcers in the colon. Pus may
be present in cancer. Hemorrhage is of frequent occurrence, and is an
important diagnostic symptom, especially if profuse and occurring
without symptoms of obstruction, of gastric ulcer, or of hemorrhoids.
The fragments of tissue found in the stools may point to the nature of
the process. Large amounts attend the dysenteric process. The frag-
ments may be composed of the mucosa, connective tissue, and the
muscular coat. Pain occurs in many of the cases. It may be general
and colicky, or circumscribed in cases of ulcer of the colon. Perfora-
tion of the intestine is followed by localized or general peritonitis.
The occurrence of the latter depends largely upon the situation and the
rapidity of the ulceration. If the perforation is in the posterior wall
of the colon, a circumscribed abscess may develop. AVhen it is situ-
ated in the upper zone the pus may accumulate underneath the dia-
phragm, or in the lesser peritoneal cavity. The signs of pyopneumo-
thorax subphrenicus occur when the latter accident takes place, as both
pus and air accumulate in the abscess-cavity. In such instances the
ulceration usually takes place at the splenic flexure. Perforation of
an ulcer of the caecuni may simulate appendicitis.
Tuberculosis of the Intestine. The disease is usually secondary
to chronic tuberculosis, but may be primary, especially in children.
The symptoms are usually those of diarrhoea, and in the primary form
this is associated with general emaciation, which advances rapidly, and
with anaemia. Fever of the intermittent or remittent type is present.
There is meteorism ; the abdomen is much distended, but eventually
becomes contracted. The mesenteric glands can be made out along
the spinal column, and the intestines may become bunched into a mass,
yielding a dull tympany on percussion in the centre of the abdomen.
The diarrhoea is attended with colicky pains. The diagnosis is based
upon the rapid emaciation, irregular fever, enlargement of the mesen-
teric glands in a patient, usually a child, who had probably been ex-
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 843
posed to tuberculous infection. In one of my cases, the child, aged
four years, ate of the same food, using the same utensils, as a brother,
a young man of twenty-two years, dying of pulmonary tuberculosis.
The child was constantly with the brother. The remainder of the family,
eight in number, remained in perfect health, and Avere all of good
physique. The elder brother became infected by association with
tuberculous subjects in improper quarters away from home.
Intestinal Obstruction.
Intestinal obstruction may be acute or chronic. Acute obstruction
may set in in the course of chronic obstruction due to stricture of the
bowel, to occlusion due to external pressure, or to accumulations within
the bowel.
Causes. Acute intestinal obstruction is due, first, to constriction by
bands or strangulation of the bowel through apertures ; second, to
volvulus of the colon ; third, to acute intussusception.
In the first instance the type of the obstruction is seen in strangu-
lated hernia, but similar strangulations occur in apertures within the
peritoneal cavity. Thus loops of the intestine are caught and con-
stricted in. the duodeno-jejunal fossa, the so-called Treitz' retro-
peritoneal hernia, or in the foramen of Winslow, also known as
inter-sigmoid hernia ; finally, diaphragmatic hernia, in which protru-
sions of the intestine through the diaphragm, along with other abdominal
viscera, may take place. The above-mentioned forms of hernia may
exist without symptoms, or may lead to constriction or twisting of the
loop of the intestine, with occurrence of acute obstruction. Moreover,
lacerations in the omentum may give rise to internal constrictions.
External constrictions, however, take place, most commonly in the
regions of hernias, on account of the gut being constricted by dense
fibrous adhesion ; or about the uterus or Fallopian tubes, which had
previously been the seat of inflammation. The constricting bands
that follow the local peritonitis may gradually occlude the gut, or be
in such position that the latter becomes twisted about it. In other
forms of peritonitis similar constricting bands may form, which are
liable to produce this accident. Disease about the vermiform ap-
pendix, with secondary adhesions, has been observed to cause con-
striction. A frequent form of intestinal obstruction is due to the
tangling of the intestines in the foetal remains of the omphalomesen-
teric duct, Meckel's diverticulum, which is situated a short distance
above the ileo-csecal valve.
Volvulus is a form of acute obstruction due to twisting or knotting
of the intestine. The condition is not common. It occurs most fre-
quently at the sigmoid flexure of the colon. The mesentery of the
latter is often congenitally narrowed, on account of which the colon is
unduly dragged upon, and, if filled with masses of feces, cannot restore
itself ; the twisting becomes permanent, and obstruction takes place.
Peristalsis is set up and other portions of the intestine wind about
the pedicle of the loops, so as to form a regular knot. Abnormal
peristalsis, on account of diarrhoea, often precedes the appearance of
844 SPECIAL DIAGNOSIS.
the obstruction. External injury is said also to give rise to the forma-
tion of an obstruction.
Intussusception (Plate XXXIX., Fig. 1), as a cause of intestinal
obstruction, occurs most frequently in children, and is due to a portion
of the bowel being pushed into the lumen of that which lies next below
it. A circumscribed portion of the intestine may be paralyzed. In the
portion above, the peristaltic action continues and the energetic move-
ments push it into the paralyzed part. Intussusception is found fre-
quently after death in the bodies of children dying from exhaustion.
In such cases it occurs just before death. Intussusception also occurs
when intestinal polypi drag one portion of the bowel into the lower
portion. Large portions of the intestine may be involved. The inva-
gination usually takes place at the lower portion of the ileum, or into
the caecum ; sometimes the invaginated portion may reach the rectum
and project externally. Intense inflammation and adhesion are set up.
The internal portion becomes gangrenous, on account of constriction of
the afferent vessels. This portion may slough and pass with the dejec-
tions, followed by spontaneous cure.
Chronic intestinal obstruction may be due to occlusion by external
pressure, or by the excessive accumulation of material within the
bowels, or to stricture. The various causes are specified below.
Intestinal obstruction, to view it from another stand-point, may be
due to (a) disease outside of the intestines ; (b) to disease of the intes-
tinal walls ; (c) to accumulation within the intestine.
The obstruction takes place under the same circumstances as ob-
struction in other channels.
A. Diseases Outside of the Intestines. 1. Pressure of tumors, chiefly
ovarian tumors, uterine tumors, tumors of the omentum, and pelvic
abscess, or abscess about the ceecum. The obstruction may be acute
or chronic. The symptoms of obstruction develop gradually, although
in some instances they may take place suddenly, especially if aided
by the accidental occurrence of fecal impaction.
2. Constricting bands, hernial openings, the remains of foetal struc-
tures, cause constriction of the intestine. In this class of cases there
is usually pain, and the history preceding the obstruction is that of
peritonitis, general or local, of old hernia, of appendicitis, of pyosal-
pinx, or of inflammation about the gall-bladder and gall-ducts. The
onset may be acute or chronic. If the constriction is clue to protrusion
into hernial openings, the onset is usually sudden and without previous
symptoms.
3. Peritonitis is a most common cause of acute intestinal obstruction.
It may be due to overdistention by gas and paresis of the bowel, or to
pressure by external exudation.
4. Knots and twists of the intestines, usuallv seated about the sis;-
moid flexure, causing volvulus, are a common cause of acute constriction.
B. Disease of the Intestinal Walk. 1. Invagination, or intussuscep-
tion. The attack is acute, although the affection may continue over a
long period of time.
2. Cancer and other tumors of the intestine generally lead to stric-
ture and chronic obstruction.
PLATE XXXIX.
FIG. 1.
TumofA,
Invagination of the Ileum.
T
FIG. 2.
Carcinoma of the Coloi
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 845
3. The healing of ulcers, which are syphilitic in the larger number
of cases, rarely tuberculous, will lead to stricture. The obstruction
belongs to the chronic variety. It is seated, in the larger number of
instances, in the rectum or sigmoid flexure of the colon.
C. Accumulations within the Intestines. 1. Feces. The obstruction
takes place gradually, occurs in weak and debilitated people in the
course of constipation, especially the constipation of acute disease.
2. Accumulations of improper food or foreign materials. The seeds
of fruits or the husks of grain accumulate and cause obstruction.
Magnesia, iron, and other articles taken as medicines, from their accu-
mulation lead to obstruction of the intestine. In both of the above
mentioned varieties obstruction is chronic.
3. Impaction of gallstone within the intestine is followed by acute
obstruction.
The Symptoms. When symptoms of intestinal obstruction occur
it is important to ascertain, in addition, first, the duration of the ob-
struction and its mode of onset ; second, the possible cause of the ob-
struction ; third, the seat of the obstruction.
The Symptoms Common to Acute Obstruction. The symptoms of intes-
tinal obstruction depend upon the nature and the seat of the obstruction.
Constipation. The major symptom is stoppage of the intestinal contents.
AVhen this takes place suddenly, and there is a local injury to the
bowel, the symptoms, both local and general, are severe and alarming.
"When the constipation is complete there is no escape of flatus. Pain.
The pain is at the seat of obstruction or about the umbilicus. It
occurs suddenly, and is intense and colicky or lancinating in character,
radiating from the point of obstruction. There is tenderness over the
painful part. The pain is due to the injury by the constricting agent
or to violent peristalsis. It may be relieved by pressure. When inter-
mittent, the obstruction is incomplete ; when constant, it is absolute.
Tumor. In many instances a tumor can be outlined due to single loops
of intestine, thickened walls, or abnormal contents. This is particularly
the case in the obstruction of invagination and the obstruction due to
volvulus. Peristalsis. The obstruction further causes increased peri-
stalsis. This takes place above the point of constriction. Sometimes
the movements of the intestine can be seen through the abdominal
walls. The extent of the peristalsis is an indication of the site of the
obstruction. The higher the obstruction, the less the peristalsis.
Meteorism. The obstruction causes accumulation of gas above the
point, giving rise to meteorism. If the obstruction is low down, the
distention and meteorismus are general. If high up, as in the small
intestine, on account of constriction by Meckel's diverticulum or inter-
nal hernia, the meteorism is in the upper part of the abdomen, and
may be limited in extent, or dilatation of the stomach alone may be
present. Vomiting. Vomiting soon occurs in acute intestinal obstruc-
tion, due to decomposition of intestinal contents, to irritation of the
stomach by the intestinal contents, to a trauma of the peritoneum at
the seat of the obstruction, or, finally, to the occurrence of peritonitis.
At first the contents of the stomach are ejected, then watery fluid, bile
tinged or largely made up of bile, and later feculent matter. Although
846 SPECIAL DIAGNOSIS.
of fecal odor, this is not true stercoraceous vomiting ; the latter occurs
later in the course of the disease. It must not be forgotten that any ob-
struction of the intestine may develop with extreme rapidity, so that
fecal vomiting may occur within two hours of the commencement of an
obstruction. It is recognized by the odor of the matter vomited and
by its color. It is a grave symptom, indicating complete obstruction
of the intestine. If the obstruction is high up, as in the jejunum,
fecal vomiting does not occur. The vomiting, however, is more per-
sistent in high obstruction. Eructations of gas are frequent. The
general symptoms are those of extreme 'prostration or shock in its most
pronounced form. The abdominal fades previously described develops
very rapidly. The tongue is not changed at first, but soon becomes
dry and brown. In a few instances, as in invagination, there may be
fever, but in other cases usually at once, or very soon in its course, the
temperature falls to normal or subnormal, or remains at this point if
it has not risen. The extremities are cold, the features pinched, the
eyes sunken, the expression anxious. The pain causes the patient to
double up in bed. The pulse becomes rapid, weak, and thready in
character. The respirations are proportionately hurried, but are also
made more rapid and shallow by the tympany. The mind remains
clear until the supervention of peritonitis and septicaemia.
The Symptoms Common to Chronic Obstruction. The symptoms are
those of chronic constipation, with local symptoms due to the cause of
the obstruction. The bowels are moved infrequently, and then in
small amounts. In obstruction due to stricture from cancer, or cica-
tricial closure, the feces are ribbon-shaped. Reference must again be
made to the occurrence of so-called spurious diarrhoea, with or without
the passage of small scybalous masses, on account of impaction of feces.
Some credence can be given to the oft-repeated expression of the pa-
tients that they have a sense of obstruction in the bowel and that they
experience great relief when there is a free evacuation. In chronic
obstruction the general symptoms are those of inanition, with the ner-
vous train of symptoms that have been described in constipation ;
while the local symptoms depend upon the cause. When the local
symptoms are due to the pressure of a tumor, or accumulation of pus
or fluid within the abdomen, there is a history of local disease, on ac-
count of which the tumor developed ; such history is obtained in
fibroids or ovarian tumor, or in previous inflammation, which was fol-
lowed by the occurrence of a tumor about the locality of the inflam-
mation, as the pelvis or the appendix.
If the obstruction is due to stricture from cancer of the intestine, the
symptoms of that affection are present. A tumor can be made out at
some situation in the course of the bowel. The symptoms are (1) the
cachexia, emaciation, and anaemia ; (2) pain ; (3) tumor ; (4) constipa-
tion with scybalous discharge ; (5) bloody discharge ; (6) mucous dis-
charge. If the cancer is seated in the rectum, we find tormina and
tenesmus, and the discharge of blood and scybalous masses. Local
examination reveals the presence of a malignant mass. Obstruction
due to stricture from the healing of an ulcer is seated in the rectum or
sigmoid flexure of the colon. Pain and a sense of obstruction are
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 847
referred to that locality. A history of syphilis may be obtained, and
frequently the rectal tube, or the finger, will detect the stricture. In
both instances there is a history of imperfect, irregular action of the
bowels from time to time, with intervals of comparative comfort.
These symptoms precede the constipation. When feces accumulate in
the colon the larger accumulations take place in the sigmoid flexure
and in the caecum. Fecal tumors, described under Constipation, are
felt through the abdominal walls. Obstruction from fecal accumula-
tion is preceded by a history of constipation (q. v.). The accumula-
tions can be easily discerned as a rule. It must not be forgotten that
chronic intestinal obstruction may at any time become acute.
Chronic intestinal obstruction always occurs in adults. The onset is
gradual. The pain that attends obstruction of this form is intermit-
tent, and if there is fecal accumulation, it is not very prominent.
Vomiting occurs late in the disease, is small in amount, and generally
is not a prominent factor. Obstruction to the passage of feces may be
constant, or alternate with diarrhoea. In fecal accumulation it be-
comes complete, although spurious diarrhoea may attend it. The dis-
charges may be bloody, which points to cancer. Tenesmus is present
in stricture low down in the large bowel. Meteorism is not marked
when the obstruction is high up, as in acute obstruction. When the
obstruction is in the large intestine it may be extreme, and in fecal
obstruction gradually increases as the obstruction becomes more
marked. Coils of intestine in peristaltic movement are seen only in
cases in which there is marked emaciation.
The forms of chronic obstruction that are attended by tumor have
been mentioned.
The Differential Diagnosis. It is essential in order to distin-
guish the form of acute obstruction to ascertain the nature of the ob-
struction, and to determine, if possible, its site.
The Nature of the Obstruction. Various factors must be
considered in order to estimate the cause of the obstruction.
The Age. Obstruction from intussusception occurs early in life ;
from bands or through apertures, in adult life, usually prior to forty
years of age ; from volvulus, between forty and sixty years. Obstruction
due to a gallstone occurs during the middle or later period of life —
always after the fortieth year.
The Previous History. In obstruction by bands of adhesion there
is a history of peritonitis, or, as Treves points out, previous attacks of
obstruction more or less marked. In volvulus the patient has been
subject to constipation prior to the attack, and in intussusception there
has been no previous history, unless polypus was present, causing drag-
ging, colicky pains, and occasional discharge of blood.
The Symptoms. The symptoms of the various forms of acute obstruc-
tion vary somewhat. Pain in strangulation, from bands or hernia, is
severe and paroxysmal in character, attended by collapse. It occurs
early in volvulus, though it is not so severe as in the former, and
occurs at long intervals, becoming constant with exacerbations. In
acute intussusception the pain occurs early, and is steady. It in-
creases, and then may suddenly subside. At first it is paroxysmal.
848 SPECIAL DIAGNOSIS.
attending discharge of blood and mucus from the bowels. Local ten-
derness in the first group of cases occurs late. In volvulus it occurs
early, and may be noted over distended coils. In intussusception it is
usually common about a sausage-shaped tumor. Vomiting is marked
and occurs in strangulation, soon becomes feculent, and increases the
severity of the paroxysms of pain. In jejunal obstruction it is ex-
cessive and non-feculent. In volvulus it does not come on so quickly,
but is severe and constant when it takes place. The relaxation that
attends vomiting often affords relief to the obstruction. In intussus-
ception it does not occur as early as in the other forms, and is not so
severe. It becomes feculent in only a small number of cases. Con-
stipation is continuous in all cases except intussusception. In the
latter there is some constipation, but it is not absolute ; diarrhoea is
not uncommon, and discharge of blood in the stools occurs in 80 per
cent, of the cases, according to Treves. Prostration is severe in all
cases, although probably not so marked in volvulus. Because of its
close proximity to the rectum tenesmus occurs in volvulus. It is of fre-
quent occurrence in intussusception, often beginning early in the attack.
The Physical Signs. (Plate XXXIX. , Figs. 1 and 2.) On palpa-
tion of the abdominal wall it is noted to be soft and flaccid in most of
the cases, unless peritonitis has ensued. This occurs early in volvulus,
hence rigidity is marked. In a large number of cases a tumor can be
made out only in intussusception. It is seated in the lower right
quadrant of the abdomen. Early in the attack it is oblong and of
sausage-shape. When peritonitis ensues it disappears, on account of the
tympany. A portion of the gut may protrude at the anus, or be felt
on rectal examination. Meteorism occurs about the third day in a
strangulation ; it occurs early, is very rapid and pronounced in volvu-
lus, and is absent in intussusception, unless constipation or peritonitis
takes place. It is not marked in high obstruction.
The Site of the Obstkuction. The seat of obstruction is in a
measure indicated by (1) the location of the pain or abnormal sensa-
tions, (2) the character of the swelling, (3) the character of the stools,
(4) the degree of meteorism, (5) the results of a rectal examination, (6)
the change in the urine, (7) the general condition. The patient is
often able to indicate the location of the obstruction fairly well by the
sensations of obstruction or fulness and by the great relief experienced
when a free evacuation of the bowels is naturally or artificially pro-
duced. On auscultation, when the bowel is irrigated, a murmur, like
the deglutition-murmur, may be heard at the point of constriction of
the gut. In obstruction high up there is but little meteorism, the
tumor is usually not detected, and pain is seated about the umbilicus
or the upper quadrants of the abdomen. Obstruction at the ileo-csecal
valve may be indicated by a tumor in the lower right quadrant over
the region of the valve or just above it. It is usually at this point
that invagination takes place, and hence we may look for a tumor in
this situation. (Plate XXXIX., Fig. 1.) On the other hand, in vol-
vulus of the colon, or stricture of the rectum, the obstruction, being
low down, is attended by much meteorism and by pain in the left
lower quadrant of the abdomen. A tumor may be detected in this
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 849
position. The position of the obstruction is sometimes indicated by
the seat of peristalsis. This may be seen to stop at a given point,
which usually indicates the position of the obstruction. The seat of
obstruction may be indicated by the number of coils of intestine that
are engaged in the peristaltic movement. The coils of intestine in front
of the tumor are dilated and hypertrophied. In active movement they
cause prominences which follow the course of the bowel. Wyllie has
called them " patterns of abdominal tumidity." If the obstruction is
in the jejunum, peristalsis may not be observed. If the lower end of
the large intestine is obstructed, the colon is prominent ; if the gut
about the ileo-csecal valve, the region about and below the umbilicus is
prominent. The Urine. The position of the tumor, it is said, can be
ascertained by changes in the urine. When the obstruction is in the
small intestine, indican is much increased from the decomposition of
albuminous substances and products of putrefaction. In this location
the urine may be suppressed. In stenosis of the large intestine indican
is not increased unless there is cancer. The value of the information
derived from the character of the stools and the results of rectal
examination are obvious. Obstruction in the duodenum or jejunum is
followed by rapid collapse and anuria. In general, it may be said the
more severe and rapid the symptoms the more likelihood that the
obstruction is in the small intestine.
Intussusception (Plate XXXIX., Fig. 1), or invagination, occurs
most frequently in children prior to the tenth year. It is characterized
by severe colic and pain in the abdomen, first complained of about the
navel. The severity increases in paroxysms, and only lessens if com-
plete strangulation has taken place. With the onset of the pain there
are one or two movements of the bowels, which contain mucus and
blood. After this there may be constipation, or the stools continue to
be loose, and are as frequent as fifteen or twenty in a day. Sometimes
they are quite bloody, and almost always there is some tenesmus. In
a short time after the attack vomiting commences. It may be constant
or occur only after taking food. At first the abdomen is soft, but
tender on pressure. A sausage-like tumor can be felt on the right side
below the transverse umbilical line. On inspection of the rectum a
portion of the intestine may be seen, dark and gangrenous in appear-
ance, or it may be felt by palpation. If there is much tenesmus, the
anus often remains open. In rare cases the bowel may slip back and
the symptoms subside spontaneously. On the other hand, peritonitis
may rapidly ensue, with high fever, followed by collapse and death.
Diagnosis. It must be distinguished from the entero-colitis of child-
hood or the proctitis due to a polypus. In entero-colitis there is no
tumor, and the collapse and prostration do not occur so early and are
not so rapid. There is greater likelihood of a number of the stools
being greenish, like spinach. In a polypus of the rectum the symp-
toms are local. The child is worn out and restless, but great abdominal
tenderness, and the tumor, meteorism, vomiting, and collapse are absent.
The rectum must be examined.
Intussusception must be distinguished from peritonitis, in which
symptoms of stenosis of the bowel from ileus paralytica may be present.
54
850 SPECIAL DIAGNOSIS.
The history and sequence of events must be watched carefully. Often
the commencement of the affection about hollow viscera which have pre-
viously been the seat of disease, or its onset with sudden perforation,
will point to the nature of the affection. In peritonitis there is no
active peristalsis ; there is general distention of the abdomen, with
general tenderness ; the urine is diminished, but does not contain in-
dican in excess. Collapse ensues rapidly. Signs of effusion within
the abdomen may appear.
It must be distinguished from embolism or thrombosis of the mesenteric
artery and infarction of the bowel. In the latter the symptoms take
place suddenly. The patients have reached middle or late life, and have
atheroma of the general arterial system. Sudden pain in the abdomen,
with vomiting and symptoms of collapse, takes place. Moderate ob-
struction occurs, with distention of the abdomen. After the pain diar-
rhoea with the passage of blood follows. The age and the absence of
tumor distinguish it from intussusception, the only intestinal condition
for which it may be mistaken.
Hernia and Constriction by Bands. Obstruction due to these con-
ditions occurs in adults after the fortieth year of age, in both sexes.
In stricture from pressure of bands there has usually been a history of
previous attacks of peritonitis or of inflammation of the structures in
relation to the peritoneum. Hence, a cholecystitis or appendicitis are
often found to precede the obstruction. The attacks begin suddenly,
and the symptoms may from the start be most pronounced. They are
the typical symptoms of intestinal obstruction. The local tenderness,
however, may not be present as early as in other forms of obstruc-
tion. It is quite characteristic not to find a tumor or positive local
cause for the obstruction, and also not to have meteorismus. This is
due to the fact that the obstruction is usually high up in the intestinal
tract.
Volvulus. Volvulus occurs most frequently in males. It occurs
late in life, and is usually preceded by a history of constipation. Pre-
monitory symptoms may have been present for a few days, but the
symptoms of obstruction develop suddenly. They are the symptoms
of acute obstruction, but as the lesion is in the lower portion of the
bowel, meteorismus is present to a marked degree, and rectal symp-
toms are found. Tenesmus is present in a small proportion of the
cases. Peritonitis is likely to set in early, with increase in the temper-
ature, increased tenderness of the abdomen, and more pronounced
symptoms of collapse.
Diagnosis of Intestinal Obstruction from Other Conditions. Intestinal
obstruction must be distinguished from peritonitis and appendicitis.
This is sometimes very difficult. Careful attention must be paid to the
evolution of the case and the history of previous abdominal disease, or
of lesions on account of which, on the one hand, peritonitis may occur,
or, on the other, obstruction of the bowel. In peritonitis the attack
follows disease in the uterine appendages, the vermiform appendix, or
the gall-bladder, or perforation in some portion of the gastro-intestinal
tract. Fever usually attends the inflammation, with or without chill.
I omiting will probably occur at the onset, and then subside until the
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 851
peritonitis becomes general. The first paroxysms of vomiting are appar-
ently due to shock. The vomiting that occurs rarely becomes feculent.
As the peritonitis advances the vomiting becomes passive ; a simple
constant regurgitation of a large amount of fluid, greenish or grayish-
yellow, or watery, takes place. It pours into the mouth, and is simply
discharg-ed without the occurrence of retching. The abdomen is swollen
and tympanitic. The symptoms due to excessive tympany are more
marked than in intestinal obstruction. As the diaphragm is interfered
with, breathing is harried. The abdomen is tender on pressure and is
the seat of general pain. The general pain and tenderness, however,
can usually be found to be more marked at the possible primary focus
of the disease. Further, on local examination, in these positions ful-
ness or undue prominence or swelling may be observed. On palpation
over the point of origin there may be localized asdema. The symptoms
of collapse do not differ from those of intestinal obstruction in marked
degree, although the peculiar appearance of the face and other nervous
features occur more rapidly in peritonitis than in obstruction. It must
be remembered that peritonitis in a large majority of cases attends ob-
struction.
In appendicitis the symptoms are somewhat like those of intestinal
obstruction. There may be constipation and vomiting. The former
is not pronounced, and can usually be relieved. Vomiting subsides
after the first twenty-four hours, unless peritonitis supervenes ; it is
never stercoraceous. The local physical signs are characteristic. In
appendicitis there is fixed tenderness on pressure at McBurney's point.
Some swelling can almost always be observed. On light or deep per-
cussion there is change in the note as compared with the other side.
Fluctuation can often be detected in from two to four or five days.
Both the tumor and fluctuation can be detected by bimanual examina-
tion of the abdomen and flank. Examination by the rectum may
reveal a tumor at the brim of the pelvis in the right side. Fever
attends the attack throughout. When peritonitis supervenes there is
rigidity of the entire abdomen, which at first was localized to the right
lower quadrant.
Intestinal obstruction must not be confounded with enteritis. In all
forms there is diarrhoea, in many vomiting. Pain of a colicky nature,
spreading from the neighborhood of the umbilicus, is marked when-
ever obstruction to the passage of feces or gas takes place. Vomiting
is not stercoraceous, and the general symptoms, collapse, etc., do not
occur. Acute hemorrhagic pancreatitis is also attended by symptoms
similar to those of intestinal obstruction. There is sudden severe pain
in the upper half of the abdomen, with vomiting and the rapid develop-
ment of collapse ; there may be constipation ; the situation of the pain is
of some significance. Vomiting never becomes stercoraceous ; flatus can
usually be passed and the bowels opened by an enema. Meteoi ismus does
not take place, although the epigastrium is tympanitic. If the symp-
toms are not so severe, there may be increased dulness, and possibly a
tumor on deep palpation in the left upper quadrant of the abdomen
along the margins of the ribs, which should be dull on percussion, or,
on account of its relation to the stomach, give a dull tympanitic note.
852 SPECIAL DIAGNOSIS.
The symptoms of internal hemorrhage are present, pallor of the face
and extremities, syncope, and, in addition, prostration and other symp-
toms of collapse.
Cancer of the Intestines. (Plate XXXIX., Fig. 2.) Obstruc-
tion must not be confounded with carcinoma of the intestines. The
disease usually occurs late in life, and is associated with progressive
emaciation and cachexia. There may not be any symptoms save general
failure of health until the sudden occurrence of obstruction of the bowel.
The symptoms vary with the position of the carcinoma and the direc-
tion of growth of the tumor. In some instances with the general symp-
toms there may be irregular pain in the abdomen, with irregularity of
stools. The tumor may be detected if the small intestine is involved
Its detection is facilitated by having the patient get on the hands and
knees and palpating the abdomen in this position, and by clearing out
the colon by a large enema. On auscultation the water may be heard
to enter the dilated colon beyond the tumor, the sound resembling the
deglutition-murmur at the cardiac end of the stomach. If the tumor is
situated in the lower colon, pain in the sacral region, resembling sciatica,
may be complained of ; if the caecuni or the sigmoid flexure is the seat
of disease, a tumor is usually detected. Wherever the situation, the
tumor found is tender, usually lying in the axis of the intestine —
movable if in the small intestine, fixed if in the csecurn or the sigmoid
flexure. In the latter location the tumor may be felt per rectum. One
notable characteristic is that it may be palpable some days and not be
present at other times. The position and size may vary from day to
day, although it is always hard and knotty, not doughy. By means of
the proctoscope, with the patient in the knee-chest position, as described
by Kelly, the presence of tumors of the descending colon will be dis-
closed. Constipation is characteristic of most of the cases. It may
alternate with diarrhoea. Paralysis of the sphincter ani may take place,
with incontinence. The stools are frequently ribbon-shaped, or they
may pass in scybalous masses, and large or oftener small amounts of
blood, chiefly the latter, are passed with pus or mucus ; sometimes
masses resembling cancer can be found in the stools. If the tumor is
in the rectum, there is great difficulty in defecation ; the act is attended
by pain. Later the pain becomes constant, and may radiate to the
hip or the genitalia. Sometimes this pain is the only symptom com-
plained of.
The diagnostic symptoms are : (1) The general symptoms of cancer.
(2) The tumor. (3) The occurrence of constipation which leads to
complete obstruction, or obstipation, alternating with diarrhoea. Blood
in the stools, with alteration in the shape of the feces, is significant. 1
Diseases of the Rectum.
Consideration of rectal lesions belongs to the surgeon. It is proper,
however, to insist upon the very frequent deleterious effect of such
lesions in neurasthenic subjects. Indeed, the bleeding which attends
1 Musser: "Carcinoma of the Descending Colon." Univ. Med. Mag., 1896.
DISEASES OF STOMACH, INTESTINES AND PERITONEUM. 853
hemorrhoids may be sufficient to lead to profound anaemia, upon which
neurasthenia may readily develop. The local suffering due to rectal
fissure, or prolapse, may aggravate any tendency to the state of neuras-
thenia, or aid materially, with other conditions, to fasten it more
firmly upon the system. In cases of anaemia, of neurasthenia, of the
gastric neuroses, of debility, or prostration, the cause of which cannot
be ascertained, the rectum should be examined. The appearance of
hemorrhoids and other rectal affections is described in works on surgery.
Hemorrhoids, ulcers, fistula, and carcinoma are to be sought for in
abdominal affections.
Inspection and palpation are necessary. The symptoms are those of
local pain, tenesmus, and frequently hemorrhage. The pain follows a
movement of the bowels. There may be a feeling as of a foreign body
in the rectum, with some itching and burning about the anus. The
pain may be so severe as to inhibit defecation. The timid subjects
will not endure the act ; in consequence they suffer from vertigo, head-
ache, tympanites, and symptoms of gastro-intestinal disorder. In
some instances there is chronic catarrh of the rectum, with discharge
of small stools containing mucus or pus streaked with blood. Cases
occur in which hemorrhage is the only symptom, the constant recur-
rence of which leads to grave constitutional results. Hemorrhoids are
the lesions for which the rectum is most frequently examined. They,
as well as other lesions, are of diagnostic significance in affections
beyond the rectum. Thus in all forms of portal congestion internal
hemorrhoids are of constant occurrence, and when found in a toper
may be one of the first indications of cirrhosis of the liver. Rectal
fissure is not of much diagnostic significance. The finding of a small
cancer, the symptoms of which may be those of hemorrhoids, may ex-
plain emaciation and the development of cachexia. Ulcer of the
rectum may be due to syphilis, cancer, or tuberculosis. A fistula is
often tuberculous. The rectum must be examined in cases of pyaemia,
particularly of the portal variety, when jaundice, enlargement of the
liver, and hectic fever are present, for local rectal disease may cause
pylephlebitis.
CHAPTER VI.
DISEASES OF THE LIVER, SPLEEN, AND PAXCREAS.
The symptoms of disease of the liver are due to the morbid pro-
cesses, to disturbance of the functions of the hepatic cells, or to obstruc-
tion of the channels for the flow of blood and of bile. As these channels
extend beyond the glandular structure of the liver they may be affected
by disease outside of the organ. Hepatic symptoms may, therefore, be
due to diseases other than those of the liver.
The morbid process may, in time, cause alterations in function, ob-
struction of channels, or physical alterations in the size and shape of
the liver. But the channels may be obstructed and the size and shape
of the liver changed by disease outside of the liver.
Symptoms due to the Morbid Process. The morbid processes
are the congestions, the inflammations, the degenerations, the morbid
growths, and gross parasites.
In congestion of the liver the symptoms are (1) the symptoms of the
cause, (2) enlargement of the organ from the increased amount of
blood, (3) functional disturbance from the same cause. The conges-
tion is not limited to the vessels in relation with the liver-cells, but
involves the vessels of the mucous membrane also, hence the latter
swell, obstruct the ducts, and produce jaundice in moderate degree.
The inflammations are toxic and infectious. The symptoms are due
to the cause (intoxication or infection), to the degree of obstruction of
the vessels and ducts, to the shape and size of the liver, and to the
alteration of its function. AVhen the inflammation is diffused, as in
the cirrhoses, the hepatic symptoms are more marked ; when local, as
in abscess, the infectious symptoms are in preponderance. If the
ducts are the seat of infection, the bile chanuels are obstructed — jaun-
dice arising ; if the vessels, ascites. In morbid growths of the liver
the symptoms are those of malignant disease in general, to which are
added symptoms due to change in the size of the liver, and, more fre-
quently than in inflammation, symptoms due to obstruction of the
channels. The degenerations are so frequently secondary to and
masked by the symptoms of their primary cause that, save in regard
to change of size, there are no hepatic symptoms worth mentioning.
Symptoms due to Functional Disturbance of the Liver.
The functions of the liver are to secrete bile ; to destroy the haemoglobin
of the blood ; to destroy, modify or neutralize poisons entering, or to
modify and render available for nutrition the peptones absorbed by, the
portal circulation ; the elaboration of glycogen. Bile is not secreted
when the liver-cells are destroyed, as in acute yellow atrophy. The
liver does not destroy the usual amount of haemoglobin. On the other
hand, haemoglobin may be so much in excess that the liver cannot
DISEASES OF LIVER, SPLEEN AND PANCREAS. 855
destroy it ; jaundice then results. (See Hematogenous Jaundice.) Func-
tional disturbances of the liver are manifested clinically by symptoms
due to the entrance into the circulation of imperfect products of diges-
tion, or poisons not destroyed by the liver.
Lithcemia is a common toxic condition, and is believed to be due to
functional liver-disturbance. There is an excess of uric acid and
urates, or of other metabolic compounds in the blood. It may be a
convenient term for the auto-intoxication which takes place in disease
of the gastro-intestinal tract. The symptoms are, first, symptoms of
excess of lithic acid in the system ; second, the effects of the lithic
acid upon the nervous system. Lithsemia may be acute or chronic.
Acute Lithcemia ; Biliousness. When acute the local disturb-
ances are : furred tongue, a bitter taste in the mouth, anorexia, nausea,
disgust at the sight of food, with possible morning vomiting. There
is some tenderness in the upper mid-abdomen, and, after eating, weight,
and fulness and distress in that region. Flatulency occurs. Symp-
toms of intestinal dyspepsia may arise secondarily. Slight fever or
feverishness may attend the attack. The skin is hot and burning ; or
cold perspirations may break out at irregular times, alternating with
flashes of heat. The bowels are constipated, the stools are clay-col-
ored. The symptoms may be attended by slight obstruction to the
ducts, causing a moderate degree of jaundice. In some instances the
liver is slightly enlarged. The urine is loaded with urates and uric
acid. It is scanty and high-colored, and there may be painful mictu-
rition. The nervous symptoms are usually those of depression, as head-
ache, some dulness, or stupor ; the patient may be unusually drowsy.
The headaches may be the most prominent feature of the attack. They
are frontal, attended by slight vertigo, flashes of light or spots before
the eyes, and ringing in the ears.
The same group of symptoms is seen in acute gastro-duodenal catarrh.
Chronic Lithcemia. In chronic lithcemia the symptoms are varia-
ble, and are characterized by disturbance of function in nearly all the
organs of the body. They have been classically described by Murchi-
son, Da Costa, and others, and while the theory is fairly satisfactory
to work upon for lines of treatment, the same group of symptoms may
be met with in forms of chronic indigestion, particularly the forms in
which there is inability to digest sugars and starches. The symptoms
are attributed by some to chronic intestinal catarrh.
Symptoms. The patients are in ill health and subject to chronic
indigestion. They may be under weight or corpulent. The skin is
harsh and dry, its nutrition poor. It is subject to erythema ; or local
inflammations, as eczema, may arise. Irregular sweats occur, alter-
nating with intervals when the skin is hot and dry. The extremities
are cold and clammy, and tingling and numbness are often com-
plained of.
Gastro-intestinal Symptoms. The symptoms are those of chronic
indigestion. There is constantly a furred tongue with local dyspeptic
symptoms. The bowels are irregular or constipated ; sometimes
mucus is passed. Flatulency is excessive, both gastric and intestinal.
An icteric tinge may be seen on account of a slight local catarrh of the
856 SPECIAL DIAGNOSIS.
ducts, or of hepatic congestion. It recurs at frequent periods, while a
sallow complexion is more or less constant.
Respiratory Symptoms. The patient is liable to attacks of catarrh
of the upper air-passages, and especially to pharyngitis. In lithaemic
states tonsillitis is not uncommon. Chronic pharyngitis is present.
On the other hand, some persons, particularly those over fifty years,
have chronic bronchitis, and attacks of asthma are common. The
bronchitis cannot be distinguished from that due to other causes, except
by the fact that the subject is lithaemic. Emphysema of the lungs
develops on account of bronchitis and tissue degeneration.
Cardiac Symptoms. Palpitation is a constant accompaniment of
many forms of lithaemia ; in others there may be unduly rapid action
of the heart, or, during exacerbations, slowness of the heart's action.
In the later stages pseudo-angina pectoris is of common occurrence.
In the earlier stages pain about the heart or in the left side is fre-
quently complained of.
Nervous Symptoms. Constant headache, worse in the morning, re-
lieved toward the end of the day. Some vertigo may be present.
Depression of spirits and inaptitude for mental exertion exist. The
memory is dull, the faculties blunted. The patient is subject to back-
ache, chiefly in the loins. Pain in the right shoulder is of frequent
occurrence. In addition, pains along the course of the nerves (neuritis),
and myalgias, are of common occurrence. The nerve-trunks may be
tender. There is tenderness in the sheaths of the muscles, or at the
insertions of fasciae and tendons. Peripheral nerve-sensations are
common. Xumbness and tingling are frequently complained of.
Paraesthesiae of all forms, variously distributed, are a source of annoy-
ance. Local sensations of heat or burning alternate with areas of
coldness. Tingling, pricking of needles, and other forms of pares-
thesia occur.
The Urine. The urine is high-colored and contains an abundance
of uric acid and urates. The amount is scanty, the specific gravity
high. There may be albumin, small in amount, depending upon the
irritation of the urates in their passage through the kidneys. Cylin-
droids are present ; casts are not common, although at times, when
the uric acid is passed in excess, there may be a secondary nephritis,
with albumin, blood, and casts. As an ultimate result of such condi-
tion we may have gallstones, or calculi in the kidneys and bladder.
Lithaemic patients are subject to attacks of hepatic or renal colic.
As part of the same process or an accompaniment we may have
gout or rheumatism. Acute inflammatory rheumatism (rheumatic fever)
does not belong to this category, but muscular rheumatism, subacute
inflammation of the joints with moderate fever, true gout, and gout
with its modifications when seated in the various joints, are the ultimate
results of this process in the patient. Attacks of gout may occur in
a patient who has not shown any symptoms of lithaemia, but those
who have symptoms of lithaemia are more susceptible to causes which
produce attacks of gout. The gouty and rheumatic manifestations are
due to the deposition of uric acid and urates in tissues which are not
highly vitalized, and in which, therefore, the circulation is sluggish.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 857
Lithseniia later assumes the gouty aspect Tophi are seen in the
situations natural to them. The appearance of the face is character-
istic, with capillary congestions and stases. The patients usually be-
come more or less obese and are subject to attacks of glycosuria.
Early in their life degenerations of vessels take place. The kidneys
are always under an excessive strain. A good deal of material is not
discharged ; its effects upon peripheral vessels are such as to cause
vasomotor spasm and heightened tension, leading to low-grade inflam-
mations, with the development of atheroma. For the same reason
chronic interstitial nephritis is set up, and, because of heightened strain
in the vascular system, chronic sclerotic valvulitis.
Functional symptoms from disorder of the liver are otherwise not
marked, unless we include a group of cases in which sudden coma and
convulsions take place, presumably because material has been absorbed
from the gastro-intestinal tract and enters the general circulation
through the temporary cessation of the function of the liver, the office
of which is to destroy the material. Such symptoms may arise in
organic disease of the liver, as cirrhosis.
Symptoms due to Obstruction of the Channels. (1) Obstruc-
tion of the bile-duds, either from disease or external pressure, causes
jaundice, pain, and fever. The three symptoms may occur singly or
combined. Jaundice may occur alone in obstruction by gallstones ;
pain may occur with it ; or jaundice, pain, and fever may occur
together ; rarely, pain or fever may be present alone. Each symptom
will be described later. (2) Obstruction of the blood-channels causes
congestion of the liver, which may be active or passive, or ported ob-
struction. The symptoms of each will be discussed ; suffice it to say
that here again the symptoms are modified by the process. Thus in
portal obstruction from pressure the symptoms are quite different from
those in portal obstruction due to suppurative inflammation of the vein.
Congestion of the Liver. In the congestions the liver is enlarged.
If the hyperemia is active, painful distention may be complained of,
and the organ may be the seat of some tenderness. There may be, in
addition, weight and fulness in the liver-region. Active hyperemia
may follow a chill or suppression of the menses, but more frequently
occurs after indiscretions of diet, the free use of alcohol, or stimulating
food, followed by an attack of acute gastro-intestinal catarrh. It is
more common in the tropics, and is due in that climate to suppression
of the perspiration. It is recognized by the occurrence of symptoms
of acute gastritis with enlargement, pain, and tenderness of the liver.
Slight jaundice may attend the attack.
Passive congestion is also attended by enlargement of the liver. The
enlargement may cause a sense of weight or fulness, but pain is not
complained of. The organ is not tender, the edges are smooth and
indurated. The liver may pulsate. This is detected by placing the
hand over the surface of the liver, when, with each impulse of the heart,
the organ can be felt to expand. The symptoms of the cause of the
passive congestion combine with those just enumerated as due to en-
largement of the organ. In addition we have symptoms due to obstruc-
tion of the flow of blood in the portal circuit.
858 SPECIAL DIAGNOSIS.
Passive congestion occurs in organic heart disease after compensa-
tion has failed and the right heart is dilated. The organ rapidly be-
comes congested because of its close proximity to this chamber. In
emphysema of the lungs, in fibroid phthisis, in intrathoracic tumors
pressing upon the vena cava, mechanical congestion also takes place.
The recognition of passive congestion is not difficult. The symptoms
due to enlargement (see Objective Symptoms) and the symptoms due
to portal obstruction point to the true nature of the morbid process.
Portal Obstruction. Disease of the portal vein or occlusion of its
branches in the liver, obstructs the flow of blood. The diseases of the
portal vein are thrombosis, and adhesive and suppurative inflammation.
Obstruction of the terminal venous radicles in the liver is caused by
cirrhosis.
Thrombosis of the portal vein attends cirrhosis of the liver, or may
occur secondarily to pressure upon the vein by a tumor. Disease of
the pancreas was the cause of the pressure in a patient under my
observation. As a result of thrombosis adhesive inflammation of the
vein takes place, with or without the establishment of a collateral cir-
culation to replace its function.
The symptoms of disease of the trunk of the portal vein are the same
as those of obstruction of the terminal branches, and are known as the
symptoms of portal congestion. (See below.) In one respect only do
they differ. While we have ascites in both, in thrombosis of the
portal vein it occurs suddenly, and is characterized by rapid recurrence
after tapping.
Suppurative inflammation of the portal vein is attended by symptoms
resembling pyaemia, and is also called portal pyaemia. The inflamma-
tion is secondary, and depends upon inflammation in the portal area.
It may follow appendicitis, infectious inflammation of the hemorrhoidal
veins, or of the veins anywhere in the gastro-intestinal tract. Pus is
carried into the liver by the portal current. In consequence thereof,
multiple hepatic abscesses arise. Three pathological affections are
therefore seen : (1) Suppuration in the portal area ; (2) inflammation
of the vein ; (3) multiple abscesses of the liver (for the symptoms of
which see Abscess).
Occlusion or overfilling of the branches in the liver occurs in passive
congestion, and most typically in cirrhosis of the liver. The circula-
tion in the liver is interfered with ; the blood is thrown back into the
portal vein, and overfills the vessels of the portal area. As a result
we have (1) congestion of the mucous membrane of the stomach and
bowels, with the symptoms of gastro-intestinal catarrh. (2) Dilatation
of the veins, chiefly the hemorrhoidal, giving rise to hemorrhoids. (3)
Ascites. (4) Hemorrhages. The hemorrhages may occur in any part
of the gastro-intestinal tract. Hsematemesis and intestinal hemor-
rhage are seen singly or combined. The vomited blood may be small in
amount, often with mucus. In some cases large, sometimes fatal, hemor-
rhages take place either from the mucous membrane of the stomach or
from the veins about the oesophagus, which often become varicosed in
cirrhosis. Hemorrhages from the intestine may be from enlarged
hemorrhoidal veins, from an intestinal ulcer, or from the intact mucous
DISEASES OF LIVER, SPLEEN AND PANCREAS. 859
membrane. (5) Enlargement of the spleen. (6) Changes due to the
collateral circulation. If complete collateral circulation is established,
the above symptoms may not ensue. The collateral circulation may
be through deep-seated or through superficial veins. If the latter,
the external veins of the abdomen are enlarged. The epigastric and
mammary veins become prominent. The veins about the umbilicus
may become so enlarged and prominent as to form a swelling, to
which the term caput Medusce has been applied. The venules along
the line of attachment of the diaphragm in the lower thoracic zone
are overdistended. They may be the seat of pulsation.'
In consequence of the portal overfilling the enlarged terminal
branches of the vein press upon contiguous structures, interfere with
the circulation of blood in the major vascular system of the liver, and
invite catarrh of the terminal ducts, with obstruction, and hence jaun-
dice. This is seen quite frequently in passive congestion of the liver,
rarely in cirrhosis.
Symptoms due to the Changes in Shape and Size. The liver
may be enlarged, contracted, or irregular. (See Objective Symptoms.)
When the liver is contracted symptoms of portal obstruction usually
occur ; when enlarged they occur occasionally.
The Data Obtained by Inquiry.
A knowledge of etiological factors is of aid in the diagnosis of
hepatic affections. In disease of the liver more than in any other
organ of the body we find the affection secondary to disease elsewhere.
Moreover, diseases of the liver are almost always associated with defi-
nite causes, the presence or absence of which is of great diagnostic sig-
nificance. In the study of hepatic disease we consider, therefore,
among etiological factors, the age, the sex, the habits of life, the
climate, and the presence or absence of disease in other portions of the
body. Primary liver disease is comparatively rare. Secondary liver
disease, on the other hand, is of common occurrence. There are but
few general diseases or states of the system that do not in some way
influence the liver. The above remarks refer to organic disease. Func-
tional disorders of the liver, as previously remarked, are so difficult
to separate from functional disorders of the stomach and intestines,
that, practically, from an etiological and clinical stand-point, they go
hand-in-hand
The Social History. The Age. Diseases of the liver usually
occur late in life, because the causes upon which they depend are oper-
ative only at that period. In a case, therefore, of ill health in a young
subject, when the cause cannot well be determined, the liver is not so
likely to be the seat of disease as in older subjects. Late in life we
have gallstones with their multiple consequences, inflammation, cir-
rhosis, and cancer. We may, however, have the congestions and the
degenerations in early life, although not so frequently.
The Sex. The sex is not of much significance from a diagnostic
stand-point. Cancer may be more frequent in the female sex, because
1 Musser: Trans. Phil. Path. Soc, vol. xi. p. 20.
860 SPECIAL DIAGNOSIS.
cancer of the uterus and other organs is more common. Cancer of
the biliary passages is more frequent in females, because in that sex
gallstones, which are etiological factors in cancer, are more common.
Cirrhosis, also, is said to be relatively more frequent in females.
The Habits. It is always necessary to inquire into the habits. Alco-
holism points to cirrhosis ; the excessive use of stimulating foods to
hypersemia ; sedentary habits and the use of starches and fats to gall-
stones. The occupation has but little influence in' the development of
hepatic disease. With regard to the climate, it may be said that in
tropical countries hyperemias and abscess of the liver are more fre-
quent.
The Family History. But little avails in the study of the family
history for diagnosis, as most of the morbid processes are secondary
to disease elsewhere. This does not apply to biliary calculi, the
formation of which appears to be confined to members of special
families.
Previous Disease. It is absolutely essential to inquire into this
to establish a diagnosis, as liver disease is usually secondary. The
occurrence of heart disease or obstructive lung disease points to a con-
gestion ; infectious diseases to cirrhosis when that is not otherwise
accounted for ; dysentery to abscess ; ulceration or suppuration in the
portal area to multiple abscess ; syphilis to syphilitic diseases ; tuber-
culosis, suppurations, bone disease, and syphilis to amyloid disease ;
pyaemia to multiple abscesses ; tuberculosis to fatty liver.
The Subjective Symptoms.
The subjective symptoms are such as belong to functional disorder
of the liver, conspicuous among which are gastro-intestinal symptoms
and toxaemia. (See Functional Disturbance and Lithaemia.)
Pain is a frequent symptom of liver disease. When sudden in
onset, acute, and increased by pressure or movement, it is due to peri-
hepatitis. Acute paroxysmal pain below the ribs or in the epigastrium
points to gallstones. It may be in the seventh or eighth interspace.
Pain with distention occurs in congestion. Stabbing or darting pains
belong to cancer. The pain of perihepatitis may attend abscess.
Pain in the liver must not be confounded with pleurisy. In pneu-
monia there is often congestion of the liver and perhaps perihepatitis.
The associated pain has been mistaken for the pain of hepatic colic.
The Data Obtained by Observation. The Objective Symptoms.
Topographical Anatomy. (See Plates XIII., XIV., and XXXV.)
The right lobe of the liver is applied to the concavity formed by the
lower lobe of the right lung, being separated from it by the diaphragm.
The thin lower edge of the right lung overlaps the liver at its upper
part, but the greater portion of the anterior surface of the right lobe of
the liver is in contact with the ribs. The under surface of the liver
is in relation with the stomach, transverse colon, duodenum, right
kidney, and right suprarenal capsule. " The highest part of its con-
DISEASES OF LIVER, SPLEEN AND PANCREAS, 861
vexity on the right side is about one inch below the nipple, or nearly
on a level with the external and inferior angle of the pectoralis major.
Posteriorly the liver comes to the surface below the base of the right
lung, about the level of the tenth dorsal spine." (Holden.)
A needle thrust into the right side, between the sixth and seventh
ribs, would traverse the lung, and then go through the diaphragm at
its central attachment, into the liver. The lower border of the liver
extends in the median line, one-third of the distance from the tip of
the xiphoid cartilage to the umbilicus. In the right mammary line it
extends to the lower border of the ribs ; and in the mid-axillary line
to the tenth rib. The upper border is opposite the upper border of
the sixth rib in the mammary line, and extends horizontally in the
axilla to the ninth rib behind.
The attachments of the liver permit of a certain amount of move-
ment. Hence, the liver can be depressed by deep inspiration, emphy-
sema of the lungs, or right pleural effusion. If the patient lie upon
his left side, the left lobe of the liver rises higher and the right ex-
tends lower, and vice versa if the patient lie upon the right side, the
liver turning upon the suspensory ligament as an axis. (Gerhardt.)
Inspection. Inspection is not of very great assistance in the diag-
nosis of diseases of the liver. Frequently there is a swelling or tumor
in the right upper quadrant, which may or may not be produced by
an enlargement of the liver, but which should direct attention to that
organ. The lower right zone of the thorax may also be distinctly
prominent. Such a swelling may be observed in amyloid disease,
hydatid tumor, cancer, abscess, and, less frequently, in fatty liver.
In amyloid and fatty livers the projection hi the right upper quadrant,
which may extend to the left beyond the median line, presents a
smooth surface, whereas in hydatid tumor there is frequently a rounded
projection at some part of the prominent area, and, in cancer, several
nodules may be large enough to cause slight rounded projections, which
the eye is more apt to detect after the sense of touch has first directed
attention to their presence.
Enlargement and occasionally pulsation of the superficial abdominal
veins are accompaniments of cirrhosis.
Jaundice. The Symptoms. The color of the skin and of the mucous
membranes in jaundice has been described. (See page 121.) In
addition to the yellow discoloration we find : 1. Irritations of the
skin. Pruritus is common and intense, and may cause great dis-
tress. An attack of jaundice may be preceded by general itching.
It occurs in all forms, but is more marked in obstructive jaundice
of long duration. Scratch-marks are seen on the surface of the skin,
and erythematous eruptions and boils frequently occur. Xanthelasma
is a peculiar affection occurring on the tongue, on the skin of the
eyelids, and about the ears. (See page 92.) 2. Discoloration of the
secretions. All the secretions of the body are changed in color, as
previously described. 3. Bile absent in the feces. The stools are ashy
or gray in color. 4. Sloicness of the pulse. The heart's action falls to
40 or 30 to the minute, or even lower. 5. Hemorrhages. In the later
862 SPECIAL DIAGNOSIS.
stages of all forms of jaundice hemorrhages are of common occurrence.
In acute malignant jaundice they are seen underneath the skin, and
come from the mucous membranes. 6. Cerebral symptoms. Irrita-
bility and depression of spirits are marked. As the disease advances
the mind grows sluggish ; the patient is dull, and sleeping most of the
time. Gradually the symptoms of the typhoid state develop. In the
acute febrile forms coma and convulsions are of common occurrence.
In the affection known as acute yellow atrophy the cerebral symptoms
are marked, and occur soon after the onset of the disease. Within
the first twenty-four hours there may be convulsions, with delirium
in the intervals, and subsequently coma.
Causes. Jaundice is of two varieties, the hepatogenous and the
hsematogenous.
Hepatogenous Jaundice. Jaundice is hepatogenous when there
is obstruction of the ducts. The obstruction may take place in the
large ducts or in the smaller terminal ducts. The obstruction may be
due to disease outside of the ducts ; to disease of the ducts, or to ob-
struction within the ducts.
1. Jaundice from disease outside of the ducts. External pressure.
External pressure by tumors of the stomach, kidney, pancreas, or
omentum ; by tumors of the liver itself, or enlarged glands in the
fissure of the liver ; by accumulated feces in the colon ; by an abdom-
inal aneurism ; and by the pregnant uterus, in rare instances, may cause
jaundice. Jaundice due to disease outside of the ducts is gradual in
onset, varies in degree with the amount of pressure, and becomes
chronic, except in pregnancy and from fecal accumulation ; it may
cause death, or persist until such termination results from the primary
disease. It is recognized by the absence of pain ; the presence of dis-
ease in other localities, indicated by its peculiar symptoms and signs ;
the absence of a history of gallstones ; and, finally, by the patient's
age. Its nature must be inferred from the symptoms and physical
signs of disease in neighboring structures. If the jaundice is due to
enlargement of the lymphatic glands, its nature may be inferred from
the presence of primary carcinoma in other organs of the body, or from
the condition of the lymphatic glands in other parts. If they are the
seat of malignant disease, it can usually be recognized. Cancer of the
liver must be excluded by its symptoms — enlargement with jaundice,
with moderate fever, rapid emaciation, and short duration of the dis-
ease. In the large majority of cases this form of jaundice is due to
disease of the pancreas, particularly carcinoma.
2. Jaundice from disease of the ducts themselves. Catarrhal in-
flammation, suppurative inflammation, or adhesive inflammation of the
ducts ; and cancer or other tumors of the duct cause jaundice.
Jaundice due to disease of the ducts presents various features. The
most common form is that clue to catarrhal inflammation of the ducts.
The jaundice comes on suddenly, at least within forty-eight hours after
the onset of the symptoms ; there is no pain, but it is attended by
vomiting and other symptoms of mild gastritis, and is usually accom-
panied by itching. It follows indiscretions in diet, and occurs in
young subjects. A definite cause for the gastritis can usually be found.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 863
The diagnosis is based upon the age, the association of the jaundice
with gastritis, for which a definite cause can often be assigned ; the
absence of organic heart disease, or any lesion within the body, on
account of which jaundice might arise ; the moderate degree of jaun-
dice, the absence of emaciation and symptoms of portal obstruction,
the occurrence of moderate enlargement without pain. It must not be
forgotten that jaundice due to obstruction from gallstones, or to press-
ure from tumors outside of the duct, is characterized in its onset by
symptoms similar to those just mentioned. It is often necessary to
wait before giving an opinion ; a history of previous attacks of jaun-
dice and the age of the patient, over forty years, also lead to caution
in the diagnosis.
If the jaundice is due to suppurative inflammation of the ducts, cho-
langitis, the infection is usually associated with a previous history of
gallstones. It must not be forgotten, however, that other lesions, which
cause jaundice, may mvite an infectious inflammation of the ducts also,
such as obstruction by external pressure. The course of the jaundice
is chronic. Fever and other symptoms of an infection attend it. In
adhesive inflammation there is a history of trauma from gallstones, and
the affection is chronic. In cancer of the gall-ducts the advent of jaun-
dice is slow, the course protracted ; the symptoms are the symptoms
of carcinoma, to which are often added the physical signs of an en-
larged gall-bladder. (See Diseases of the Gall-ducts.)
3. Jaundice from obstruction within the ducts. Foreign bodies
within the ducts, as inspissated mucus, gallstones, or parasites, such as
round worms or hydatid cysts, are the common causes of the occlusion
of the ducts which may cause jaundice.
Foreign bodies within the ducts cause jaundice by direct obstruction,
or by the catarrhal inflammation which their presence excites. The
symptoms occur suddenly in the former instance, gradually in the
latter. The characteristic symptoms of gallstones precede the jaundice.
The patient is usually a woman past forty years, with habits of life
which predispose to the formation of calculi. Colicky pains occurring
in paroxysms, intermittent jaundice varying in intensity, and an inter-
mittent fever, point to this form of obstruction.
Jaundice due to lowering of the blood-pressure in the liver, so that
the tension between the bile-ducts and the blood-passages is altered,
occurs suddenly, is light in degree, and is not attended by marked
symptoms ; it is due usually to shock or emotions.
Hematogenous Jaundice. Jaundice is hematogenous or non-
obstructive when (1) the function of the liver-cells has been suppressed,
as in acute yellow atrophy of the liver ; (2) when blood-destruction
is in excess of the capacity of the liver to remove the product of
destruction — the urobilin, as in certain forms of malaria, in perni-
cious anaemia, in certain fevers, and other toxaemias. The onset of
the jaundice is rapid, the general symptoms are more pronounced, par-
ticularly the cerebral symptoms. They occur simultaneously with the
jaundice. They are infectious, as in acute yellow atrophy of the liver
and in Weil's disease. The toxic forms of hematogenous jaundice are
not severe ; the discoloration of the skin is light yellow, and may not
864 SPECIAL DIAGNOSIS.
even be observed by the patient, nor cause pronounced symptoms.
The blood is destroyed rapidly in these cases, and, as it cannot be
disposed of by the liver, spleen, or kidneys, the transformed haemo-
globin is deposited in the tissues. In this class of cases the urine
contains but little bile-pigment, but there is a large amount of urobilin
and indican. The stools are not clay-colored.
Malignant or Infectious Jaundice. Acute Yellow Atrophy of the
Liver. Acute diffuse inflammation of the liver, with necrosis of the
cells, characterized by jaundice and cholsemia. Many of the cases
occur during pregnancy. It is most common prior to the thirtieth
year. It is said to follow fright. The symptoms are local and gen-
eral. Jaundice is at first noticed after an attack of gastroduodenal
catarrh. It is light, occasionally extends over the entire body, and is
not usually attended by itching. After a continuance of these mild
symptoms for from two days to two weeks, the patient complains of
headache ; delirium sets in with stupor and convulsions. The headache
is attended with vomiting. Fever of moderate degree begins at the same
time, although in some cases it is absent.
Although the jaundice is not intense, the effects upon the blood are
early seen ; hemorrhages underneath the skin and from the mucous
membrane take place. In pregnant women abortion follows, the hem-
orrhage from which may be very excessive. The stupor and delirium
are followed by coma, and death takes place in the first week ; or coma
may be preceded by the typhoid state, and the disease lasts longer
than a week. The urine is bile-stained, and contains albumin and
casts. It diminishes in amount, and is soon passed involuntarily.
Leucin and tyrosin are always present. The latter may be seen in the
sediment, although it is more marked when a few drops are evaporated
on a cover-glass. The bowels are loose and the stools involuntary and
clay colored.
On examination the liver is found to be diminished in size ; this
may not be appreciated by percussion in the anterior region, but in the
axillary region the width is reduced one to two inches. There may
be some tenderness over the liver and over the ducts.
Diagnosis. The data upon which a diagnosis is based are the age,
sex, pregnancy, the rapidity of onset of cerebral symptoms following
jaundice, diminution in the size of the liver, with leucin and tyrosin
in the urine. It must be distinguished from the jaundice of hyper-
trophic cirrhosis of the liver, which at times becomes malignant. Some
observers have thought that acute yellow atrophy may supervene upon
this form of cirrhosis, thereby causing malignant jaundice ; but there
is more fever than in atrophy, while leucin and tyrosin are not found
in the urine. It must not be forgotten that all cases of jaundice may
terminate suddenly with delirium, followed by coma, or by the develop-
ment of the typhoid state.
In phosphor as-poisoning the hemorrhages, the jaundice, and diminu-
tion in the size of the liver are the same as in acute yellow atrophy.
Gastric symptoms are more marked, and leucin and tyrosin are not
present in the urine.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 865
Weil's Disease. This infection, in which jaundice is the chief
symptom, is considered in the chapter on Infections Diseases.
Yellow Fever. The account of the jaundice attending this infec-
tion is found in the chapter on Infectious Diseases.
Infantile Jaundice. Jaundice in infants is due to two causes :
First, congenital obliteration of the ducts ; and, second, catarrhal in-
flammation. It must not be confounded with the yellow discoloration
of the skin, due to the excess of coloring-matter in the blood, which is
not disposed of by the liver.
In congenital obliteration of the gall-ducts jaundice rapidly ensues
and deepens to an intense degree ; hemorrhages occur, the child be-
comes stupid or comatose, may have convulsions, and death takes place
in coma. There is rapid emaciation, and the liver and spleen are en-
larged. The child may live many months.
Simple catarrhal jaundice in infants is associated with moderate
gastric disorder. The jaundice is light ; the conjunctivae alone may
be discolored. In infants malignant or infectious jaundice may be
due to inflammation of the portal veins, secondary to umbilical phleb-
itis. The jaundice develops after suppurative inflammation about the
umbilicus, and is attended by fever. There may be some tenderness over
the liver ; frequently peritonitis develops at the same time. Pysemic
symptoms may set in, and pus may be found in other situations. If
death does not ensue early the jaundice becomes more pronounced and
causes cutaneous and mucous hemorrhages. Convulsions and coma
are apt to supervene before death. Jaundice in infants also occurs in
interstitial hepatitis of syphilitic origin. The evidences of hereditary
syphilis are seen in the skin and mucous membranes. The liver is
enlarged, and there may be tenderness from perihepatitis.
Fever. Hepatic Fever. The occurrence of fever may be of diag-
nostic importance in distinguishing the various forms of obstructive
jaundice. Fever occurs frequently in jaundice ; but is significant in cer-
tain forms only. In catarrhal jaundice it is present for three or four
days only, disappearing as the severe gastric symptoms subside. It is
probably toxic. In hepatic colic, with jaundice, it is transitory and
associated with chills and SAveats. In jaundice from obstruction it
occurs when an infectious cholangitis, primary or secondary, arises.
A peculiar type known as intermittent hepatic fever (see page 202) is
often seen. The intermittent fever is associated with gallstones in the
following groups : First, with each paroxysm of hepatic colic moder-
ate fever and jaundice are present. The latter becomes more intense
after each paroxysm, but disappears in a short time. The paroxysmal
attacks may recur at intervals for years. Second, the hepatic colic is
attended by distinct ague-like paroxysms of chill, fever, and sweat,
after each of which the jaundice, which continues to the end, is more
intense. Third, hepatic colic and gastric disturbance occur with fever,
but without jaundice. The symptoms occur in distinct paroxysms.
Gallstones are probably the cause in all these conditions, leading in
some cases to chronic obstruction of the duct without infection.
If an infectious cholangitis, with or without gallstones, is present, the
symptoms are somewhat different, although the fever is of the same
866 SPECIAL DIAGNOSIS.
type. Thus (1) there is more tenderness in the hepatic region, with
enlargement of the gall-bladder ; (2) the paroxysms are more frequent ;
(3) jaundice is not so intense and not influenced by paroxysms ; (4)
the patient is ill in the intervals, and there is wasting. There are no
periods of improvement locally or in the general condition. The most
important point in cases of gallstone is the subsidence of all symptoms
between the paroxysm of fever.
Intermitting fever of this character must be distinguished from
malaria. The history of gallstones, with pain in the region of the
liver, and the negative appearance of the blood, are sufficient to estab-
lish the diagnosis.
Hepatic fever also occurs in cancer when the neoplasms grow rapidly,
in certain forms of cirrhosis, and in obstruction from other causes than
gallstones. It is particularly common in suppurative inflammation of
hydatid cysts, or after they rupture and discharge into the biliary
vessels. Without previous knowledge of the hydatid cyst the diagno-
sis is almost impossible, save that the pain is less wheu the obstruction
is due to this cause than in obstruction from the passage of gallstones.
Palpation. By palpation the lower border of the liver can be de-
termined in thin subjects, or in those in whom the liver is greatly
enlarged. It may be difficult to determine the border when the abdo-
men is distended on account of flatulency. Careful palpation must be
made with the tips of the fingers, pressing them firmly inward along
the margin of the ribs, at the same time securing relaxation of the
abdominal muscles by having the patient take a full breath, and
having the legs drawn up and the shoulders elevated. The pressure
should be made in the intervals following the act of inspiration. By
care and patience the fingers can be pushed deeply inward and be
made to feel the border of the liver, even in health. Care must be
taken not to cause contraction of the right rectus muscle, for if this
takes place the indurated mass may simulate tumor or enlargement of
the liver. The left lobe of the liver, below the ensiform cartilage,
extends half-way to the umbilicus. Here it is most accessible to pal-
pation. By palpation we also determine the size of the gall-bladder
and the degree of movement of the liver in respiration. On full in-
spiration the liver descends, and during the act of expiration rises
again. This movability is of service hi distinguishing the liver from
other organs that are fixed within the abdomen.
In amyloid disease the lower edge is smooth, rounded, the tissue
dense and unyielding to pressure, and the anterior surface perfectly
smooth, as a rule ; but when the liver is also cirrhotic or syphilitic the
surface may be irregular and fissured. 1
The fatty liver has also a rounded smooth border, but its tissue is not so
dense and resistant, except when cirrhosis coexists. Its surface is smooth.
In single abscess the liver is enlarged, but not uniformly, and not
invariably. If the abscess is located in the right lobe, and nearer the
anterior than the posterior surface, palpation may be able to detect not
only enlargement, but also deep-seated obscure fluctuation, surrounded
1 See Musser: "Amyloid Disease of Liver," Penna. State Medical Journal, 1899.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 867
by a zone of hard tissue. The tumor is round, smooth, tense, tender,
and painful.
In multiple abscesses the liver is enlarged uniformly, and usually
none of the abscesses are large enough to be felt as a distinct promi-
nence. The liver is tender and painful.
In hydatid tumor the degree of enlargement depends very much
upon the situation of the cyst, upon its stage of development, and upon
the activity of the echinococci. Sometimes the cyst is so small that
its existence remains unsuspected ; at other times the enlargement is
so great as to fill the abdominal cavity. As in abscess, the possibility
of detecting the tense, globular, fluctuating, painless tumor character-
istic of the disease depends upon its situation. If it is on the anterior
surface or lower border, it is easily detected, especially if the tunior is
at all large ; but if it projects from the posterior surface or from the
upper or lateral borders, detection is difficult, and may be impossible.
In congestion of the live)- the enlargement is not so great as in ab-
scess, nor are pain and tenderness so pronounced. Moreover, the
enlargement is usually not permanent. The lower border, if it pro-
jects below the edge of the ribs, is smooth.
In hypertrophic cirrhosis the enlargement is moderate, the surface
smooth, or but slightly roughened, denser than normal, and somewhat
tender.
In cancer the enlargement resembles that of single abscess and
hydatid tumor in that it is irregular. But, unlike hydatid tumor, the
irregularities are due to knobs or bosses which project from the sur-
face of the liver, are usually entirely free from any fluctuation, and are
tender on palpation. There may be a single large mass, or a number
of knobs or nodules. The part projecting below the ribs may be free
from any nodules.
Palpation of the liver may discover a friction from perihepatitis, and
pain or tenderness from that cause, or from cancer or abscess. Pulsa-
tion of the liver may be a transmitted impulse from the abdominal
aorta or a venous pulse, such as occurs also in the jugulars, from tri-
cuspid regurgitation.
Floating liver is diagnosticated by feeling in the lower, most fre-
quently the right portion of the belly, a large tumor, which may, how-
ever, easily be confounded with tumors of other organs. It can be
distinguished as liver : (1) By recognizing the notch ; (2) by the pres-
ence of a tympanitic note in the proper region of the liver, as loops of
intestine lie between the diaphragm and liver ; (3) by the excessive
movability of the tumor ; and (4) by the fact that it is possible to re-
place the liver ; (5) by its size and consistency. It occurs almost
exclusiv elv in women, possibly as the result of a congenital lengthen-
ing of the suspensory ligament, although more likely from relaxed
abdominal walls. It may be confounded with ovarian cyst, appendi-
citis with tumor, and movable right kidney with hydronephrosis.
Constriction of the liver from tight lacing (Schnurleber) occurs chiefly
in women. Tight corsets, and, still more, tight waist-straps or bands,
squeeze the liver downward, especially the right lobe, so that it can be
palpated. In more pronounced cases a furrow, often palpable, is pro-
868 SPECIAL DIAGNOSIS.
duced, and, below this, a constricted lobe which may extend as far
down as the anterior superior spine of the ilium and carry the gall-
bladder with it. In other instances, the right lobe is elongated, ex-
tending even to the crest of the ilium. 1
Lobes so depressed are usually thin and easily movable, and can be
grasped with the hand and moved to and fro. If the lobe does not
reach so far downward, it is more rounded and blunt in shape. It is
not always easy to demonstrate its connection with the liver, because
coils of intestine lying over the liver in the furrow make palpation diffi-
cult, and cause a tympanitic note between the liver-dulness and the
dulness of the constricted lobe.
Confusion with tumors of other kinds can be avoided usually by
deep palpation or percussion.
Gall-bladder. When the gall-bladder has a certain degree of
fulness, it may, according to Gerhardt, be not only felt in healthy
persons, if the stomach and bowel are empty, as a smooth, round, fluc-
tuating tumor at the lower border of the liver, but be even visible and
be outlined by percussion. If a line is drawn from the right acromion
process to the umbilicus, it will bisect the gall-bladder at a point where
it passes over the margin of the ribs. The fundus is situated below
the edge of the liver, at about the ninth costal cartilage, just outside
the edge of the right rectus muscle. Palpation is easy when, owing
to closure of the cystic duct, the gall-bladder is distended with bile or
with inflammatory exudate, or enlarged by thickening of its walls or
by an accumulation of gallstones. A pear-shaped tumor is then felt
which, if not adherent to the border of the liver, is movable with it.
In simple stasis, hydrops vesicae fellese, and purulent inflammation
the tumor is tense and elastic ; in inflammatory or carcinomatous
thickening of the wall, dense and irregular. Calculi can often be recog-
nized by the form or hardness or by the sound made by rubbing them
together.
Aspiration. We are warranted in determining the nature of an
obscure enlargement of the liver or of the gall-bladder by aspiration.
In abscess, pus; in hydatid disease, the characteristic fluid, may be
withdrawn.
In a case of local enlargement the apex of the swelling should be
aspirated. If aspiration is performed near the upper border, the
needle should be thrust downward ; if near the lower border, upward.
The left lobe should be aspirated with care, in order that the stomach
be not pierced. (See Aspiration in Diagnosis.)
Auscultation. By auscultation we may detect a friction-sound in
perihepatitis ; a grating or rubbing when the gall-bladder contains cal-
culi if it is palpated ; a continuous murmur in tricuspid regurgitation.
Percussion. The Size and Shape of the Liver. (See Plate
XVI., Fig. 1.) Diminution in size can only be recognized by per-
cussion. The normal extent of hepatic dulness is diminished. This
1 Musser : Transactions Philadelphia Pathological Society, vol. x.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 869
is usually more marked in the anterior and lateral regions. The
diminution is due to simple or acute yellow atrophy of the liver or
cirrhosis. It must not be confounded with the apparent diminution
that takes place in emphysema, or that which occurs from distention
of the bowels with flatus, as in peritonitis. Absence of hepatic dulness
may occur when there is gas in the peritoneal cavity. When there is
considerable distention of the intestines by gas, the anterior and lateral
hepatic areas may be tympanitic.
Enlargement of the liver is determined by inspection, palpation, and
percussion. By percussion the size of the liver is accurately made out.
Any marked increase of hepatic dulness beyond the normal limits (see
p. 861) usually means increase in size of the liver. Both superficial
and deep percussion must be performed. Palpatory percussion is of
great advantage.
The upper border is determined by percussing from a point above
the liver-area toward the liver — anteriorly from the third interspace
downward, laterally from the fourth, and posteriorly from the angle of
the scapula. In health the upper border of the liver is found at the
fifth interspace ; in the axilla, at the sixth ; and in the back, at the
ninth interspace. Thence downward hepatic dulness should continue
to the margin of the ribs. It falls short of this position by at least
an inch in the aged, and in deep-chested persons it may not be more
than two inches in width in front. The width of the liver-clulness in
the right mid-clavicular line is about four inches, in the mid-axillary
line six inches, and in the mid-scapular line three inches.
Extent and direction of enlargement. The entire liver may be en-
larged and of normal shape, or its outline may be irregular ; again, the
enlargement may be limited to one lobe. Hence, the area of dulness
may be increased in all directions, or the increase may be above or
below the normal limit, if the normal shape is preserved. By percus-
sion it may be found that the enlargement is regular from increase in
size upward or downward, or increase in the area of dulness in both
directions. On the other hand, if the enlargement is irregular, the
liver-dulness may begin higher in the anterior region than in the axil-
lary region, or may extend beyond the margin of the ribs in a limited
area. When the enlargement is limited to the left lobe it is revealed
by increase in the dulness from the xiphoid cartilage downward as far
as the umbilicus. The entire middle region to the navel may be filled
up by the enlarged liver.
Uniform enlargement of the liver is due to congestion, hypertrophic cir-
rhosis, fatty degeneration, amyloid disease, leukaemia, cancer, and some-
times to hydatid disease and abscess. Enlargement of one lobe of the liver
is due to hydatid disease, to abscess, or to cancer, in nearly all cases.
Either the right or the left lobe may be the seat of such enlargement.
Enlargement in one direction is due also to the three conditions just
indicated. Although in abscess or hydatid disease enlargement down-
ward is the more common one, it may be directly upward, the lower
border of the liver occupying the normal position. When enlargement
of the liver extends upward it is due to a cyst, or an abscess in the
convex surface of the right lobe.
870 SPECIAL DIAGNOSIS.
Irregularity in the shape of the liver-diiliiess occurs in cancer, in
abscess, and hydatid disease. Notwithstanding the apparent irregu-
larity, enlargements of the liver conform to its usual outline, with but
moderate variations, and always occupy the normal site of the organ.
Diagnosis. Enlargement of the liver must be distinguished from
enlargement of organs in contiguity with the liver, and from structures
usually containing air, which have become solid or non-resonant. The
enlargement must, therefore, be distinguished from pleural effusion,
from disease of the lungs which causes dulness on percussion, or from
disease of the abdominal organs causing increased dulness near the
hepatic region. Hence, in renal tumors, in tumors of the large intes-
tine or stomach, in ovarian tumors, in tumors due to accumulation of
feces, the physical signs on percussion may simulate enlargement of
the liver.
Simulated Enlargement. It is well to bear in mind the conditions
which simulate enlargement of the liver. Of these we have :
1. Congenital malformation : the liver may be of abnormal shape,
on account of which the area of dulness will be increased in a particu-
lar direction. It may be quadrangular or rounded. The liver may
be found in the right pleural sac in congenital diaphragmatic hernia.
The increase of dulness upward will simulate enlargement of the liver.
Congenital malformations may be suspected in the absence of any
symptoms of hepatic disease, or of conditions which may cause other
forms of spurious enlargement. Moreover, the increased dulness will
have existed from early life.
2. In rhaehitis, on account of the malformation of the chest, the
position of the liver may be such that its area will be increased. For
the same reason the liver may be felt below the margin of the ribs.
3. Disease of the spinal column causes dislocation, on account of
which the liver may apparently be increased in size.
4. Enlargement of the liver must be distinguished from pleural
effusions. This is sometimes difficult. The symptoms of the pulmo-
nary affection must be considered. The general conditions which
cause hydrothorax must be borne in mind. The difficulty in distin-
guishing the two arises because the dulness of each is continuous. In
pleural effusion, however, there is uniform bulging of the affected side.
The liver is not movable, the chest-expansion is lessened. The upper
border of dulness of the fluid may be movable if the effusion is not
large, while the line of dulness is S-shapecl — that is, high behind and
high in front. If the effusion is large, the upper limit of dulness is
horizontal. The upper limit of dulness in the pleural effusion changes
its position in many instances. In enlargement of the liver the lower
ribs are often everted, but in pleural effusion a depression may be seen
between the lower margin of the ribs and the upper surface of the
liver, if the latter is dislocated by pressure of the fluid. Sometimes
enlargements of the liver give rise to secondary pleural effusion, so
that too often, after finding pleural effusion, the size of the liver is not
estimated.
5. Pericardial effusion and dilated heart are said to simulate enlarge-
ment of the liver. The history of the case, the origin and mode of
DISEASES OF LIVER, SPLEEN AND PANCREAS. 871
development of the symptoms, the physical signs of cardiac disease,
point to its trne nature.
6. Enlargement of the liver may be due apparently to subdiaphrag-
matic abscess. The history of the case is generally essential to a diag-
nosis. The accumulation between the liver and diaphragm causes the
latter to be pushed downward. It is very difficult to distinguish the
spurious from the false enlargement in these instances. Aspiration
may help in the diagnosis.
7. Abnormal Condition of the Abdominal Parietes. Increased ten-
sion or spasm of the recti muscles, giving rise to phantom tumors of
the abdomen, simulate enlargement of the liver. They occur in young
girls, and are associated with gastro-intestinal catarrh and symptoms
of hysteria. Anaesthesia must often be employed to disperse the
swelling.
8. Tight Lacing. This may displace the liver upward or downward,
according to the direction of the pressure. It may also, by exerting
lateral compression, bring more of the liver into contact with the ante-
rior abdominal wall. And finally, if the constriction has been by a
strap or tight cord, a portion of the liver may be more or less detached
and appear as a movable tumor.
9. Some enlargements of the abdominal contents cause spurious en-
largement of the liver. In the same way increased abdominal pressure
(ascites, tympanites, etc.) causes the liver to rise higher than normal.
a. The accumulation of feces in the colon. This causes continuance
of liver-dulness downward, on account of which it may be thought
that the patient has liver disease. A purgative must be given.
6. An ovarian cyst.
c. The presence of ascites. Exclusion of the latter is sometimes
difficult, because the ascites may be loculated and situated in the hepatic
region. It may give rise to symptoms of hepatic enlargement. Prob-
ably aspiration alone can establish the diagnosis. Ordinary ascites
should be easily distinguished by the physical signs and the result of
exploratory puncture.
d. Tumors of the omentum, chiefly tuberculous, may occupy such
relation to the liver as to increase the dulness downward. The history,
the occurrence of the omental tumor, with symptoms of tuberculosis,
may aid in determining the true condition.
e. In tumors of the kidney, which simulate enlarged liver, it is
found that the edge of the liver cannot well be felt, but Murchison
thinks the fingers can usually be inserted between the ribs and the
upper part of the renal tumor. The renal tumor, however, is not
fixed. It is rounded on every side ; it has the shape of a kidney.
It may be associated with changes in the urine.
/. Enlargements of the liver must be distinguished from pancreatic
cyst, or effusion in the lesser peritoneal cavity. This can usually be
accomplished with ease, except in hydatid disease of the left lobe hear
the suspensory ligament. In effusion in the lesser peritoneal cavity
the tumor occupies the left upper quadrant, and may extend as low as
the transverse umbilical line. It causes dislocation of the heart, so
that the apex is as high as the third interspace, and beyond the mid-
872 SPECIAL DIAGNOSIS.
clavicular line. It is accompanied by an increase in the dulness pos-
teriorly, so that the upper limit may extend to the angle of the left
scapula. Puncture may furnish the necessary information.
The presence or absence of pain may sometimes furnish a clue to
the nature of the enlargement of the liver. Murchison considers this
a reliable distinction. Painless enlargements of the liver are due to
passive congestion, to hydatid disease, to fatty and amyloid disease of
the liver. Painful enlargements of the liver are seen in abscess, cancer,
and syphilitic disease, with perihepatitis.
In children the lower border of the liver is normally lower than in
adults, because the liver is itself proportionately larger. For the same
reason the upper border is at a higher level.
Enlargement of the Liver. Enlargement of the liver occurs
in the congestions ; the acute inflammations, except acute yellow atrophy ;
the chronic inflammations, except cirrhosis ; the degenerations, the
morbid growths, and in hydatid disease. The physical signs have been
considered seriatim in the pages immediately preceding. It must be
remembered that the disease may occur without great changes in the
size of the liver. The congestions have been considered in the previous
pages.
The remaining diseases of the liver will be considered in accordance
with their pathological classification. After the congestions, we have
the inflammations, then the morbid growths, then the degenerations,
and, finally, hydatid disease.
Abscess of the Liver.
Two forms are seen : tropical abscess, so-called, in which one or two
abscesses are found ; and multiple abscesses, found throughout the
liver-structure. The single or solitary abscess usually occurs in the
course of dysentery, and, in all probability, in the amoebic form only.
A single abscess may also be due to traumatism, particularly in chil-
dren. Multiple abscesses occur secondarily to inflammation somewhere
in the portal area. Inflammation and abscess about the rectum, in-
flammation of the appendix, ulceration anywhere in the gastrointesti-
nal tract may be followed by multiple hepatic abscesses. The abscesses,
however, do not occur directly by means of emboli, as in the case of
amoebic abscess, but after inflammation of the portal vein or suppura-
tive pylephlebitis. Multiple abscesses of the liver also follow obstruc-
tion and infectious inflammation of the biliary passages (suppurative
cholangitis).
Tropical abscess or amoebic abscess varies in its clinical course. In
a typical case the clinical picture is that of the general symptoms of
suppuration setting in in the course of, or soon after, an exacerbation
of amoebic dysentery, with local symptoms referred to the liver.
Symptoms. The general symptoms are those of intermittent fever,
paroxysms of which may occur daily or only every second day, attended
by chill, fever, and sweat. The fever may be remittent or continuous.
The complexion in tropical abscess of the liver is peculiar, as all
writers upon tropical disease agree. The skin is sallow, 1 he complex-
PLATE XL.
FIG. 1.
Oedema
Tender-
ness
w
V5
A\
Abscess of the Liver.
FIG. 2.
Hypertrophic Cirrhosis of the Liver with Enlargement
of the Spleen.
DISEASES OF LIVER, SPLEEN AND PANCREAS.
873
ion muddy, the face pale. Through this a slightly icteroid tint may
be seen, and the conjunctivae are bile-tinged. Distinct jaundice is rare.
The local symptoms. Pain in the region of the liver ; this may be
referred to the region of the right or left lobe. It may be seated hi
the fifth or sixth interspaces anteriorly, or behind at the ninth and
tenth ribs. There may be pain in the right shoulder. The pain may
be paroxysmal, or it may be intense and persistent.
The patient complains of weight and fulness in the region of the
liver ; the enlargement causes some dyspnoea, and may cause cough
and some vomiting.
Fig. 201.
Intermittent fever in abscess of the liver.
Physical Examination. (Plate XL., Fig. 1.) The liver is enlarged.
The enlargement may be uniform ; if the abscess is central, the entire
organ takes part in the swelling ; on the other hand, it may be an
enlargement upward in the anterior, the axillary, or the posterior region.
If the convex surface of the right lobe of the liver is affected, the en-
largement is usually upward. If the lower portion of the right lobe is
affected, enlargement extends downward, and the lobe of the liver can
readily be detected on palpation. The mass may extend outward from
the liver-edge. At first it is hard ; ultimately it softens and may fluctu-
ate. If the abscess is limited to the left lobe of the liver, and is situ-
ated about the suspensory ligament, the enlargement may be seen
below the xiphoid cartilage. It may extend to the umbilicus and
project forward. Sometimes it may be so large as to cause eversion of
the ribs of each side, and render the entire epigastrium unusually
874 SPECIAL DIAGNOSIS.
prominent. The surface may become reddened. Over the tumor
there is tenderness on palpation, and there may be, as in other situa-
tions, fluctuation. GEdema of the surface is frequently seen.
The irregular enlargement above mentioned is made out by percus-
sion. The enlargement may be difficult to ascertain, on account of
secondary pleural effusion, or secondary pleural inflammation, with the
development of a hepato-pulmonary fistula, causing dulness posteriorly.
If the case has been seen from the first, a friction-sound may be heard,
followed by the physical signs of effusion.
The appetite is lost, and nausea at the sight of food is pronounced.
The condition of the bowels may vary with the state of the intestinal
tract at the time of the hepatic complication. The dysenteric symp-
toms may subside entirely or they may continue. Often there is only
constipation, with the passage of mucus and hardened feces. In an
obscure case the study of the stools should be made. The detection
of amoebae in the mucus or in the feces may point to the true conclusion.
Atypical eases are characterized by the absence of general symptoms,
or the absence of local signs. Fever may be absent entirely, exhaus-
tion alone being present, which could probably be ascribed to the pre-
vious dysentery. Pronounced anaemia due to the dysentery may be
associated, and even be the most marked symptom, as well as inflam-
mation of the joints, or neuritis. In a case under my care the only
symptom for a long time, with the exception of anaemia and loss of
appetite, was severe pain in the sixth interspace. In other instances
there are no liver-symptoms whatsoever. General symptoms of infec-
tion, or an irregular, or even a continued fever, the cause of which
cannot be ascertained, may alone be present. In one of my cases
there was moderate continued fever, with loss of appetite and dyspeptic
symptoms. There was no diarrhoea. ]STo cause could be given for
the fever, although it was noted that there was slight enlargement of
the liver. The patient slipped out of the ward and went down to the
yard to smoke ; on his return he was seized with an intestinal hemor-
rhage which could not be checked and which resulted fatally. At the
autopsy a large abscess of the liver was found, and there was ulceration
of the rectum from which the intestinal hemorrhage took place.
The diagnosis is usually not difficult in the typical cases. Under
all circumstances attention must be paid to the facts bearing upon the
etiology and the association of general and local symptoms. If the
general symptoms of suppuration are present, malarial abscess may be
mistaken for an intermittent fever. The result of an examination of
the blood and of treatment by quinine would establish a diagnosis of
malarial fever. It is difficult sometimes to determine whether the
abscess is in the abdominal wall or in the liver proper, or whether it
is situated beneath the diaphragm. If the liver is movable with respi-
ration, the two former conditions may be excluded. An abscess in the
abdominal wall is not influenced by respiration, and in subdiaphrag-
matic abscess the movement is impaired. Suppuration of a hydatid cyst
cannot be distinguished unless it has been known beforehand that a
simple hydatid was present in the liver. Under such circumstances,
if suppuration occurs, it is likely to be confined to the cyst. Abscess
DISEASES OF LIVER, SPLEEN AND PANCREAS. 875
of the liver must be distinguished from gallstones, attended by inter-
mitting fever without suppuration. While the distinction is difficult
in many cases, yet the history of the case, the association of jaundice
which deepens after each paroxysm, and the good general nutrition of
the patient point to gallstones. Abscess of the liver is of shorter dura-
tion than cholelithiasis, and its primary cause can usually be ascer-
tained by examination of the rectum or the discovery of suppuration
in other parts of the body.
Exploratory puncture must be employed in many cases, and it can
usually be done with safety. Puncture must be made over the region
in which the enlargement is greatest, or at which the swelling is most
prominent. In abscess secondary to dysentery a brownish-colored
pus will be withdrawn, resembling anchovy sauce. It may be of a
peculiar odor, and, on examination, amoeba? common to this form of
dysentery may be found. If there is no point of election, the needle
may be introduced in the lowest interspace in the anterior axillary, or
the seventh interspace in the mid-axillary line. A fairly large-sized
aspirator should be used. Suppuration may be present, and yet not
be reached by aspiration.
Suppurative Pylephlebitis. Abscess of the liver may be due
to pycemia. It may be a part of general pysemia, or of portal pyaemia.
Parasites and foreign bodies, as well as gallstones, may excite an ab-
scess. The echinococcus cyst may suppurate, or round-worms may
penetrate to the liver and cause suppuration.
The symptoms of suppurative pylephlebitis and of pywmic abscess are
general and local. Jaundice is more common than in solitary abscess,
and there are greater pain and tenderness over the liver, which is uni-
formly enlarged and tender. With the enlargement of the liver and
jaundice we have the symptoms of pypemia. They are not peculiar.
Sometimes the fever is distinctly intermitting, or it may be irregular
and septic in character.
The symptoms of solitary abscess of the liver, as has been previously
stated, may be obscure, and attention be called to the liver only when
symptoms arise due to a rupture into the neighboring organs. If per-
foration takes place into the peritoneum, it is not likely that the cause
can be established during life. The perforation frequently extends
through the diaphragm to the pleura, and then to the lung. An em-
pyema may be set up, the true source of which may not be ascertained
unless the pus is examined. The physical signs are those of empyema
— dulness or diminished resonance, absence of fremitus and vocal reso-
nance, diminished breath-sounds, and impaired movement, together
with symptoms of cough and dyspnoea. When the lung is infected
the physical signs may resemble those of consolidation. We find dul-
ness, bronchial breathing, and increased tactile fremitus. A harassing,
convulsive cough occurs, and, sooner or later, expectoration of a red-
dish-brown, brickdust-colored material which resembles anchovy sauce.
This characteristic expectoration is decisive. It contains amoebre, and,
in addition to blood-pigment and corpuscles, orange-red crystals of
hsematoidin, cholesterin-plates, and leucin and ty rosin. When the
abscess perforates into the stomach or bowel the discharge from either
876 SPECIAL DIAGNOSIS.
cavity may be of the above-mentioned nature. Perforation into the
pericardium is usually followed by immediate death.
Cirrhosis of the Liver.
A diffuse interstitial inflammation of the liver, frequently with atro-
phy of the organ, is caused, in the large majority of cases, by irritants
which enter the portal circulation through the stomach. Of the irri-
tants alcohol is the most common, and particularly the stronger liquors,
as gin and whiskey. Other irritants, as spices used to excess, may
likewise cause the diffuse inflammation. Cirrhosis of the liver may,
however, be a sequel to the infectious diseases, notably scarlatina, and
may be incited by malaria. The infectious forms of cirrhosis usually
lead to atrophy of the liver.
Another form is due to obstruction of the bile-ducts, with secondary
overgrowth of the connective tissue. It is known as hypertrophic or
biliary cirrhosis. In addition, cirrhosis of the liver may arise in the
course of syphilis ; the histological characteristics are different from
those of true cirrhosis. A secondary cirrhosis of the liver arises in
the course of passive congestion of that organ, producing the so-called
nutmeg-liver.
Cirrhosis of the liver of the atrophic form, due to alcohol, presents
various clinical features. In the first place, it may exist without
causing any symptoms whatever during life. It may be found after
death from other causes, or it may not present symptoms until an acci-
dent occurs in the course of the disease, as hemorrhage from some por-
tion of the collateral circulation. In both cases the symptoms are
absent because the collateral circulation is complete. If this is incom-
plete, however, grave symptoms, local and general, ensue.
Before detailing them it may be well to state that the occurrence of
one symptom, which we have termed accidental, may lead to the infer-
ence that cirrhosis of the liver is present, particularly if the patient
has been an alcoholic. This symptom is hemorrhage. It may be of
the stomach, causing death at once or after repeated hemorrhages ; it
may also take place from the intestine.
The Symptoms of Cirrhosis. The symptoms are general, due to in-
terference with the nutrition of the patient ; and local, their extent
depending upon the degree of obstruction to the portal circulation.
General symptoms rarely occur unless the local symptoms are present,
as the latter cause malnutrition and mal-assimilation from interference
with the gastro-intestinal digestion.
The symptoms have been divided into those of the first stage, or
stage of enlargement, and those of the second stage, or contraction.
Tiie so-called first stage is not always observed.
During the first stage the symptoms are those of gastritis, with en-
largement of the liver. The gastric symptoms are : morning retching
or vomiting, with discharge of mucus, associated with other symptoms
of gastric catarrh, as loss of appetite, nausea, tenderness in the epigas-
trium, eructations, and constipation, with loss of flesh and strength.
The liver is enlarged, but the outline is regular.
PLATE XLI.
,<^
Cirrhosis of the Liver with Ascites.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 877
During the second stage more severe symptoms arise, due to obstruc-
tion of the portal capillaries. The abdomen becomes distended and
a sensation of weight and pressure is complained of. On examination
ascites is detected. This may be enormous, causing monstrous disten-
tion, with pouting of the umbilicus. The spleen is found to be en-
larged, extending over twice or three times the normal area of per-
cussion. If ascites does not interfere, the edge of the spleen can be
readily made out The portal obstruction causes secondary gastro-
intestinal catarrh, if it was not already present, on account of the alco-
holism. Although constipation is usually present, there may be per-
sistent diarrhcea, usually lienteric and occurring in the morning only.
Hemorrhages may take place from the gastro-intestinal tract at any
time, either from the stomach or the intestine. Not infrequently they
occur from the oesophagus, due to varicosity of the veins at the junc-
tion of the oesophagus and the cardiac end of the stomach. Hemor-
rhoids are always present and may bleed at each stool. Jaundice is
not the rule, and, if present, is usually light and due to the duodenal
catarrh. The skin has a yellowish tinge or only a grayish earthen
color.
Physical Examination. (Plate XL., Fig. 2, and Plate XLI.) This
may be rendered difficult before paracentesis is performed by the exten-
sive ascites. The enlarged liver of the first stage will be found to have
undergone contraction, although diminution in the area of dulness is
not by any means as absolutely confirmative of contraction as the oppo-
site condition is of hypertrophy. Percussion should be performed seve-
ral times, because the distended intestinal coils may affect the results.
AVith the distention of the abdomen enlargement of the superficial
veins is also observed. This may be very pronounced, particularlv
about the umbilicus. The enlarged, swollen mass of veins in this situ-
ation has been called, from its appearance, the caput Medusce.
The general symptoms of cirrhosis, and particularly the symptoms
of the later stages, are striking and diagnostic. The nutrition is much
impaired. The patient, who, in the large majority of cases, had been
corpulent, becomes emaciated. The skin changes in color and becomes
of an earthy-gray or dirty sallow hue. The capillary venules of the
face are dilated ; the distended capillaries on the nose are distinct.
Later, ecchymoses may occur in the skin, and hemorrhages take place
from the mucous membrane and into the retina. Debility ensues ;
oedema of the ankles is almost sure to occur, and sometimes general
anasarca may take place. It is extremely rare to have fever unless
complications occur. The pulse is small and becomes more rapid than
normal ; the heart-sounds grow weaker. The skin may be the seat of
eruptions, and chronic skin diseases of various kinds develop.
The urine throughout the disease presents no characteristics ; as
ascites develops, it becomes scanty and dark, and loaded with urates
and uric acid. In rare instances it may contain sugar, and, if the uric
acid is in excess, albumin.
Collateral Circulation. The collateral circulation that develops in
order that the portal blood may reach the right heart takes place in
various ways. First, communication may be formed between the veins
878 SPECIAL DIAGNOSIS.
of the mesentery and those of the posterior abdominal walls ; second
between the coronary veins of the stomach and the veins of Glisson's
capsule and the phrenic veins ; third, between the hemorrhoidal and
the inferior mesenteric veins ; fourth, between enlarged veins occupy-
ing the position of the obliterated umbilical vein in the ligamentum
teres, and the epigastric and mammary vein.
In the study of a case of cirrhosis of the liver a judgment as to its
nature may be, in a measure, confirmed by the presence of other phe-
nomena due to the same cause. Very frequently we have, at the same
time, cirrhosis of the kidneys and sclerosis of the arteries, with second-
ary atheroma, both of which have led to hypertrophy of the heart.
Striimpell refers to the association of cirrhosis and chronic tubercular
peritonitis. He thinks the former is the primary lesion which predis-
poses to the development of the latter. The course of the disease is
prolonged.
The duration cannot be determined accurately, as the onset is usually
insidious. After the ascites appears the duration may vary from six
to eighteen months. Of course, this depends largely upon the com-
pleteness of the compensatory circulation. Death usually occurs from
intercurrent disease or progressive exhaustion. In not a few cases
cerebral symptoms occur. In addition to the cirrhotic cachexia, the
sudden occurrence of coma and convulsions, preceded by delirium,
may ensue ; the cause of this is not fully known. It must be borne
in mind that the occurrence of these symptoms in an alcoholic subject
may be due to a cirrhosis, the presence of which had not been sus-
pected during life.
Diagnosis. The diagnosis is usually not difficult if the complete
picture of the case is presented. It cannot be established positively
without definite knowledge of the cause. If the patient comes under
observation after ascites has developed, the diagnosis is more difficult.
It must, in the majority of cases, be based upon exclusion of heart,
lung, and kidney disease. A history of alcoholism and the presence
of other symptoms of liver disease point to the hepatic origin of ascites.
Ascites may be due to other causes within the abdomen, notably chronic
peritonitis, exclusion of which is sometimes difficult. The general ten-
derness, the less marked distention of the abdomen, and the absence
of enlargement of the spleen point to peritonitis. The fatty cirrhotic
liver may present symptoms similar to those of the atrophic form,
except that it is enlarged.
Hypertrophic cirrhosis, or so-called biliary cirrhosis, presents a
somewhat different picture. In the first place, the cause is different.
There is a history of gallstones, or obstruction of the duct from other
causes. The liver is uniformly enlarged, and the surface is smooth
and strikingly indurated. There are weakness and loss of appetite.
Jaundice ensues very early, or may be the first symptom. It increases
and persists throughout the course of the disease. Ascites is very slight
or absent altogether. The enlargement and jaundice may continue for
months or even years without the development of grave symptoms.
Fever may, however, set in at any time, being in all probability due
to the biliary obstruction. It is continuous ; the temperature rises
DISEASES OF LIVER, SPLEEN AND PANCREAS. 879
to from 102° to 104° ; the tongue becomes dry and brown, the pulse
rapid. All the symptoms of febrile jaundice ensue. The patient may
be seized with convulsions in the course of the disease, followed by
coma and death. Most authorities state that the enlargement persists
throughout the course of the disease, but some observers say that after
a long period of enlargement, with jaundice, contraction of the liver
takes place, with symptoms of portal obstruction. Then the spleen
may become enlarged and ascites take place, while the symptoms of
digestive disturbances become more prominent. There may be ner-
vous symptoms, due to acute, diffuse necrosis (acute yellow atrophy),
setting in in the course of the disease.
The diagnosis is often difficult. Gradual and persistent jaundice
without cause, continuing for a long time, associated with persistent
enlargement of the liver without symptoms of portal obstruction in
the non-alcoholic subject, points pretty certainly to hypertrophic cir-
rhosis of the liver.
Syphilitic Disease of the Liver.
Syphilitic disease of the liver may result in cirrhosis, or in the
development of gummata. Syphilitic cirrhosis presents the same symp-
toms as the alcoholic form. The history, the marked irregularity on
the surface of the liver, and the existence of syphilis elsewhere may
lead to a diagnosis of the true condition.
In congenital syphilitic disease of the liver the inflammation is
diffuse ; the liver is enlarged and hard ; the surface is smooth ; there
are usually syphilitic lesions in other organs ; the patient presents
syphilitic eruptions, and has the well-known wizened appearance that
belongs to this affection.
Syphilitic gummata in the liver may exist without presenting any
symptoms whatsoever, or they may reveal their presence by pain and a
localized swelling and discomfort, which call the patient's attention to
the region, particularly if his general health is reduced at the same
time. Tumors are situated in the left lobe, in the median line, or
along the margin of the ribs. The pain is usually localized in this
region, but may extend more or less over the entire liver, particularly
if there is general perihepatitis along with other evidences of syphilis ;
the latter are not always present, however. If the temperature is
taken frequently, a moderate febrile range will be observed. It may
not rise above 100§°, but in the absence of other causes it is a valu-
able diagnostic symptom. 1 In other instances the gummata may grow
in such situation as to interfere with the portal circulation, or press
upon the gall-ducts. The latter is very rare. If the gummata are
felt, they appear as enlarged bosses which give the sensation of flat-
tened hemispheres. Sometimes several separate elevations can be
made out on the surface of the enlarged organ. To determine the
exact nature of the lesion is often very difficult. The symptoms may
conclusively point to hepatic disease. Knowledge of the presence of
1 "The Diagnostic Importance of Fever in Late Syphilis." Musser: University
Medical Magazine, October, 1892.
880 SPECIAL DIAGNOSIS.
syphilis aids in the diagnosis. If without a syphilitic history there
are scars in the throat, nodes on the bones, or other signs of syphilis,
the diagnosis will be tolerably certain. Severe pain is more promi-
nent in svphilis than in cirrhosis, and the nodules of syphilis are very
different from the granular surface of cirrhosis.
The Fatty Liver.
The symptoms of fatty liver are not marked. The physical sign is
a uniform enlargement extending in all directions. On palpation the
edges can be felt ; they are rounded and smooth. They are soft at
first, but later become indurated. Fatty liver may be followed by
cirrhosis after a period of alcoholism. The general symptoms are
those of the primary disease. Fatty liver occurs in gouty subjects,
but is notably present in wasting diseases, in tuberculosis, in chronic
hip-joint disease, and in amyloid disease of the liver.
Fatty liver sometimes follows the congestion of the liver which is
present in the course of organic heart disease. It is not a true fatty
liver, but a fatty cirrhosis. There is increased fatty degeneration with
an overgrowth of connective tissue. This form is associated with heart
and kidney disease. On palpation the edges of the liver are indurated.
The liver may undergo diminution in size later, and the symptoms of
cirrhosis ensue.
Amyloid Disease of the Liver.
Enlargement of the liver without pain is often due to amyloid dis-
ease. Similar disease is found in other organs, and there is present,
to point to the nature of the enlargement, syphilis, bone disease, pro-
longed suppuration, or tuberculosis. In amyloid disease the pallor of
the patient is great ; the face may be swollen, and the ankles slightly
oedematous. The spleen is enlarged, the urine albuminous and abun-
dant, but of moderate specific gravity. A history of syphilis is an
important point in establishing the diagnosis. Fatty liver can readily
be distinguished from amyloid disease by palpation. In the latter the
surface is smooth, but very much indurated.
Cancer of the Liver.
The etiological factors upon which the diagnosis of cancer is based
are : the age of the patient — most frequently between the fortieth and
sixtieth year ; the female sex, in a measure ; and heredity. The dis-
ease is nearly always secondary to cancer in some other situation ;
consequently, in cases in which symptoms point to cancer of the liver,
search must be made for the primary lesion elsewhere. The most fre-
quent seat is the rectum, the uterus, the stomach, the remainder of the
gastro-intestinal tract, the eye. The eye has been removed for obscure
disease, and symptoms of carcinoma of the liver have subsequently de-
veloped. The nature of the hepatic symptoms was obscure during life,
but at the post-mortem examination melanotic sarcoma was found ;
the primary lesion undoubtedly had been in the eye. Further etio-
logical influences that may bear upon the diagnosis are : (1) The occur-
PLATE XLII.
\ \
Carcinoma of the Gall Bladder with Involvement of the Liver.
-"-,
Enlargement of the Gall Bladder
DISEASES OF LIVER, SPLEEN AND PANCREAS. 881
rence of gallstones, which act as the exciting cause in the development
of primary cancer of the ducts, thence spreading to the liver ; (2) the
occurrence of trauma.
The symptoms of cancer of the liver may be due to (1) increase in
the size of the liver ; (2) to pressure of the growths upon the ducts or
terminal portal vessels ; and (3) to the general effects of carcinoma
upon the system — the cachexia.
Physical Signs. (Plate XXXVIII., Fig. 2, Plate XL., Fig. 2, and
Plate XLIL, Fig. 1.) The liver is enlarged and its surface irregular.
The organ can be made out, by palpation, extending below the margin
of the ribs. The edges are irregular, and, on the surface, bosses can
be distinctly felt. In rare cases one or two masses only may be pres-
ent, growing out of the substance of the left lobe of the liver, causing
a large tumor below the sternum. The nodules are usually hard, but
sometimes may be soft and even fluctuate. After emaciation becomes
marked the nodules can be seen as well as felt near the surface of the
skin, and their number distinctly made out. The abdomen is dis-
tended.
The liver is movable with inspiration. Progressive enlargement can
be noted while under observation. The enlargement can be well de-
fined by percussion, and, while the surface is irregular, the general
shape of the dulness corresponds to that of the liver. The increased
size and inflammation of the capsule cause a sensation of weight in the
hepatic region and pain which may be intermitting in character. The
nodules may be tender on palpation. The superficial veins are enlarged.
In not every instance do we find enlargement. In some cases the
cancer is associated with cirrhosis of the liver, or may itself be of a
nodular type, and in the course of the disease undergo shrinkage. The
liver is then normal or diminished in size, as indicated by percussion.
The symptoms that attend cancer are : 1. Jaundice, which is not
very deep unless the common duct is affected. 2. Ascites, which is
always present in the atrophic forms, but may be absent when the
liver is enlarged. 3. The general symptoms are those of rapid emacia-
tion, prostration, and, in some instances, moderate fever. Fever
attends the rapidly-growing cases. It is usually continuous, but may
be intermittent, especially if there is suppuration or suppurative in-
flammation of the ducts. It is a well-known fact that gallstones are
of common occurrence in patients suffering from cancer in any location
whatever. The symptoms of biliary calculus or of obstruction may
attend those of secondary cancer of the liver, and the stone has an
etiological significance.
In many instances secondary cancer of the liver may be present
without symptoms to attract attention to this organ during life. If
cancer in certain other regions has continued for the usual period of
time, it is almost certain that at the autopsy cancer of the liver will be
found to be present.
Diagnosis. The diagnosis of cancer of the liver is not difficult when
the changes in the liver can be made out on palpation and percussion.
In rare instances, in which the liver is smooth, it may be mistaken for
fatty or amyloid liver. A definite cause can usually be assigned for
56
882 SPECIAL DIAGNOSIS.
the latter, while the occurrence of jaundice, the rapid increase in size
of the liver, and the general symptoms of the cancerous cachexia indi-
cate cancer of the liver. The syphilitic liver with irregular gummata
may cause serious doubt ; the history of the case and other signs of
syphilis aid in the diagnosis. Locally the condition may exactly sim-
ulate carcinoma. The jaundice, however, is not so frequent in occur-
rence, or so deep in syphilitic gummata ; the cachexia does not ensue,
but the therapeutic test may be essential in order to make a diagnosis.
In hypertrophic cirrhosis of the liver the jaundice is deep and the
liver enlarged ; but there is little wasting or anaemia. The surface of
the liver is smooth ; there are certainly no bosses, and the organ is
painless. Ascites is more common in cirrhosis ; the patient is usually
affected earlier in life than in cancer.
In a large growing cancer one or two of the nodules may suppurate
and simulate abscess of the liver. Abscess follows a definite cause
usually, and occurs in middle life ; cancer is secondary to disease in
other organs and occurs usually in late life. The results of aspiration
differ in each. Moreover, a history of dysentery, the occurrence of
pain, of profound anaemia, of pronounced hectic fever with irregular
enlargement of the liver, but without jaundice or cachexia, point to
abscess.
Cancer of the liver may be simulated by cancer of organs in close
proximity to the liver, as the pancreas, the pyloric end of the stomach,
or the colon. In addition to the usual symptoms of pyloric cancer, it
will be found that jaundice occurs late. Cancer of the pyloric end is
not movable with respiration unless it becomes adherent to the liver.
Cancer of the omentum and colon are not modified by respiration. The
percussion-note over them is different ; they frequently extend beyond
the liver-confines and are associated with symptoms of obstruction of
the bowels. Fecal accumulation in the transverse colon must not be
mistaken for cancer of the liver. The large masses adjacent to the
liver may closely simulate cancerous nodules. In doubtful cases the
colon should be emptied. Cancer of the liver and hydatid disease
must not be confounded. The tumor in hydatid disease is usually
single ; it is large, and may fluctuate or yield the hydatid fremitus. It
causes irregular enlargement of the liver, when the tumor presents
in the epigastrium or along the margin of the ribs. It is painless.
Aspiration yields the characteristic hydatid fluid.
Cancer of the bile-ducts cannot always be distinguished from cancer
of the liver. Jaundice early in the course of the disease, in a person
who has had gallstones, followed by enlargement of the liver and gall-
bladder, in the absence of primary disease elsewhere, suggests cancer
of the gall-bladder or ducts. This is more or less confirmed if the
smooth and painless gall-bladder becomes hard, irregular, and tender
on pressure. Cancer of the pancreas also presents difficulties ; a tumor
in the mid-costal region, however, with vomiting and the early devel-
opment of jaundice, before the liver has become enlarged or nodular,
and associated with other characteristic symptoms, such as intestinal
dyspepsia and fatty stools, points to the pancreas as the primary seat
of the disease.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 883
Hydatid Disease of the Liver.
Hydatid disease is comparatively rare in this country, but, in my
own experience at least, it is undoubtedly increasing in frequency.
Without any increase in the opportunities for observation, I have
seen seven cases within the last two years, compared to the same
number during the five previous years. The disease occurs in people
who live Avith dogs. It may occur at any age, but is most common
in adult life. It is very rare before the fifth year.
The symptoms are local, depending upon the size of the tumor.
Small cysts may be present without any disturbance. Large and
growing cysts cause signs of tumor, with great increase in the size of
the liver. The physical signs depend upon the situation of the tumor.
It may be found in the median line above the umbilicus, causing a
distinct prominence, tense and firm, which sometimes yields fluctua-
tion. Quite often the tumor grows at the suspensory ligament, pushing
the diaphragm upward, dislocating the heart, and causing an increased
area of dulness in the left upper quadrant. In this position it may
simulate a pancreatic cyst or effusion in the lesser peritoneal cavity.
If the tumor is in the right lobe, the enlargement of the liver may be
upward or downward. The upper border of liver-dulness may begin
two or three interspaces higher than normal posteriorly or in the axil-
lary region. If the cysts are superficial, when palpated Avith the fingers
of the left hand and percussed with the right, a vibration or trembling
movement is felt, Avhich may continue for a certain time. It is known
as the hydatid fremitus. It is not always present. The enlargement
is painless. Local sensations of Aveight and dragging may be complained
of. If suppuration sets in, there may be a good deal of pain.
The general symptoms are negative ; the nutrition does not suffer
unless the enlarged mass interferes, by its pressure, Avith physiological
acts of digestion and assimilation. If suppuration sets in, the general
symptoms of abscess of the liver arise. Jaundice is more common than
in tropical abscess. The abscess may perforate into one of the adjacent
hollow \ r iscera, or into the pleura and bronchi. It may perforate exter-
nally. It may perforate into the pericardium or vena cava, and cause
death. If perforation takes place in the biliary passages, obstructiA^e
jaundice arises, Avith secondary suppurative cholangitis. When the
cysts rupture, or if they are aspirated, an eruption of urticaria may
break out. This is not of diagnostic significance, except that it may
point to rupture of the cyst.
Diagnosis. The diagnosis is not difficult. The occurrence of irregu-
lar, painless enlargement of the liver Avithout general symptoms is sig-
nificant. If fluctuation is detected, or the fremitus, a more positiA^e
conclusion can be reached. When suppuration takes place the symptoms
are like those of abscess of the liA^er. Hydatid disease is to be distin-
guished from syphilitic hepatitis, in Avhich the enlargement is hard and
irregular, and does not fluctuate. Sometimes the symptoms resemble
cancer, but the age of the patient, the presence of jaundice, and the
extreme emaciation and cachexia indicate that affection rather than
hydatid disease. Enlargement of the gall-bladder containing a mucoid
884
SPECIAL DIAGNOSIS.
fluid, in which fluctuation can be detected, may simulate hydatid dis-
ease. The enlargement, however, may be preceded by conditions -which
cause obstruction of the cystic duct. The gall-bladder is movable. In
some instances there may be resonance between it and the liver. It is
usually of a pvriform or oblong shape. In hydronephrosis the symptoms
Human echinococci. (From Finlayson, after Dayatne.)
A, a group of echinococci, still adhering to the germinal membrane by their pedicles.
B, an echinococcus with head invaginated in the body. X 107.
C, the same compressed, showing the suckers and hooks of the retracted head.
D, echinococcus with head protruded.
E, crown of hooks, showing the two circles. X 350.
X40.
of a localized cyst are present. It does not move with respiration, as in
hydatid disease ; it is attended by symptoms of renal disease ; explora-
tory puncture is sometimes necessary to establish a diagnosis. A hydatid
cyst is frequently confounded with pleural effusion of the right side, for
there may be all the physical signs of effusion at the right base. The
Fig. 203.
Hooks from tenia echinococcus. X 350.
distinction can be made by the character of the line of dulness. In
hydatid cyst, as Frerichs points out, it is a curved line, the greatest
height of which is found in the scapular region. It is not difficult
usually to distinguish hydatid cyst from other forms of painless enlarge-
ment. In fatty and amyloid disease the enlargement is uniform. Both
DISEASES OF LIVER, SPLEEN AND PANCREAS. 885
occur more commonly in individuals of previous ill health, whereas
hydatid disease occurs in healthy individuals.
An absolute diagnosis of hydatid disease is based upon the results of
exploratory puncture. When this is made over a tumor, or the centre
of dulness, if it is due to hydatid disease, a clear fluid, slightly opales-
cent, is withdrawn. The fluid is of a specific gravity of 1005 to 1009 ;
it is of neutral reaction, does not contain albumin, but contains chlorides
and sometimes traces of sugar. Hooklets may be found in the clear
fluid.
Diseases of the Gall-ducts.
Pain and jaundice are symptoms of disease of the biliary passages.
Pain may be constant or paroxysmal. If it occurs in mild degree, with
tenderness and with jaundice, it is probably due to catarrh of the biliary
passages. If severe, and in paroxysms with or without jaundice, it is
due to gallstones.
Inflammation of the Bile -ducts. This is due to inflammation and
obstruction of the terminal portions of the common bile-duct. But few
words are necessary, as it has been referred to frequently in speaking
of jaundice. The symptoms are those of moderate jaundice, occurring
coincidently with or following in a few days upon an attack of acute
gastritis. The disease may occur in epidemic form.
Gallstones. Gallstones form in the biliary passages, and may remain
there without creating symptoms, or they may, by the efforts to pass
them, cause attacks of pain called hepatic or biliary colic, after which
the stone may pass into the intestinal tract without further hepatic
symptoms. It may become impacted in the biliary canal and set up
catarrhal or suppurative inflammation, which in turn may be followed
by stricture. Gallstones usually form or at least show signs of their
presence after the age of forty years, most frequently in women and
in people who have led a sedentary life and partaken of rich and indi-
gestible food. Individuals in different generations of the same family
may be predisposed to them.
Hepatic Colic. The passage of gallstones may be attended by a
slight amount of pain only, which, unless in the right upper quadrant,
would pass for an attack of simple indigestion. In the large majority
of cases the pain is severe. The attack may be preceded by biliousness
or indigestion for twenty -four hours, and moderate pains or a sense of
weight and fulness in the liver. It frequently follows the taking of
food. Ringing in the ears, disturbance of vision, or undue flushings
are said to precede it in some instances.
The attack may be sudden. The patient is seized with pain along
the margin of the ribs of the right side, or there may be pain above
the ribs, over the liver, and in the right shoulder at the same time.
From the hepatic region it extends to the median line. Very fre-
quently the pain begins and continues in the epigastrium. It may be
most pronounced in this locality from the first. The pain is intense
and paroxysmal. The patient is doubled up in agony. It causes more
or less collapse. The pulse increases. Vomiting usually occurs at the
same time, consisting first of the contents of the stomach, and then of a
SPECIAL DIAGNOSIS.
yellowish, bile-stained fluid. The vomiting may be extreme, so that
the patient is tormented by the pain, the retching, and vomiting. The
attack sometimes disappears as suddenly as it occurred, or wears off
gradually. When most severe, symptoms of shock follow. The bowels
are not disturbed during the attack. The urine may become suppressed ;
it is usually high-colored, and after the attack may contain bile.
At the time of the attack there is considerable tenderness below the
xiphoid cartilage and in the hepatic region. The tenderness is more
marked on deep pressure in the gall-bladder region and to the right of
the mid-clavicular line, at the margin of the ribs. The epigastrium
may be slightly swollen. The tenderness persists after the attack,
and the stomach may be weak or irritable for some time ; pain, how-
ever, usually disappears at once. The attack may recur frequently until
the stone has been passed, so that in twenty-four hours the patient may
have a dozen or more paroxysms. After the attacks have subsided
light jaundice may supervene, which usually does not continue more
than a week at' the furthest, during which there are also symptoms of
mild gastritis. (See Intestinal Colic.)
In some instances a chill precedes or immediately follows the pain,
after which the temperature rises. After the paroxysm subsides the
fever disappears rapidly, being followed by profuse perspiration. If
the gallstones have set up catarrhal inflammation, moderate fever may
continue for a few days. (See Fever in Obstruction.)
During any paroxysm of hepatic colic it is desirable to determine
whether or not a gallstone has been passed. This can only be done
by placing the feces in a sieve and pouring water upon them until they
dissolve. Instead of gallstones, dark-colored granular bile, which has
become inspissated, is sometimes seen in the movements. Bile in this
form gives rise to as much pain, according to Harley, as true biliary
concretions. If the stone is not passed, it may fall back into the gall-
bladder and cause no further symptoms for a time, or become impacted
in the ducts. The impaction may be such that no obstruction is caused
by its position, the bile being forced through or around it ; or complete
obstruction may take place. (See Jaundice.)
Obstruction of the Common I) act by Gallstones, (a) In addition to
jaundice paroxysms of chill, fever, and sweat occur, with catarrhal
inflammation of the biliary passages. (1) The paroxysms resemble
intermittent fever ; (2) the jaundice may continue for years and deepen
after each paroxysm ; (3) hepatic colic may occur with the paroxysm ;
(4) the health fails but slightly. The paroxysms may occur daily or
only once a week, or they may be tertian and quartan in type. The
pain is referred to other situations than the gall-bladder or the epigas-
trium. It is often relieved by vomiting or by certain positions of the
body. The jaundice may be intermittent or remittent. On account
of the obstruction in this situation the liver becomes enlarged. It is
firm and smooth on palpation. The enlargement, as determined by
percussion, is uniform. The gall-bladder is not enlarged. Fenger's
thorough studies show that the intermittent phenomena are due to ball-
valve action of a single stone. He also points out that emaciation is of
common occurrence. (6) Gallstones may cause suppurative inflammation
DISEASES OF LIVER, SPLEEN AND PANCREAS. 887
of the biliary ducts, just as suppuration of the gall-bladder may ensue.
The symptoms, both general and local, are pronounced. The fever may
be intermittent, but is more likely to be remittent ; jaundice is present,
but it is constant in its intensity. The local signs of enlargement and
tenderness are made out. The patients die of exhaustion or septicaemia.
Sometimes the gall-bladder ruptures into the stomach or colon, and
temporary abeyance of the symptoms may result.
The Accidents of Gallstones. While these effects of the presence of
stones in the biliary passages may rightly be considered as accidents,
nevertheless their occurrence is so common as to be part and parcel of
the history of gallstones. As accidents, we have most commonly the
occurrence of localized peritonitis, which leads to dislocation of the gall-
bladder, constriction of the duodenum, with secondary dilatation of the
stomach ; we also have the formation of biliary fistula, with passage of
the gallstone into the contiguous organs or channels. The stone may
ulcerate into the gall-bladder from one of the ducts, may perforate the
portal vein, or may perforate into the abdominal cavity — the most fre-
quent accident. Perforation also takes place into the duodenum, into
the colon, and, rarely, into the stomach. Such perforation can only
be inferred from its secondary effects : (1) An attack of gallstones ;
(2) local inflammation with fever ; (3) the occurrence of peritonitis, or
the discharge of pus by the bowels, or by vomiting. That it is due to
gallstones is proved in those rare instances in which the stone is passed
per rectum. Often it may be impacted in the intestinal canal, causing
symptoms of acute obstruction, or in the rectum, causing local tormina
and tenesmus. The perforation, however, occurs in other directions.
Sometimes fistulous connection is formed between the gall-bladder and
the urinary passages, calculi and pus being discharged in the urine. In
other instances nstulse between the bile-passages and the lungs are
formed. The bile is coughed up and expectorated, sometimes with small
calculi. In the most common form ulceration proceeds toward the sur-
face, with formation of cutaneous fistula. After the fistula has opened
externally gallstones in large numbers may be passed. If not, the
cause of the fistula must be determined by the history and the results
of investigation by probe, due attention being given to the condition of
other organs.
Enlargement of the Gall-bladder. (Plate XLIL, Fig. 2.) Enlarge-
ment of the gall-bladder may be due to obstruction in the cydic duct.
The liver is not secondarily affected. The enlargement is noted at the
edge of the liver in the usual situation, and may gradually increase to
an enormous extent, so that it has been mistaken for an ovarian cyst.
The gall-bladder is often quite movable, and on account of its location
and movability, as well as its long shape, has been mistaken for a float-
ing or movable kidney. If the gall-bladder is not too large, it can be
felt as a rounded or pyriform mass when the hand is placed along the
margin of the liver, becoming more marked when the patient takes a
full breath. The enlargement is not attended by any other symptoms
except mechanical ones, unless the contents of the gall-bladder are
purulent. In obstruction with simple enlargement the fluid of the gall-
bladder, should aspiration be performed, is thin, of a mucoid nature,
SPECIAL DIAGNOSIS.
and alkaline in reaction. It may contain cholesterin-plates, and some-
times blood. It must be distinguished from the fluid of a hydatid cyst.
Simple enlargement of the gall-bladder must be distinguished from
enlargements due to inflammation. (1) Acute phlegmonous inflamma-
tion of the gall-bladder may take place, attended by localized pain and
tenderness, by high temperature, extreme prostration, and the rapid
development of the typhoid state. Peritonitis rapidly ensues. It can-
not be distinguished from other forms of acute inflammation in the same
region, unless there was (a) a history of gallstones ; (6) tumor of the
gall-bladder before the attack developed. (2) Suppurative inflammation
of the gall-bladder may occur from gallstones and in infectious diseases.
The colon bacillus, the diplococcus of pneumonia, and the typhoid bacil-
lus give rise to infectious inflammation of the gall-bladder. The enlarge-
ment takes place suddenly and may increase, the tumor becoming tender
and painful on palpation. The direction of growth is toward the umbil-
icus. The general symptoms are those of suppuration. Hectic fever
or markedly remittent fever occurs, and, unless surgical relief is given,
peritonitis ensues from infection or from rupture. This complication
may be suspected from the occurrence of collapse and increase of the
local symptoms.
Either of the above forms of cholecystitis is attended by pain in the
region of the gall-bladder or in the epigastrium or even as low down as
the region of the appendix. The pain is severe and paroxysmal. The
symptoms of bacterial infection, of which vomiting and fever are the
most prominent, rapidly follow. The symptoms simulate appendicitis,
intestinal obstruction, and pancreatitis.
Enlargement, or tumors of the gall-bladder, usually due to cystic
obstruction, as previously mentioned, may be mistaken for floating
kidney, for tumor of the pylorus, and for ovarian cyst.
Tumors of the gall-bladder from any of the above-mentioned causes
are recognized by their position and shape, and by the character of the
tumor. The position varies. The usual site is in the gall-bladder
region, but it may extend as low as the groin, or may be so large as to
distend the ribs and fill almost the entire abdominal cavity. If, how-
ever, the case has been under observation from the beginning, the tumor
must have been found originally in the gall-bladder region. This region
corresponds to the point of intersection of the border of the ribs by
a line drawn from the acromion process of the right shoulder to the
umbilicus, or in the direction of the foramen of Winslow. The tumor
grows from this point toward the umbilicus in nearly all the cases. It
can be recognized by its shape, which is pyriform, globular, or conical.
The character of the tumor varies. It is usually tender and firm, but
elastic on pressure, and movable. Fluctuation may often be detected.
The septic gall-bladder is symmetrical and resistant to the touch. If
the enlarged gall-bladder contains calculi, they may be felt as small,
hard masses, which cause a grating sensation, to be transmitted to the
finger. On aspiration, if the cystic duct is obstructed, the mucoid
fluid previously mentioned, or pus, is withdrawn. If the common duct
is obstructed, bile will pass through the trocar.
The enlargement must be distinguished from tumors of the liver,
DISEASES OF LIVER, SPLEEN AND PANCREAS. 889
stomach, duodenum, pancreas, or lymphatic glands. Tumors of the
liver are usually due to carcinoma. They are multiple, associated with
enlargement of the liver, with jaundice, ascites, enlargement of the
spleen, and emaciation. Tumors of the stomach, duodenum, and pan-
creas are in a different position, and are attended by functional disturb-
ance of the respective organs from which they spring. An abscess of
the liver, if purulent, may simulate enlargement of the gall-bladder.
If the abscess can be palpated, an area of induration is first felt, fol-
lowed afterward by softening and fluctuation of the swelling. In judg-
ing; of the true nature of the tumor we must bear in mind the causes of
• • • • ■
abscess. In hydatid disease the tumor develops slowly ; it is painless ;
it may yield fremitus, and, if movable, the course is slow and not
attended by general symptoms. Multilocular hydatid disease can rarely
be distinguished save by the difference in position of the tumor. It is
nodulated, hard, and tender, but is associated with jaundice, ascites,
oedema of the legs, enlarged spleen, and great emaciation and prostra-
tion, with rapid decline. A syphilitic gumma in the liver may occupy
the region of the gall-bladder. It can usually be made out as continu-
ous with the liver-structure. It is tender and painful, but irregular ;
other signs of syphilis, or a history of the infection and of symptoms
of a primary and secondary period, will aid in the distinction of the
disease.
Floating Kidney. The gall-bladder is larger and fixed at one end,
whereas the entire kidney is movable. The gall-bladder may fluctuate,
and is associated with symptoms of hepatic disease. On the other
hand, the well-known symptoms of floating kidney, the shape of the
tumor, the sensation of nausea induced by palpation, point to the renal
origin of the mass. Tumors of the kidney must be distinguished, such
as sarcoma, hydronephrosis, and pyonephrosis. 1. There may be
changes in the urine. 2. In renal tumors the intestine is in front of
some portion of them, or a zone of resonance is found between the
liver-dulness and the tumor. 3. Renal tumors are fixed. They may,
as in hydronephrosis, come and go, preceded by attacks of renal colic
and attended by anuria. From ovarian or uterine tumors the diagnosis
must be made by examination of the genital organs, although with the
former there is often difficulty.
Enlargement of the gall-bladder on account of calculous obstruction
must be distinguished from enlargement due to cancer of that organ.
This is often difficult and cannot be done without having the patient
under observation for a long period of time. Cancer of the gall-bladder
is usually primary. It may begin in the gall-ducts. In the larger
number of cases it occurs in patients who have had gallstones. It is
found most frequently in females, and after the fiftieth year. Tight-
lacing or pressure around the abdomen may predispose to it. The
symptoms are pain, jaundice, emaciation, cachexia, and the presence
of a tumor. The pain is localized and lancinating in character. Jaun-
dice occurs in 70 per cent, of the cases, and gradually increases in inten-
sity. The tumor is situated in the gall-bladder region, to the right of
the umbilicus. It is hard or firm, painful, and the seat of tenderness.
The tumor is fixed. Sometimes the disease is found in the cystic duct,
890 SPECIAL DIAGNOSIS.
and then the gall-bladder is enlarged. As the history of gallstones is
of frequent occurrence in both instances, it is impossible to distinguish
the two forms of obstruction causing enlargement, save that in carcinoma
the emaciation and cachexia may point to the true nature of the case.
In tumor of the gall-bladder due to cancer the secondary effects on the
liver are usually more marked than in tumor from other causes. The
liver enlarges and its surface becomes irregular or nodular. 1
Diseases of the Spleen.
Topography of Spleen. (Plate XXXV.) The spleen lies in the
left upper quadrant beneath, and in contact with the diaphragm above,
and below with the tail of the pancreas, cardiac end of the stomach,
and suprarenal capsule. It extends transversely between the upper
border of the ninth rib and the lower border of the eleventh rib, and
from the middle axillary line posteriorly toward the spine.
Palpation. An enlarged spleen usually retains the normal shape.
The direction of the enlargement is downward and inward. It is access-
ible to palpation in proportion to the degree of enlargement and of
relaxation of the abdominal walls. It is movable with respiration.
It cannot be said to be enlarged unless the edge is palpable at the end
of deep inspiration, notwithstanding there may be increased dulness in
the lower axillary region. When moderately enlarged, the smooth,
blunt, rounded anterior surface and sharp edge of the spleen can be
felt at the margin of the ribs, in deep inspiration ; when the enlarge-
ment is great, as in leukcemia, the organ can be grasped with both
hands, and its hilus clearly mapped out. The same thing can be done
in the rare instances of floating spleen, but here a knee-chest position
will favor successful palpation. The posterior border of an enlarged
spleen can usually be made out by passing the hand backward over the
resisting organ. At its posterior border a non-resisting space can be
detected between the border and the mass of lumbar muscle. In chil-
dren it is always easy to define this border. Xo such space exists in
renal enlargements. The existence of this space and the direction of
enlargement of the spleen are due to the costo-colic fold of peritoneum
(Jenner). In splenic leukaemia the spleen may be larger after a meal,
yield a creaking fremitus on palpation, a murmur on auscultation, and
may even pulsate. The spleen may also lessen in size after diarrhoea
or free hemorrhage. As it lies entirely behind the ribs, it does not, of
course, admit of palpation when the size is normal.
Percussion. (Plate XVI., Fig. 2.) Being a solid body it gives
a dull sound on percussion, contrasting with pulmonary resonance
above, intestinal tympany below, and stomach tympany anteriorly.
Posteriorly and below its dulness merges into that of the lumbar region
and kidney. The upper posterior portion is hidden behind the dia-
phragm and overlapping lung, and hence is not accessible to percussion.
Practically, therefore, the normal splenic dulness extends between the
ninth and eleventh ribs, in the middle and posterior axillary lines, the
spleen being there in contact with the ribs.
1 Musser: Trans. Assoc. Amer. Physicians, vol. iv., 1889.
DISEASES OF LIVER, SPLEEN AND PANCREAS. 891
In percussion of the spleen the patient should lie on his right side.
Beginning from above downward we percuss gently until pulmonary
resonance is succeeded by dulness ; then anteriorly, proceeding toward
the axilla, until stomach tympany yields to dulness. In the same
way, percussing from below upward, the line is reached where intestinal
tympany gives way to dulness.
Splenic dulness may be encroached upon by the stomach or colon
distended with gas, or its dulness may appear increased through disten-
tion of the stomach and colon with solid matter, or by a left pleural
effusion, or left basal pneumonia. The spleen may also be pressed
upward by ascites or by a large abdominal tumor, so that its normal
dulness is much lessened.
If the ligament which holds it in place becomes relaxed, the spleen
may become floating. According to Stint-zing, a floating spleen is
increased in density, is generally enlarged, and is recognized by its
form (notch, etc.), by being movable to and fro, and by the absence of
splenic dulness in the normal position, and its reappearance when the
spleen is replaced.
Enlargement of the Spleen. Enlargement of the spleen may be
acute or chronic. Acute enlargement occurs in certain infectious dis-
eases, particularly typhoid fever, typhus, smallpox, relapsing fever,
scarlet fever, diphtheria, epidemic cerebro-spinal meningitis, the mala-
rial fevers and meningitis, and in diseases with blood-poisoning, as
septicaemia, puerperal fever, and erysipelas.
A rare cause of enlargement is acute splenitis. Generally, it is the
result of emboli lodged in the spleen and starting from an endocarditis.
The area of splenic dulness extends rapidly, and there is local pain
and tenderness on pressure, increased by coughing and deep inspira-
tion ; other symptoms are fever, nausea and vomiting, and occasionally
delirium. If, as frequently happens in splenitis, emboli lodge in the
kidneys also, the urine will be albuminous and bloody. If suppura-
tion ensues, the fever becomes hectic, and the spleen continues to
increase in size. Splenic abscess may, however, remain latent until
rupture occurs.
Chronic enlargement of the spleen occurs as hypertrophy and as the
result of amyloid disease, leukaemia and pseudoleukemia, chronic mala-
rial poisoning (ague-cake), syphilis, hydatid tumor, and cancer. En-
largement is greatest in leukaemia and in ague-cake. The spleen in
well-marked cases of these affections may reach to the umbilicus and
even beyond, filling up the hypogastrium and extending to the right
iliac region, measuring thirteen or fourteen inches in length and half
as much in breadth, and proportionately increased in thickness.
Primary splenic enlargement may occur (1) without local or general
symptoms ; (2) anaemia, profuse hemorrhages, and brown pigmentation
of the skin may be present with the enlargement. Hemorrhages are
usually limited to the gastro-intestinal tract. The anaemia is of a chlo-
ritic type, and there is no change in the leucocytes. (3) Enlargement
may be associated with cirrhosis of the liver and jaundice, with gastro-
intestinal hemorrhages and with ascites. This affection is commonly
known as Banti's disease. The blood changes are almost a counterpart
892 SPECIAL DIAGNOSIS.
of those in progressive pernicious anaemia. It may be confounded with
chronic inflammation of the peritoneum, giving rise to ascites and
associated with mediastinal pericarditis.
Diagnosis of Enlargement of the Spleen. (Plate XLIIL,
Figs. 1 and 2.) Enlargement of the spleen can be distinguished from
enlargement of the left kidney by the greater movability of the spleen.
1. The spleen does not extend as far back toward the spine as the kidney,
so that the fingers can be thrust behind its posterior border, and, if the
other hand grasps the anterior edge, the organ can be moved backward
and forward. Splenic dulness extends to the ninth rib or higher.
Kidney-d ulness has no thoracic area, but reaches to the spine (lumbar).
2. Again, the spleen is more movable with respiration than the kidney
is. 3. The spleen falls further toward the median line, when the patient
is in the knee-chest position, than does the kidney. 4. An enlarged
kidney has the colon in front of it, and hence its dulness is obscured by
the tympany of the bowel. 5. The shape of an enlarged kidney is more
globular than that of the spleen. The anterior surface of the latter is
smooth and rounded, but at its junction with the flat posterior surface
there is a sharp edge. 6. Pain in renal disease often shoots down the
ureters and into the testicles. In diseases of the spleen the pain is
generally localized to the splenic region, and may shoot into the left
shoulder. 7. Result of examination of the urine will often make clear
that the disease is renal, or, by its negative result, will point to the
splenic origin of the tumor.
It is sometimes difficult to demonstrate enlargement of the spleen
when the liver, and particularly the left lobe, are enlarged. Careful
palpation reveals the edge of the spleen, which descends further than
the liver in full inspiration. Having found the anterior edge, pressure
with the other hand posteriorly will bring the spleen forward, which
would not occur if the suspected enlargement was the left lobe of the
liver.
The diagnosis of splenic leukcemia (Plate XLIV., Fig. 1) rests princi-
pally upon the blood-condition, particularly upon the existence of a
marked increase of white blood-cells. Red cells are decreased, and
altered forms are present. In addition to characteristic blood-changes
there is a great disposition to hemorrhages ; dropsies and priapism are
common ; and, in later stages, fever, diarrhoea, great weakness, and
grave complications, such as pneumonia. Hemorrhage in splenic leu-
kaemia occurs from the nose, bowel, stomach, gums, or kidney. It may
also be subcutaneous, intermuscular, cerebral, or retinal.
Regarding the diagnosis of splenic hypertrophy (ague-cake) in chronic
malarial affections, Osier says : " The history of malarial cachexia, the
absence of lymphatic enlargement, and the blood-condition will usually
be sufficient for the purpose of a diagnosis. Great increase in the
white blood-corpuscles is not often seen in the chronic splenic tumor of
malaria ; indeed, they may be much diminished in number. Toward
the end in very chronic cases the clinical picture may be very similar ;
the large abdomen, possibly ascites, dropsy of the feet, and' irregular
fever may resemble closely splenic leukaemia, and the absence of an
increase in the colorless corpuscles may be the only marked difference."
PLATE XLIII.
FIG. 1.
FIG. 2.
Enlargement of the Spleen. Tumor of the Left Kidney.
PLATE XLIV.
FIG. 1.
m^b. D.l Drawn by J. D. Z. Chase.
DISEASES OF THE KIDNEYS. 949
urine ; and (4) cases in which micrococcus-chains are voided in the
urine.
The pathogenic organisms which are more or less closely associated
with infectious diseases, septic processes, and tuberculosis are found
at times in the urine, and can be demonstrated by the proper stain ing-
methods.
Fig. 216.
<
Vibriones in urine. (Roberts.)
Dock has given an admirable account of the occurrence of the tri-
chomonas in the genito-urinary passages. This parasite belongs to the
flagellate infusoria. The prominent symptoms caused in Dock's case
were painful, difficult, and frequent urination, followed by hematuria.
The urine contained pus, epithelium of all kinds, and a number of bodies
slightly larger than pus-corpuscles of a peculiar amyloid appearance —
the trichomonades.
Morbid Growths. The urine very rarely contains the elements of
morbid growths. Von Jaksch says he never has found them in any
way reliable in the case of tumors of the kidney. The detection of
cancer-cells or pigmented cells, such as occur in melanotic cancers,
may confirm the diagnosis if the clinical symptoms point to cancer.
Tumor-elements are most likely to be found in ulcerating tumor of the
bladder.
Unorganized Sediments. Uric Acid. Uric acid is present in small
quantities (eight to ten grains a day) in normal urine. It is increased
in febrile and wasting diseases, such as phthisis ; in diseases of the
liver and spleen (leukaemia), and in malarial fever, diabetes, scurvy,
rhachitis, and following an attack of gout. Excessive use of milk is
said to increase it. Its excretion is also increased by certain drugs —
colchicum, corrosive sublimate, salicylic acid, and euonymin.
It is diminished in ansemia, chlorosis, and during a paroxysm of gout ;
in chronic nephritis ; by certain drugs — large doses of quinine (Ranke),
caffein, sodium chloride and sodium carbonate, lithia, and iodide of
potash. (Plate XLVIIL, Figs. 1 and 2.)
According to Roberts, a deposit of uric acid occurring some twelve
to twenty-four hours after the urine has been passed has no patholog-
ical significance. If the deposit occurs within three or four hours after
the urine has been passed, it is certainly not natural. It is frequently
observed in convalescence from febrile complaints, especially articular
rheumatism ; also in the middle periods of chronic B right's disease, in
chorea, in certain types of diabetes, and in enlargement of the spleen.
If, however, the uric acid is precipitated before the urine cools, or im-
mediately afterward, it is probable that the same precipitation may occur
within some part of the urinary passages, and so form a calculus.
950
SPECIAL DIAGNOSIS.
Urates. Amorphous urates appear under the microscope as opaque
granular particles, which dissolve upon heating, and respond to the
murexid test. The deposit is more or less dense, and is sometimes
arranged so as to resemble granular casts.
Fig. 217.
Sodium urate.
a a. From a gouty concretion. 6 b. Arti-
ficially prepared by adding liq. sodse to the
amorphous urate deposit. (Roberts.)
Ammonium urate spontaneously
deposited.
a. Spheres and globular masses, b.
Dumb-bells, crosses, rosettes. (Rob-
erts.)
Sodium urate appears as spherules or globules, from which project
short spines, either straight or curved. It occurs most frequently in
concentrated acid urines, such as are passed by children with acute
febrile diseases. (Fig- 217.)
Fig. 218.
Ammonium urate.
Ammonium urate resembles sodium urate. It is frequently asso-
ciated with phosphatic deposits, and is precipitated from alkaline
urines. Sometimes it appears in the shape of dumb-bells. (Figs. 217
and 218.)
Phosphates. Phosphates appear in the urine as ammonio-magne-
sium phosphate and as the crystalline and amorphous phosphate of lime.
DISEASES OF THE KIDNEYS.
951
They are precipitated in alkaline or faintly acid urines, which produce
a cloud upon being heated ; the cloud is distinguished from albumin,
as already pointed out, by the fact that it disappears when the urine is
Fig. 219.
Triple phosphates.
acidulated with acetic or nitric acid. Ammonio-magnesium phosphate
is easily recognized by its rhombic prisms — " coffin-lid " shape. Other
shapes are 'produced by modification of the primary one, chiefly by
bevelling of the edges and hollowing out of the sides. These crystals
Calcium phosphate crystals.
are usually large, and are frequently found, together with amorphous
phosphates, bladder epithelium, and pus, in cases of cystitis.
Amorphous phosphate of lime consists of fine granular particles much
resembling amorphous urates, but distinguished from them by not dis-
952 SPECIAL DIAGNOSIS.
appearing upon the application of heat, but instantly dissolving when
the urine is acidulated.
Crystalline phosphate of lime is a not infrequent deposit. It is
found as narrow-wedged crystals, occasionally grouped together in the
form of stars, sheaves, or bundles, with their apices at a common
centre.
According to Roberts, this deposit, in quantity, is an accompaniment
of some grave disorder. He has found the stellar phosphates in cancer
of the pylorus, once in phthisis, and more than once in patients ex-
hausted by obstinate rheumatism. It may, however, occur in health,
when the urine is rich in lime and its acidity greatly reduced.
In one or two cases of renal colic the writer has observed numerous
shining particles, which, upon microscopical examination, have been
shown to be an opalescent film, covered with small, sharp phosphatic
(probably calcium) crystals. (Fig. 221.)
Fig. 221.
Opalescent film in a case of renal colic.
Oxalate of Lime. Oxalate of lime occurs in the form of small octa-
hedral crystals, or, more rarely, as dumb-bells, and in the form of ovals
or disks. It is precipitated almost always from acid urines. (Plate
VI., Fig. 2 ; and Fig. 222.)
Oxaluria. According to Beneke, oxaluria has its proximate cause in
an impeded metamorphosis, an insufficient activity of that stage which
changes oxalic acid into carbonic acid.
When oxalates are constantly found in the urine a condition of pro-
found hypochondriasis is found to exist, but it has no necessary relation
to the oxaluria. An increase of oxalates in the urine is found in dia-
betes, especially when there is diminution in the amount of sugar. It
is in excess in certain forms of indigestion. Its constant passage may
be attended by pains in the back and loins. Flatulent and nervous
dyspepsia usually accompany the increase, and neurasthenia also may
be present.
DISEASES OF THE KIDNEYS.
953
Cystin. Cystin occurs in the form of hexagonal prisms, either as
irregular masses or superimposed one upon another, so as to form
truncated pyramids. It is a very rare sediment, but appears to be
most common in children and young male adults. Several members
of the same family have been known to pass it. Its chief clinical sig-
nificance arises from the fact that rarely it is the basis of calculi.
Fig. 222 .
<-
fa 7
v\
&>
<>
m>
&3 o
Calcium oxalate.
Leucin and Tyrosin. Leucin and tyrosin are generally described
together, though the former is not spontaneously deposited from urine.
It appears in the form of spheres, which refract light strongly and have
a radiating arrangement. (Fig. 223.)
Fig. 223.
Crystals of leucin (different forms). (Crystals of creatinin chloride of zinc resemble the leucin
crystals depicted at a.) The crystals figured toward the right consist of comparatively impure
leucin. (From Charles : Chemistry.)
Tyrosin has been found as a sediment, of a light greenish-yellow color,
in typhoid fever and acute yellow atrophy of the liver. It appears in
the form of tolerably long, needle-like crystals, or as bundles and
sheaves. Frerichs attaches great importance to leucin and tyrosin in
the diagnosis of acute yellow atrophy of the liver. (Fig. 224.)
954
SPECIAL DIAGNOSIS.
Cholesterin. This occurs at times in fatty degeneration of the kid-
neys, jaundice, chyluria, diabetes, and, according to Pohl, in the urine of
epileptics treated with bromide of potash. (Fig. 225.)
Fig. 224.
Tyrosin crystals.
Melanuria. Melanin is held in solution or suspended in small gran-
ules. The urine is dark in color, and blackens intensely when sulphuric
acid or tincture of chloride of iron is added to it. A concentrated solu-
tion of perchloride of iron serves to detect the presence of the substance.
Fig. 225.
Crystals of cholesterin.
A few drops added to the urine turn it gray. If a few drops more are
added, the phosphates are precipitated aloug with the coloring-matter.
Both are dissolved by an excess of the iron solution. Melanin is usually
found in cases of melanotic carcinoma.
DISEASES OF THE KIDNEYS. 955
Catheterization and Exploration of the Ureters.
Examination of the bladder, the ureters, and the pelvis of the kidney
has been wonderfully advanced by the genius of Howard Kelly. The
following instruments are required for the examination of the bladder :
Female catheter ; urethral calibrator ; a series of urethral dilators ; a
series of specula with obturators ; common head-mirror and a lamp,
Argand burner or electric light ; long, delicate mouse-toothed forceps ;
suction-apparatus for completely emptying the bladder ; ureteral
searcher ; ureteral catheter with a handle ; small bran-bags for ele-
vating the pelvis.
The procedure is as follows : Empty the bladder ; measure the meatus
urinarius externus ; dilate the urethra to twelve or fifteen millimetres ;
insert speculum of diameter of last dilator and remove obturator ;
elevate the hips of the patient about a foot above the level of the
table ; inspect with light ; remove residual urine by suction or with
cotton and mouse-toothed forceps.
For anaesthesia, a pledget of cotton saturated with a 5 per cent, solu-
tion of cocaine may be introduced seven minutes before dilatation. On
removal of the obturator the bladder becomes distended with air. The
bladder is viewed by turning the speculum, and each ureteral orifice is
brought into view by turning the speculum thirty degrees to one side
or the other. Kelly says : " The orifice appears as a dimple or a little
pit, or, in inflammatory cases, as a round hole in a cushioned eminence ;
at other times as a x \_ with the point directed outward ; again, it may
be scarcely visible even to a trained eye, appearing as a fine crack in
the mucosa, and occasionally is so obscure as to be recognized only by
the jet of urine as it escapes, or by a slight difference in the color of
the mucous membrane at that point. In rare cases it has the form of
a truncated cone with gently sloping sides ; this appearance is most apt
to be developed in the knee-breast position. The bladder mucosa is
usually of a slightly deeper rose color around the ureter, and in the
presence of an inflammatory process it even appears deeply injected/ 1
Catheterization of the Ureters. The catheters are sterilized ; they are
stiffened with a wire stylet. The orifice is exposed, and then the outer
end of the catheter being held over the shoulder by an assistant, the
conical end is introduced and pushed up the ureter, while at the same
time the stylet is being removed. The speculum is removed and again
introduced beside the first catheter. The remaining ureter is then cath-
eterized ; both are properly designated and allowed to drain into test-
tubes plugged with sterilized cotton and fixed in a block of wood. By
catheterization, aspiration, and exploration of the ureters with a bougie,
the source of pyemia anywhere from the urethral orifice to the renal
pelvis can be found ; renal calculi diagnosticated ; strictures of the
ureter located ; hydronephrosis distinguished from soft malignant
growths ; and the functional value of each kidney determined.
Kelly suggests the following guide to the ureteral orifice : " A. point
is marked on the cystoscope 5 } cm. from the vesical end, and from this
point two diverging lines are drawn toward the handle with an angle
of sixty degrees between them. The speculum is introduced up to the
956 SPECIAL DIAGNOSIS.
point of the V, and turned to the right or left until one side of the
V is in line with the axis of the body ; then by elevating the endo-
scope until it touches the floor of the bladder the ureteral orifice will
usually be found within the area covered by the orifice of the speculum."
By means of a searcher, or sound, the suspected orifice is further ex-
amined.
Objective Symptoms due to Impairment of the Function
of the Kidney.
Uraemia. Under symptoms due to impairment of the functions of
the kidney belong the various manifestations of uraemia. Diseased
kidneys do not eliminate the products of tissue-waste, which are poison-
ous materials. The toxic matter is retained within the blood, and
produces toxaemia, which may be acute or chronic. In acute uraemia
the manifestations develop suddenly and continue but a short period
of time, with alarmingly active symptoms until death or recovery. In
chronic uraemia the onset is gradual. The manifestations may be lim-
ited to one or two conditions, as headache or morning nausea, or they
may include the more pronounced symptoms of uraemia.
Nervous Symptoms. 1. Headache. The pain is situated in the
occipital region, and may extend down the neck. It is severe and of
a bursting character. It may be associated with giddiness. In both
acute and chronic nephritis it is often the first manifestation. It may
be associated with eye-symptoms. It may be present on waking, and
continue only through the morning hours. In acute uraemia it persists
throughout the attack. Numbness and tingling of the fingers are often
complained of at the same time.
2. Delirium. The delirium may be mild. This is usually the case
in the typhoid state or if a subnormal temperature prevails. It is
sometimes attended by delusions. There is often subsultus, and pick-
ing at the bedclothing. The delirium may amount to true mania, and
the patient may exhibit other maniacal symptoms. On the other
hand, the patient may be noisy, restless, and sleepless. Melancholia
and delusional insanity may develop after the violent nervous symptoms
of uraemia pass off.
3. Convulsions. A convulsion may be the first indication of disease
of the kidneys, or it may succeed a few days of persistent headache,
or follow an attack of uraemic vomiting. The convulsion resembles
epilepsy, and hence is known as an epileptiform convulsion. If the
spasms recur in rapid succession, the interval is occupied by delirium
or coma. If they are infrequent, the patient's mind may be clear in
the intervals. Sometimes a focal or Jacksonian epilepsy occurs instead
of the true epileptiform convulsion. The temperature is usually elevated.
In worn-out subjects, or those who have had exhaustive diarrhoea, or
are debilitated from other causes, the temperature may be subnormal.
A temporary blindness often follows the convulsion (urcemie amaurosis).
Uraemic deafness may occur.
4. Coma. After the convulsion the mind may be restored, or the
patient may lapse into stupor, followed by complete coma. Coma may
DISEASES OF THE KIDNEYS. 957
develop without convulsions, or immediately succeed a general convul-
sion. Headache or eye-symptoms may precede the coma. In some
instances the patient lapses into a typhoid state, in which the tongue is
heavily furred and the breath very offensive. Unless the coma is pro-
found there is usually some twitching of the muscles of the hands and
face.
5. Local palsies. Dercum was among the first to call attention to the
occurrence of uraeniic monoplegia or hemiplegia. The cases resemble
central cerebral disease. The nature of the palsy is inferred from the
results of the examination of the urine and the condition of the heart
and arteries. Palsy develops suddenly, or may occur after a convul-
sion.
6. Cramps in the muscles of the calves, particularly at night, are of
common occurrence, and should always lead to an examination of the
urine.
7. Pruritus, local or general, is another nervous symptom which may
be of uraemic origin.
8. Pain in the upper abdomen, particularly in the median line, is a
frequent precursor of more severe uraemic symptoms. It is of uraemic
origin itself. It may be seated in either of the upper quadrants, and
thence extend to the lower portion of the abdomen.
Uremic Dyspxcea. Modifications of the breathing often accom-
pany symptoms of uraemia. The dyspnoea may be constant. It may
occur in paroxysms, or both types may alternate. A common type in
the uraemia of chronic nephritis is the Cheyne-Stokes breathing.
Paroxysmal dyspnoea usually occurs at night, and resembles asthma
in every respect. Cheyne-Stokes breathing continues, even through
the period of coma, although not necessarily associated with it. (See
page 456.)
In addition to ursemic dyspnoea, the occurrence of inflammatory
pulmonary complications may be the first indication that the condition
of the urine should be inquired into. Bronchitis, pneumonia, and
pleurisy are common complications.
Gastrointestinal, Symptoms of Uraemia. Several forms are
seen. 1. Loss of appetite is common. It is attended with absolute
distaste for food after a small portion is taken. 2. Nausea, which
may be continuous, or more frequently limited to the early morning.
3. Vomiting may be paroxysmal, occurring chiefly in the early morn-
ing, or it may be sudden in onset, uncontrollable, and continue until
nervous symptoms of uraemia develop. Urea is found in the vomit.
The matter ejected is profuse, of a low specific gravity, and at first
acid in reaction. If chronic, it may become alkaline. The odor is
often sufficient to cause its recognition. 4. Constipation is generally
the rule in the course of chronic Bright' s disease. 5. Diarrhoza. One
of the manifestations of uraemia is the occurrence of sudden, profuse
serous purging. This may be so extreme as to cause collapse, or may
usher in coma and convulsions. 6. Hiccough, although a muscular
affection, is usually associated with gastric disturbances.
Latent uraemia was first recognized by Sir William Roberts. It is
seen in its most characteristic form in calculus suppression. The
958 SPECIAL DIAGNOSIS.
patient for several days will have subnormal temperature, myosis,
occasional vomiting, and toward the end twitching of the voluntary
muscles and slight drowsiness. After the end of five or ten days
coma, convulsions, or dyspnoea ensue.
Cardiovascular Symptoms of Nephritis. The symptoms are
the effects of the retention of morbid products. First, the heart and
bloodvessels. The poison which is not excreted circulates throughout
the system. One of its effects is irritation of the vasomotor nerves of
the bloodvessels. Excitation of these nerves causes peripheral con-
traction of the smaller vessels. At once the flow of blood is obstructed,
so that, on account of the contraction, hypertrophy of the heart rapidly
ensues. The first prominent symptom, therefore, is due to changes in
the heart-muscle.
Hypertrophy of the Heart. The most pronounced change is hyper-
trophy. The persistent spasm of the peripheral vessels causes in-
creased arterial tension. The blood-pressure is raised and causes
increased accentuation of the aortic second sound. High tension in
the artery is recognized by the peculiar character of the pulse and by
means of the sphygmograph.
Dilatation of the Heart. Unfortunately, hypertrophy of the heart
cannot always be kept up. If it fails, we then have a second con-
dition of the heart which is frequently found in renal inflamma-
tions ; it is dilatation. The state of the coronary arteries predisposes
to this condition of the heart-muscle. The previously mentioned
arterial tension favors the development of chronic endarteritis with
general atheroma. The coronary arteries take part in this process.
The endarteritis hinders cardiac nutrition, dilatation of the heart-
muscle follows, and later comes the development of two other condi-
tions, atrophy and myocarditis.
Here may be mentioned other relations of the heart and kidneys :
a. We have renal disease following forms of cardiac disease. In dila-
tation of the heart passive congestion of the particular organ takes
place. The kidney very quickly becomes the seat of such congestion.
In the course of simple dilatation, or of valvular heart-disease, the
secondary dilatation, passive congestion, and chronic inflammation
develop slowly. Embolism may also occur, b. Renal disease and
cardiac disease may develop at the same time from a common cause,
as alcoholism, gout, or endarteritis.
In addition to high arterial tension and accentuation of the aortic
second sound, the objective symptoms of atheroma of the aorta and
arteries are present with the chronic inflammations of the kidney.
These vascular changes need not be again rehearsed. (See Endarteritis.)
It is important, however, to bear in mind that they frequently occur
together, and also that in all instances of arterial disease the condition
of the urine must be inquired into. It need not be said that symptoms
due to rupture of the bloodvessels, particularly in the brain, or to an-
eurism, necessarily may be present in the course of renal inflammation.
Gastro-intestinal Symptoms. Fermentative dyspepsia, gastralgia,
chronic gastritis, enteritis, and ulcerative colitis are of common occur-
rence.
DISEASES OF THE KIDNEYS. 959
Hemorrhages. The arteries are very liable to rupture, causing
epistaxis, retinal hemorrhage, hemorrhages from the bowels and lungs,
and hemorrhages underneath the skin. Frequent hemorrhages in large
amounts from any portion of the body should call attention to the
condition of the urine.
Ophthalmoscopic Changes. The eye-ground should always be
examined ; indeed, the patient himself by his complaints often directs
attention only to the eye, the examination of which discloses the pres-
ence of an albuminuric retinitis. The changes may occur in the acute
or chronic forms of nephritis, although they are more common in the
latter. 1. A diffuse, slight opacity and swelling of the retina, due to
oedema. 2. White spots or patches of various sizes, for the most part the
result of degenerative processes. 3. Hemorrhages. 4. Inflammation
of the intraocular end of the optic nerve. 5. Atrophy of the retina and
nerve may sometimes result from and succeed the inflammatory changes.
These changes may affect one eye only (Gowers). It must not be for-
gotten that temporary blindness may occur independently of retinitis.
Dropsy. Dropsy may occur in all forms of nephritis. It is most
common in acute varieties, but it is also present in chronic diffuse neph-
ritis with exudation. Renal dropsy usually begins in the face. It may
develop suddenly in acute forms. In the marked forms, oedema of the
eyelids may continue for a long time. All varieties may be found, from
local oedema to extreme anasarca. The serous cavities are also filled.
The oedema is usually associated with a diminished amount of urine.
Its improvement is attended by increased diuresis. Dropsy, in chronic
disease, is usually due to dilatation of the heart. (See page 100).
The Cutaneous Symptoms, and Appearance of the Face,
In inflammatory affections of the kidney, the appearance of the skin
and expression of the face are often characteristic, and point at once to
an examination of the urine. The face is pallid, and of an ivory white-
ness. In the chronic form the pallor gives way to an ashen-gray or
sallow complexion. In chronic nephritis the skin becomes dry and
harsh, and, rarely, is covered with a powdery substance, giving it the
appearance of frost on the skin. The powdery substance is due to urea.
Petechia;. In the later stages of chronic inflammatory affections
hemorrhages under the skin and in the mucous membrane are seen.
Anaemia. Anaemia is a frequent symptom in all forms of nephritis ;.
it is usually marked. It is associated with the peculiar pallor just
described, and attended by all the other usual symptoms.
General Symptoms. The cause of renal disease, as far as symp-
toms pointing to the kidneys are concerned, is often latent. Instead
of renal symptoms, a generally depraved state of the system may be
seen, with emaciation and weakness. Lassitude without cause demands
an examination of the urine.
Diabetic Coma. Acetonemia is a toxemia which develops in the
terminal stages of diabetes. It is due to an accumulation of acetone
in the blood. It is also called diabetic coma. It develops acutely. A
sudden onset is attended by sharp pain in the stomach with nausea, and
frequently vomiting. At the same time there is severe dyspnoea. The
breathing is irregular and of a panting character, with inspiratory and
960 SPECIAL DIAGNOSIS.
expiratory dyspnoea. There may or may not be cyanosis. The patient
is obliged to sit up in bed on account of the air-hunger. Restlessness
begins at once. Delirium develops within the first hour. In a few
hours coma sets in. The temperature is subnormal ; the pulse is irreg-
ular, and soon becomes weak and thready. The odor of acetone is
detected on the breath.
Congestion of the Kidney.
Congestions of the kidney are acute and chronic, and depend upon
changes in the circulation, whereby blood accumulates in the kidney.
Acute congestion of the kidney is caused by the action of irritant
poisons • it follows surgical operations, particularly if prolonged, and
may follow extirpation of one kidney. Diseased kidneys are apt to
become the seat of active congestion.
Symptoms. The urine is diminished in amount, or may be suppressed
entirely. Only a small amount is passed at frequent intervals, or it can
be secured by the catheter alone. Albumin is present in considerable
amount, and blood and epithelial casts are numerous. Death may take
place, with symptoms of uraemia.
Chronic Congestion of the Kidney. It is also called passive conges-
tion. This form of congestion is usually a part of general venous stasis,
due to disease of the heart or lungs, as valvular disease of the heart,
with secondary dilatation or pulmonary emphysema. It is quite com-
mon.
Symptoms. The urine is diminished in amount ; dark in color ; of
high specific gravity, ranging from 1020 to 1030. Uric acid and
urates are increased. Urea to the amount of from 10 to 12 grains to
the ounce is passed in twenty -four hours. At first there is no further
change, but, subsequently, albumin appears in small amounts in an
intermittent manner. Later, it is constant and increased in amount.
Hyaline casts are found in the urine, and a few red blood-cells.
The condition is recognized by its association with congestion in other
organs ; by the diminution in the amount of urine, its high specific
gravity , and excess of uric acid and urates. This form of congestion
is serious, because it leads to chronic nephritis. The latter is recog-
nized by the usual changes in the urine.
Inflammations of the Kidney.
The inflammations of the kidney are divided in accordance with the
activity of the process and the degree of exudation or cell-proliferation
that attends the inflammation. We, therefore, have the following
varieties :
Acute exudative nephritis (acute Bright' s disease).
Acute productive or diffuse nephritis (acute Blight's disease).
Chronic productive or diffuse nephritis with exudation (chronic
tubular nephritis).
Chronic productive or diffuse nephritis without exudation (chronic
interstitial nephritis).
Suppurative nephritis.
DISEASES OF THE KIDNEYS. 961
Tubercular nephritis.
Acute Exudative Nephritis or Glomerulo-jstephritis. In
this form of nephritis there are congestion, exudation of plasma, trans-
udation of red and white blood-cells, and changes in the epithelium.
Causes. It may occur without definite cause, save exposure to cold,
and at times even without such history. It occurs in most of the infec-
tious diseases. It is of common occurrence after scarlet fever, and in
the course of pregnancy and in septicaemia. It occurs in diphtheria,
erysipelas, and pneumonia frequently. It is the expression of a pecu-
liar type of typhoid fever. It may complicate dysentery and acute
tuberculosis. It forms one of the modes of termination of diabetes.
Symptoms. The course of the disease may be mild, presenting only
changes in the urine, or there may be, in addition to decided changes
in the character of the urine, local and general symptoms.
In mild cases the urine is diminished in amount ; micturition is fre-
quent ; the color of the urine is increased, and the specific gravity is
usually high. A small amount of albumin is found, and a few epithe-
lial and blood-casts, and sometimes blood. At the termination of the
disease the casts are hyaline.
In severe cases the disease is ushered in by chill, attended and fol-
lowed by pain in the loins, with fever, headache, and much restlessness.
The urine may be passed more frequently than usual, but in small
amounts ; or micturition may diminish in frequency or cease entirely.
Examination of the urine reveals the characteristic changes. The
quantity of the urine is lessened ; the specific gravity is normal or
increased. There is a large amount of albumin, and an abundance
of hyaline, granular, epithelial, and blood-casts. Free white and red
blood-cells, and epithelium from the pelvis and tubules are found.
The fever continues ; the pain in the loins is sometimes very severe,
and may be taken for lumbago, unless an examination of the urine is
made. Within the first forty-eight hours the characteristic symptoms
that follow the chill and that attend the urinary changes are headache,
sleeplessness, more or less stupor, muscular twitchings, or general convul-
sions. Eye-symptoms may be present. Instead of cerebral symptoms,
dyspnoea may be marked. With both, nausea and vomiting are of
common occurrence. The heart's action is increased in force and fre-
quency. The left ventricle rapidly becomes hypertrophied. The aortic
second sound is accentuated. The pulse is hard and exhibits the char-
acteristic features of high tension. From the onset of the first symptom,
or within the first week, two other striking phenomena arise. They are,
first, the occurrence of dropsy ; second, the occurrence of ancemia.
Dropsy or oedema is one of the most constant symptoms. It appears
first in the face, especially the eyelids. It may be limited to this region.
It is worse in the morning. From the face, in bad cases, it extends to
the lower extremities and to the scrotum, and thence all over the body.
Anasarca is the name applied to the general dropsy ; the connective
tissue is infiltrated with serum. It is recognized by the pallor of the
swollen surface ; the pitting on pressure ; the absence of heat and of
pain. (See page 148.)
Effusion may take place into the serous cavities, either the pleura,
61
962 SPECIAL DIAGNOSIS.
pericardium, or peritoneum, causing the symptoms due to effusion-
In some instances there is oedema of the mucous membranes, as the
conjunctiva, the soft palate, and the glottis.
Dyspnoea may be a pronounced symptom, due either to uraemia
(uraemic asthma) or oedema of the glottis, effusions into the pleura, or
to bronchitis. If dilatation of the heart occurs, dyspnoea may arise,
due to that or to the secondary oedema of the lungs.
With or without the occurrence of nausea or vomiting there is always
loss of appetite, and usually constipation.
The fever is usually moderate and irregular in type. Prostration is
common ; often there is emaciation. Symptoms of urcemia may occur
at any time.
Exudative nephritis with excessive pus formation is of sudden onset,
characterized by high fever and extreme prostration. There is rapid
emaciation and the early development of the typhoid state. This is
preceded by delirium, headache, and stupor, with great restlessness.
There is but little, if any, dropsy. Large numbers of red and white
blood-cells and the usual casts are found in the urine. There is not so
much diminution in the urine as is usually seen. The disease may
arise without apparent cause, or complicate scarlet fever or diphtheria.
This form is very fatal, and resembles acute meningitis, from which
it is diagnosticated by the change in the urine.
Acute Productive or Diffuse Nephritis. In this form there
is an overgrowth of connective tissue, and excessive growth of the
capsule-cells in the glomeruli, in addition to the lesions of the first
form. The whole kidney is not necessarily affected, but only portions
at a time. Symptoms: The onset is sudden. The subjective symptoms
previously described are present in a marked degree. Nervous symp-
toms (uraemia) are most pronounced. Droptsy develops rapidly and to
an extreme degree. There is rapid development of anosmia and loss of
flesh. The remaining symptoms tally with those of the first affection.
The urine is scanty, bloody, and of high specific gravity. The micro-
scopical appearances are like those of acute exudative nephritis. If
convalescence is established, the urine becomes more abundant, with a
corresponding fall in the specific gravity. The albumin and casts may
appear for a time, but eventually disappear.
Diagnosis. The diagnosis of acute nephritis of either form is based
upon the examination of the urine. Etiological associations are of
value. The more pronounced cases follow scarlet fever and pregnancy.
In the latter condition it usually advances slowly. There may be
no symptoms until the occurrence of uraemia. In some instances the
disease resembles typhoid fever. In cases in which the onset is sud-
den, with early uraemic symptoms, it must not be mistaken for epilepsy,
delirium, or mania.
Chronic Productive or Diffuse Nephritis with Exudation.
In chronic inflammations the formation of new tissue always takes
place. They are divided, therefore, into exudative and non-exudative
inflammations. The exudation is from the vessels. Causes : This form
usually follows acute productive nephritis and chronic congestions or
degenerations of the kidney. It develops in the course of syphilis,
DISEASES OF THE KIDNEYS. 963
tuberculosis, endocarditis, disease of the bones, and prolonged suppura-
tion. Frequent exposure to cold and wet, a residence in damp dwell-
ings, and the alcoholic habit are causal conditions. It usually occurs
in middle life, more frequently in men. When it occurs as a primary
disease it is usually found in young adults. Symptoms : The disease
develops slowly. General symptoms may first be observed. Dropsy
may develop at first and continue throughout the disease, or recur at
long intervals. The appearance of the patient is striking. The skin
is of a peculiar pallor and is pasty in appearance. The sclerotics are
very white. The anaemia which gives rise to the pallor is profound,
and often closely resembles that of pernicious anaemia. The anaemia
is due to diminution in the haemoglobin and reduction in the number
of red blood-cells.
Headache and sleeplessness are common symptoms. Pronounced acute
uraemia does not often occur. Chronic urcemia may prove fatal by the
patient lapsing into a typhoid state, in which delirium alternates with
stupor.
The urine is variable in quantity and character. It must not be for-
gotten that the course of the disease and the urinary symptoms are often
quite variable in chronic nephritis. The urine may be normal in amount,
but during the exacerbations it is scanty or suppressed. The specific
gravity and the amount of urea lessen. In the most rapid cases it
varies between 1012 and 1020. In chronic cases it falls as low as 1005
and even 1001. In the later stages the amount of the urine and the
specific gravity may both be increased. Albumin is present' in large
amounts. When the disease is most active, and the dropsy at its
height, the quantity of albumin is very large. In the quiescent period
of the disease the amount is lessened. Casts are abundant, both epithe-
lial, fatty, and granular ; red blood-cells are often found.
Retinitis albuminurica is frequently developed in the course of the
disease.
Dyspnoea is a common symptom. The dyspnoea may be due to any
one of the many causes previously described which produce this symp-
tom in the course of nephritis. It is frequently limited to sudden
attacks which develop in the night or early morning. There is often
some bronchial catarrh.
Nausea and vomiting are common symptoms. The appetite is lost.
Hypertrophy of the left ventricle takes place in all cases, except in
those who had been previously weakened by other disease. The right
ventricle is often hypertrophied also. The second aortic sound is
accentuated, and the pulse is of high tension. Symptoms, such as
headache and vertigo, arise on account of the profound ancemia.
The disease is characterized in its course by remissions and exacerba-
tions. During the exacerbations any one of the prominent symptoms
that occur in renal inflammations may be present. (Edema is the one
symptom which occurs most frequently, and is likely to continue the
longest. The disease lasts from three months to three years, and may
pass into the second variety of chronic inflammation.
Course of the Disease. Delafield has well outlined the course. The
constant symptoms are anaemia, dropsy, and albuminuria. 1. The
964 SPECIAL DIAGNOSIS.
symptoms may be continuous and progressive in severity, death taking
place at the end of one or two years, on account of dropsy or uraemia.
2. The symptoms may continue for several months, and the patient
finally improve. Recurrent attacks take place, the symptoms being
more severe with each attack. In the intervals of the attacks there is
a small amount of albumin in the urine. 3. The patient may appar-
ently recover, but the urine continues to be of low specific gravity, and
contains some albumin. A fatal attack of uraemia, or an apoplexy, or
the onset of an acute disease may cause an exacerbation of the renal
symptoms. 4. The symptoms may persist in a mild degree for years,
the patient at the same time feeling comparatively well. 5. Spasmodic
dyspnoea may be the first and only symptom for a long time.
Chronic Productive or Diffuse Nephritis without Exuda-
tion. This is the form of nephritis which is also called interstitial
nephritis, granular kidney, or cirrhosis of the kidney.
The kidneys are diminished in size, the capsules are adherent, and
the surface roughened. There is an overgrowth of connective tissue
with atrophy of the epithelium and of the tubules, and dilatation of
some of the tubes, forming cysts.
Causes. This form of nephritis follows chronic congestion of the
kidney, and is also caused by alcohol, lead, gout, syphilis, malaria, and
by chronic endarteritis. The latter condition, as well as cirrhosis of
the liver and pulmonary emphysema, frequently develops hand-in-hand
with the nephritis. This form of nephritis is notably prevalent in
several generations of different families, so that an hereditary history
is often readily obtained.
Symptoms. The onset of the disease usually occurs late in life,
although well-defined cases may occur as early as the twenty-fifth
year. The progress at first is very insidious, and the disease may have
advanced to an extreme stage without the occurrence of a single symp-
tom. Death, indeed, may be due to other causes ; or a person in
apparently perfect health may suddenly manifest symptoms of uraemia,
or may develop apoplexy or some other usual accompaniment of inter-
stitial nephritis.
The urine is increased in amount, clear in color, and of low specific
gravity. The albumin is small in amount, or may be absent. Repeated
examinations extending over a considerable period of time may dis-
close its presence. Hyaline casts are present in small numbers. In
some cases it may be necessary to examine a dozen or fifteen slides
before they are found. Sometimes there are a few red blood-cells.
Rarely the urine is bloody at irregular periods in the course of the
disease, or actual haernaturia may take place. With the exception of
the state of the urine, the only symptom present may be the loss of
flesh and strength. At the same time the skin becomes dry and harsh.
CEdema, however, is not usually present unless there is dilatation of
the heart. Special symptoms are due to uraemia, to changes in the
heart and arteries, and to neuroretinitis.
The Heart. The left ventricle hypertrophies. The aortic second
sound is accentuated. The pulse is of high tension. The arteries
become more prominent, and present all the signs of endarteritis. In
DISEASES OF THE KIDNEYS. 965
the later stages, as nutrition fails, dilatation of the heart takes place,
with regurgitation at the mitral valve, and the development of a train
of symptoms due to these changes. Among others we find general
malaise, palpitation of the heart, dyspnoea, oedema, and visceral conges-
tions.
Urcemic Symptoms. These symptoms may occur at any time in the
course of the disease. Headache is most common and constant. It
may occur early in the morning only, or continue throughout the day.
It may be continuous and cause sleeplessness. General neuralgic pains
may be present instead of severe headache. Muscular twitchings or
general convulsions may be other pronounced symptoms, or, instead,
delirium, mild or violent, stupor, and coma may come on. These
symptoms occur suddenly or develop very gradually. In acute uraemia
with the above-mentioned cerebral symptoms there is peripheral spasm
of the arteries, causing high arterial tension, and there is elevation of
the temperature. The fever may rise to 103° or 104°, but is usually
about 102°, and is irregularly continuous. After the patient lapses
into deep coma, if the attack is fatal, the tension of the pulse is lost,
and it is increased in frequency and diminished in strength. In chronic
uraemia the cerebral symptoms develop gradually. The temperature is
likely to be subnormal, particularly if diarrhoea or other debilitating
influence is coincident. The pulse is rapid and feeble.
Pulmonary symptoms due to uraemia are quite common. They may
be the first expression of uraemia. This is seen in all forms of nephritis.
The most marked symptom, is dyspnoea, which is spasmodic and of
short duration. The attacks may occur frequently, and are usually
increased by exertion and aggravated by a recumbent posture. The
shortness of breath may occur in the early morning hours, or may con-
tinue throughout the day.
Pulmonary symptoms, other than those of uraemia, may be due to an
intercurrent bronchitis, pneumonia, or pleurisy. Chronic bronchitis or
oedema of the lungs may be present, on account of dilatation of the right
heart. The chief pulmonary symptoms that point to these conditions
are dyspnoea and cough.
Spasmodic dyspnoea is the first and sometimes the only symptom for
a long time. Later the renal symptoms become pronounced, pointing
to the true nature of the disease.
Gastro-intestinal Symptoms. Catarrhal gastritis almost always com-
plicates nephritis. In addition, gastric symptoms due to uraemia, and
hence to oleficient action of the kidney, ensue. The most common is
the occurrence of morning nausea or of morning vomiting ; the occur-
rence of spasmodic vomiting at irregular periods, or the occurrence of
violent, acute vomiting, which is followed in two or three days by other
symptoms of uraemia. The patients are usually constipated. When
the disease is complicated with cirrhosis of the liver, intestinal catarrh
is common, and intestinal ulceration with conseojuent diarrhoea is fre-
quently found. The onset of uraemia may be characterized by violent
and profuse serous purging, which of itself may cause collapse and death.
Neuroretinitis is a freopient complication of nephritis, and may
advance more rapidly than other complications, so that dimness of
966 SPECIAL DIAGNOSIS.
vision, blindness, or other eye-symptoms may cause the patient to
consult an oculist before attention is called to the condition of the
kidneys. The occurrence of this complication points at once to the
necessity of an examination of the urine.
It is common, in the course of an interstitial nephritis, to have acci-
dents due to the condition of the arteries that accompanies this disease.
On account of the atheroma, aided by the hypertrophied heart, rupture
of the vessels frequently takes place. Apoplexy is, therefore, of com-
mon occurrence, and hemorrhage into other organs sometimes occurs.
The renal disease is often not suspected until after the patient has
had an attack of apoplexy. The course of this form of nephritis is
varied very much by the occurrence of complications, notably em-
physema, endocarditis, or cirrhosis of the liver.
Catarrhs. There is always a tendency to chronic inflammations of
the mucous membranes, and to acute inflammations of serous mem-
branes in the course of chronic diffuse nephritis. It is necessary,
therefore, when local inflammations of this character are present, to
make thorough and repeated examinations of the urine, especially in
a patient over forty years of age, with a history of one of the causal
factors previously mentioned.
Course of the Disease. Several clinical forms of interstitial nephritis
are observed. In the latent form the disease may have advanced to
an extreme degree without any symptoms of renal disease during life,
death taking place from an intercurrent disease or accident. On the
other hand, palpitation of the heart may be the only symptom com-
plained of, and the observer finds a hard pulse, general atheroma, and
hypertrophy of the left ventricle with accentuation of the second sound.
Apart from this the patient may enjoy very good health. The danger
lies in the occurrence of pneumonia or inflammation of a serous mem-
brane. Often the local inflammatory symptoms are slight or masked
by the symptoms of renal disease, which develop rapidly.
In another group of cases some special symptom only may be com-
plained of. In some instances it may be gastric catarrh, in some eye-
symptoms alone may be present, while in others hemicrania or other
forms of headache are observed. With the headache there is usually
vomiting. Again, we may have constant neuralgia or persistent muscu-
lar rheumatism as the only symptom. Xose-bleed is a symptom which
may be the only indication of chronic nephritis, particularly if the
epistaxis occurs frequently.
In other cases the course is not latent, but characterized by a series
of attacks at varying intervals.
During the attacks the symptoms resemble the acute form of neph-
ritis, with acute urasmia, the occurrence of dyspnoea and loss of appetite,
nausea and vomiting. The tension of the arteries is higher at the
time of the attacks. The urine contains albumin, and is of low specific
gravity during the time of the attack ; during the interval the albumin
is found at irregular times.
Suppurative Xepheitis (Abscess of Kidney). Infectious matter
is conveyed to the kidney either through the blood, as in pyaemia and
ulcerative endocarditis (rarely dysentery and actinomycosis), or by the
DISEASES OF THE KIDNEYS. 967
ureters, as when it follows pyelitis or cystitis. A wound may infect the
kidney directly.
Symptoms. The symptoms are those of primary disease, and the
affection is usually only recognized post-mortem. Or the symptoms
are merely those of suppuration. Pus is seen in the urine only on
rupture of the abscess into the pelvis of the kidney.
Tubercular Nephritis. Fever, emaciation, anaemia, and pros-
tration characterize the course of the disease. Tuberculosis is usually
found elsewhere. There may be no other symptoms. Sometimes
hydronephrosis is present. A tumor is often present. It may be in
the loins, or may be in front, above, and a few inches to the right
or left of the umbilicus. The urine is normal or contains pus and
detritus or even bacilli. The finding of the latter is necessary often
to establish a diagnosis. In all instances of pyuria renal tuberculosis
should be suspected. Catheterization of the ureters may disclose the
organ affected. The urine should then be centrifugal] zed and the
sediment examined for bacilli, and, as Reynolds points out, a portion
inoculated in guinea-pigs. The tuberculin test may be employed.
The testicles and bladder should be carefully examined for primary
tuberculosis.
Tuberculosis of the kidney presents symptoms like those of pyelitis,
renal calculus, or a new growth. It is almost impossible to distinguish
any one of the four until an interval has elapsed. In all cases the
patient suffers from dull pain, sometimes with a bearing-down sensa-
tion. Hsematuria occurs, and the patient is liable to attacks of renal
colic. These symptoms may continue until a tumor can be made out.
Even before this pain will be elicited on palpation, which may extend
all along the urinary tract. With the occurrence of the tumor the
general symptoms of tuberculosis arise. Further diagnosis is based
upon the results of the urinary examination.
The Degenerations.
Degeneration may be either acute or chronic. The process is always
secondary, due to the action of inorganic poisons, as arsenic or phos-
phorus, or the poison of infectious disease, or is produced as the effect
of chronic disease of the organs, or by disturbance of the circulation.
In acute degeneration of the kidneys the urine is unchanged, or its
quantity is diminished. It contains a little albumin, or the albumin is
present in large amount, with casts and blood-corpuscles.
There may be no symptoms except changes in the urine, or symptoms
of uraemia may develop at once. Dropsy and hypertrophy of the heart
do not occur.
Chronic degenerations in the kidneys follow chronic congestion, or
are produced by alcoholism or syphilis. They occur in the course of
pulmonary phthisis, and of chronic suppuration ; they may develop in
the course of gout or malarial cachexia. Symptoms: In the simpler
forms there may be no clinical symptoms whatsoever. In others
there is loss of flesh and strength, the development of anaemia, and, in
rare instances, the development of the typhoid state.
968 SPECIAL DIAGNOSIS.
The changes in the urine vary. It may be abundant, scanty, or
suppressed. The specific gravity is not changed, but albumin and
casts are found.
Amyloid degeneration of the kidney is associated with similar degen-
eration in other organs. It occurs in the course of phthisis, of chronic
suppurations, of syphilis, of chronic dysentery, and is thought to occur
hi the malarial cachexia, or with gout. Symptoms : The degeneration
may be present without clinical symptoms. If symptoms arise, they
are due to the anaemia and cachexia that attend the primary disease,
and to the involvement of the other organs in the same process, as the
liver, spleen, and intestines. Purely says dyspepsia is prominent and
diarrhoea! attacks are common. The liver and spleen become enlarged
during the course of the disease in the majority of cases. QEdema may
be present, although it is more frequently absent. Ureemia is of rare
occurrence. In the uncomplicated degenerations there is no hypertrophy
of the left ventricle, and albuminuric retinitis is a rare complication.
The Urine. It may be diminished, normal, or increased, usually the
latter ; it varies from time to time in the same case, depending upon
complicating symptoms, as diarrhoea, which causes diminished amount
of urine. It is usually very pale. The specific gravity is not constant.
It ranges from 1008 to 1014. Albumin is constantly present, and usu-
ally in considerable amount. Hyaline casts and white blood-cells are
always found. When other casts are present nephritis probably com-
plicates the condition. The chief distinctive feature of the casts is their
large size and hyaline character.
The diagnosis of amyloid disease is based upon the presence of the
cause ; changes in the urine ; and signs of similar disease in other organs.
CHAPTEK VIII.
DISEASES OF THE NERVOUS SYSTEM.
The Data Obtained by Inquiry.
The Social History. This includes a knowledge of the patient's
occupation, whether he or she is married or not, the conditions under
which he may live, as, for example, in cases of great wealth, there is
perhaps more tendency or at least more opportunity to dissipation ; in
conditions of poverty the patient may have been insufficiently nourished,
or have suffered from continual anxiety. The most important factor is
probably the occupation. Occupations, from a clinical stand-point, may
be divided into those that require mental exertion, those that require
physical exertion, and those that expose the workmen to the possibility
of Various forms of intoxication.
The Family History. This is perhaps of more importance in
connection with nervous diseases than in connection with those of any
other system. By neurotic heredity we mean the fact that in certain
families a tendency to the development of various forms of nervous
disease exists, which may be manifested, however, only in certain mem-
bers of a given generation. Various terms are employed, to indicate
the nature of the inheritance. Direct inheritance means that the child
suffers from exactly the same disease as its parent. If both parents
have the same disease, the child is likely to have it more severely, and
this is spoken of as cumulative inheritance. By indirect inheritance is
meant the condition in which collateral ancestry and not the parents
have had the disease. Both the parents of the child may appear to be
healthy, and the grandparents have suffered from the same disease, and
this is called atavistic inheritance. By similar inheritance is meant the
occurrence in the offspring of a disease similar to that from which the
parents have suffered. Examples of such diseases are Huntington's
chorea, Goldflam's periodic paralysis, etc. By dissimilar inheritance is
meant the development in the offspring of a form of nervous disease
differing from that which existed in the parents, as an epileptic child
born of parents suffering from neurasthenia, hysteria, or insanity. The
indications of neurotic heredity are manifold. Inquiries must be made
in regard to cases of insanity, to cases of epilepsy, to instances of suicide,
to peculiarities of character, to criminal tendencies, to addiction to the
use of drugs, such as alcohol or opium ; to congenital deformities, or to
congenital diseases, such as deaf-mutism, etc. Charcot has called atten-
tion to the fact that certain of the so-called rheumatic manifestations
may occur in the antecedents of a patient suffering from nervous disease.
The History of Previous Diseases. This is of considerable im-
portance. The infectious diseases are sometimes followed by peripheral
970 SPECIAL DIAGNOSIS.
neuritis or lesions in the central nervous system, or they may produce
an early tendency to arterio-sclerosis. It is of importance to know
whether the foetal existence of the patient was normal, and, if possible,
to obtain data concerning the condition of the mother during this period.
Inquiry should be made regarding the nature of the birth ; the existence
of infantile spasms, at what age they occurred, when they ceased, if at
all, and if there was any suspected reason for their development. It
should be noted when the child first walked, when it first was able to
talk, the rapidity of its intellectual development and progress at school,
whether the character was normal, if there were night terrors or noc-
turnal enuresis. In boys the physician should endeavor to discover if
there is any history of severe injury, particularly to the head, whether
the boy had the opportunity for free exercise or was restricted in this
respect ; if his habits were good ; if he smoked early ; if he was over-
worked at school or obliged to work hard during early adolescence.
In the case of females the physician should inquire at what period
puberty occurred, and whether there has been any difficulty with men-
struation. The existence of luetic infection is often difficult to eluci-
date. Occasionally it will be admitted, but more frequently it is neces-
sary to discover the fact by indirect questioning.
The History of the Disease Itself. As in other conditions,
the patient should be questioned regarding the duration of the disease,
its earliest manifestations, whether exacerbations and remissions have
occurred, and the nature of its course. It is important to inquire for
slight symptoms that are usually overlooked by the patient, such as
the ocular disturbances, ptosis, paralysis of the external rectus in loco-
motor ataxia, a tendency to extravagance in paresis, the manifestations'
of nocturnal epilepsy, etc.
The Subjective Symptoms. The data obtained by inquiry in-
clude the subjective sensations of the patient. These are chiefly of
two kinds — pain and paresthesia. In addition, the patients sometimes
complain of a general feeling of restlessness, of irritability, of inability
to think consecutively, or various other forms of indefinite general and
intellectual disturbance. Pain is, however, such an important symptom
in general disease that it has been discussed in the section upon Gen-
eral Diagnosis.
Paresthesia may be defined as subjective sensations, either resem-
bling those normally occurring as a result of excessive stimulation of
the sensory nerves, or of a peculiar nature. They are exceedingly
various in their character, and may be sharply localized or indefinitely
distributed. To them belong chiefly itching, tingling, formication,
numbness, subjective sensation of heat or of cold, of moisture, of
pressure, or of tearing or rending. Sometimes the paresthesia? are
very slight in character, and may escape the notice of the patient until
his attention has been directed to them ; in some cases they become so
severe as to cause intense suffering and temporary helplessness. They
usually indicate some functional or organic disturbance of a nerve-
trunk, and are, therefore, as a rule, limited to the distribution of some
particular nerve. The functional forms, however, may be produced
by external conditions, such as pressure upon the bloodvessels leading
DISEASES OF THE NERVOUS SYSTEM. 971
to a local anaemia, exposure to cold, to heat, and the like. A peculiar
type of this condition is known as rneralgia paraesthetica, and is char-
acterized by paresthesias in the distribution of the external cutaneous
nerve of the thigh. In this disease, and occasionally in other forms of
paresthesia, the subjective symptoms are associated with objective
disturbances of sensation.
The Data Obtained by Observation.
These include nearly all the important symptoms of nervous disease,
and are, therefore, of paramount importance. They are disturbance of
sensation, of motion, of reflex actiou, of appearance and of contour,
disturbances of the special senses, of the functional activity of the
various organs of the body, and alteration of the condition of nutrition.
Sensation. New varieties of sensation appear to be discovered every
year, and it is therefore tedious and sometimes impossible to analyze all
that have been already described. Sensations may be described as those
which are relatively simple — that is, involving but a single variety of
perception, and those that are complex.
Simple Sensations. Tactile sensation, or the sense of touch, is
usually spoken of as aesthesia. It is the ability to know when some
external object has come in contact with the skin. Hypercesthesia is an
increased sensitiveness to contact ; and hypcesthesia, decreased sensitive-
ness ; ancesthesia, total loss of the ability to perceive objects touching
the skim No satisfactory instrument for the measurement of the touch
sense has as yet been devised. In general, it may be tested either
directly with the end of some hard, blunt object, or, when still acute,
with a camel's-hair brush or cotton point. The patient should close
his eyes, or, what is better, permit them to be bandaged, and should
then be instructed to indicate by some word or motion the moment
contact takes place. The investigator must be careful not to use force,
and the instrument employed should not be so sharp nor so rough as to
produce pain. From time to time the patient should be asked whether
he were touched when contact has not been made, although some move-
ment indicating the approach of the instrument to the skin has been
performed. Frequently in prolonged examinations the attention becomes
fatigued, and the patient no longer recognizes whether he is touched
or not, and answers at random. Hypercesthesia, may occur in a variety
of conditions. Its most common cause is functional exaltation or irri-
tability of the nerves, which may occur in neuralgia or neuritis. It also
occurs in organic disease of the cord, and is then limited to the area of
distribution of the spinal segment just above the destructive lesion.
This is spoken of as the zone of hyperesthesia. It is also occasionally
present in functional conditions, such as neurasthenia and hysteria, and
may be merely the result of some local irritation of the skin. The
degree of tactile perception varies considerably in different persons.
Hypcesthesia may occur in a variety of conditions — in neuralgia, in
partial lesions of the spinal cord, particularly disease of the posterior
columns, and rarely in central lesions of various kinds, particularly
those occurring in the parietal lobe, in the end of the posterior limb of
972 SPECIAL DIAGNOSIS.
the internal capsule, and in the pons. It also occurs in functional
nervous conditions, and is quite common among the insane. Anaes-
thesia results from solutions of continuity of the sensory nerves, from
destructive lesions of the cord, or from central lesions. It is also the
commonest form of hvsterical stiorua. Organic anaesthesia mav be dis-
tinguished from functional anaesthesia by its distribution. If caused
by nerve injury, it will exist in the region supplied by that particular
nerve. If caused by disease of the spinal cord, the area of anaesthesia
will be segmental in type — that is, bounded by two nearly horizontal
lines passing about the body. In unilateral lesions of the spinal cord
the anaesthesia is limited to the opposite side of the body. In central
disease the anaesthesia is commonly unilateral, and corresponds to the
paralyzed side, if paralysis is present. If due to a lesion of the cortex,
however, it may be limited to one extremity, where it is usually asso-
ciated with paralysis.
Pain sense, or algesia, is the ability to perceive pain of any kind.
Various instruments have been devised for testing its intensity.
Among the best is that suggested by Ivulbin, consisting of a needle
which is thrust into the skin for varying distances ; the amount of press-
ure required and the degree of penetration being indicated on a scale.
Even this, however, is far from accurate, and for clinical purposes it
is sufficient to use a needle or pinch a small fold of skin between the
finger-nails. In case of very pronounced disturbance of the pain-sense
it is sometimes possible to use the actual cautery or to thrust a needle
entirely through a thick fold of the skin. A faradic current is also
frequently employed, and to a certain extent is accurate, if data can be
obtained by comparing the healthy with the diseased side of the body.
As, however, it appears that there is a special form of sensation for the
induced current, its results cannot be relied upon implicitly. Hyper-
algesia is increased susceptibility to painful impressions, so that the
lightest contact may cause exquisite agony. It occurs in inflammation
and in those conditions associated with hyperesthesia. A variety of
hyperalgesia is tenderness — that is, pain elicited by simple pressure.
It is most frequently associated with local inflammation, and occurs
along the course of the nerves in neuritis and neuralgia. Hypalgesia,
or decreased susceptibility of pain, occurs as a result of partial lesion
of the nerves, or of the central portion of the spinal cord, and, occa-
sionally, as a result of focal lesions in the brain. It is also very com-
mon among idiots, immediately after epileptic attacks, and in cases of
hysteria. Hypalgesia may also be acquired as a result of constant
exposure to a mild form of irritation, as, for example, in those accus-
tomed to going bare-footed. Analgesia is an exceedingly important
symptom. It results from total destruction of the nerve ; from disease
of the central gray matter of the spinal cord, such as occurs in trans-
verse myelitis, syringomyelia ; in tumors of the cord ; and from focal
disease of the brain, particularly if situated in the parietal lobe, and
the posterior limb of the internal capsule. It also occurs in a great
variety of functional conditions, and may be general in the form of
insanity known as primary stupor. It is a very common lesion in
hysteria, and in this disease the area of distribution mav assume the
DISEASES OF THE NERVOUS SYSTEM. 973
most curious forms, being limited to one-half of the body, or tracing
geometrical figures on various parts of the skin. It may also be pro-
duced by hypnotic suggestion. Organic analgesia is frequently associ-
ated with trophic changes, either as a result of the inability of the part
to defend itself against irritation, or as a result of the intimate associa-
tion of the sensory and trophic nerve-fibres.
Visceral pain may be elicited by strung pressure upon the testicles,
ovaries, or breasts, or a violent blow upon the abdomen. It is usually
characterized by intense prostration and nausea. Visceral analgesia
occurs in some cases of locomotor ataxia and occasionally in hysteria.
The heat sense, or thermocesthesia, enables us to recognize the differ-
ence in temperature between various bodies. It is usually tested by
filling two test-tubes, one with hot and one with cold water, and apply-
ing them in irregular alternation to the region under investigation.
The difference in temperature between the two tubes is a rough test
of the delicacy of the sense. In health a difference of 1° C. can be
recognized upon the more sensitive portions of the body (the ante-
rior surface of the forearms, the skin of the face, and the chest). A
rougher test is the use of metal and wooden objects. The former con-
duct heat more rapidly from the surface, and therefore give rise to a
sensation of cold. The heat-sense is rather complicated, and is not yet
thoroughly understood. There seem to be special points upon the skin
where the nerves for heat and cold terminate. (Goldscheider.) There
may be loss of perception for cold objects, while the perception for hot
objects remains unimpaired, or the reverse may be present. Sometimes
the patient calls all objects warm and at other times he calls them cold.
Hyperthermocesthesia is practically of no value as a clinical sign, for our
methods of testing the delicacy of the sense are at present imperfect,
and hypothermocesthesia is also difficult to detect, and probably belongs
to the category of conditions in which one of the sensations is more or
less impaired. Thermoancesthesia, or complete loss of the heat-sense,
is very important clinically. It occurs in neuritis or destructive lesions
of the nerve, and in central disease of the spinal cord, such as transverse
or pressure myelitis, tumor, and especially in syringomyelia. As a
result of being most frequently associated with cord disease, the thermo-
anaesthetic area is usually segmental. The heat-sense may, in connection
with other forms of sensation, be diminished in functional nervous
disease.
The above three forms of simple sensation are those usually regarded
as of the greatest clinical importance. They may be equally affected,
or one or two may be preserved and the others diminished or lost.
The latter condition is known as dissociation of sensation. It occurs
in neuritis, but is exceedingly rare. It also occurs in various forms of
myelitis, particularly pressure myelitis. It is the most characteristic
symptom, and for a long time was considered pathognomonic of syringo-
myelia. In this form of dissociation tactile sense is preserved, and the
temperature and pain senses arc lost. When the tactile sense is lost, and
the pain sense still present, the condition is termed anaesthesia dolorosa.
Simple sensations of perhaps less clinical importance than the fore-
going are trichocesthesia, or the consciousness that a cutaneous hair has
974 SPECIAL DIAGNOSIS.
been touched. This is really the sensation perceived when tactile sense
is tested with the cotton point ; the latter is felt very well upon the
forearm, on the back of the hand, and not on the palm, where sen-
sation is distinctly more acute. Von Bechterew calls attention particu-
larly to the fact that trichosesthesia and tactile sense are not equally
delicate in various parts of the body. The former is most readily
tested by touching the individual hairs with a small needle or cotton
point. More elaborate apparatus of no particular value has, however,
been devised.
The Sensation of Locality. When any part of the surface of the body
is touched we can, under normal conditions, tell the location of the
point of contact. This varies, however, consideraoly in various parts
of the body, being more accurate on the lips and less on the skin of
the back between the shoulder blades, where an error of from 6 cm.
to 7 cm. is still within the normal limits. It may be very much dis-
turbed without any loss of the delicacy of the touch sense. It may be
tested by making contact with the finger or any blunt object. Another
method formerly much used by clinicians, and still employed by psy-
chologists, is the use of the cesthesiometer, an instrument consisting
essentially of two points that can be placed at a measured distance
from each other. It has been found that in normal persons these can
be detected as two points at the tip of the tongue when separated only
1 mm. ; but may still be felt as one on the back when separated as much
as 65 mm. This method is extremely inaccurate, for the reason that
it is difficult to apply the points with the same degree of force. More-
over, experiments have shown that the skin readily becomes educated
and able to discriminate points much closer together than is normal
for the part that is being tested.
Allochiria. This is a general term applied to the false localization of
sensory stimuli. In some cases the sensation may be felt not at the
point where it was applied, but at exactly the corresponding point on
the opposite side of the body. This occurs particularly in hysteria.
In organic disease of the spinal cord mistakes of localization are not
uncommon — thus, in hypsesthesia of the arm, irritation at the hand
may be referred to the shoulder, and the same is true of the lower
extremity.
When there exists a hypsesthesia it is of course difficult for the
patient to localize as accurately as is possible when sensation is normal.
The Electro-cutaneous Sense. This is really the degree of resistance
to the irritation of the induced current. It varies considerably in
different individuals, and in the same individual under different con-
ditions and in different parts of the body. It is perhaps most delicate
on the skin of the face, and least delicate on the back and the outer
surface of the thighs. It is curiously affected in certain nervous dis-
eases ; thus, in the periodic paralysis of Goldflam it is almost completely
abolished during the attack. In meralgia paraesthetica it is also, as a
rule, greatly diminished. In all cases of muscular degeneration the
electric current is better supported than Avhen the muscles react. It
is also greatly diminished when there is oedema of the skin or much
subcutaneous fat. It sometimes persists, however, when tactile an?es-
DISEASES OF THE NERVOUS SYSTEM. 975
thesia is present. In tetany it is greatly exaggerated (Erb's sign), and
this constitutes one of the cardinal symptoms of the disease, and it is
also increased in some of the functional nervous conditions. It is best
tested by using a simple faradic battery, employing as the electrode
for contact either the wire brush or the naked wire. No satisfactory
system of measurement has as yet been devised, but it is of advantage
to use invariably the same battery, and to note the position of the inner
coil with reference to the outer one.
Pressure Sense. The clinical significance of this has not yet been
determined. It is certain, however, that it undergoes considerable
variation as the result of various pathological changes. It may be
tested roughly by making various degrees of pressure with the finger
or a blunt object upon the surface of the skin, the limb being so placed
that it is impossible for the patient to make muscular resistance. It
may be tested more accurately by using a series of little blocks that
can be piled one on top of the other, or by filling a vessel more or less
completely with shot or mercury.
Functional Modifications of the Various Forms of Sensa-
tion. Delayed Sensation. The perception of the various forms of
stimulation that are appreciated in consciousness as sensations may
be delayed for some time after the stimulus has been applied. This
is spoken of as delayed sensation, and the interval may, in extreme
cases, be several seconds. It is not known where this delay takes
place, whether in the sensory bodies of the skin, or in the nerves, or in
the central nervous system. This symptom is manifested particularly
in tabes dorsalis, but may occur in functional nervous disease and in
various forms of organic central disease. It has also been noted in
peripheral neuritis. The delay can occur for one sensation alone, as
the pain sense, even when tactile sense is normal.
Complex Sensations. These are probably very numerous, but
only two have been so carefully studied that they are valuable for
clinical purposes. These are the so-called position or muscular sense,
and the stereognostic sense. By the position or muscular sense we mean
the ability to perceive and recognize the position of the limbs or of the
body — that is, whether, for example, the joints are in a state of flexion
or extension, supination, pronation, or rotation ; whether the spine is
bent or erect, and the position of the head with reference to the trunk.
It probably depends upon the complex co-ordination of the perceptions
received from the muscles, joints, periosteum, tendons, and skin. It
may be tested in a variety of ways. The patient should be instructed
to close his eyes or have them bandaged ; the finger is carefully grasped
on either side and flexed or extended. After each movement the patient
indicates its direction. After the fingers have been tested the same
process is employed for the wrist, elbow, and shoulder. Similar methods
may be used for the feet, and the head may be rotated to the right or
the left, bent forward, laterally, or backward. Another method is to
take one arm, bend it into some particular position, and instruct the
patient to imitate the position with the other arm ; the same thing being
done with the legs ; or the patient may be instructed to describe the
position in which his arm has been placed, without attempting an imi-
976 SPECIAL DIAGNOSIS.
tation. This sense is lost when for any reason there is total anaesthesia
of the part, and may disappear as an isolated symptom in case of disease
of the posterior columns or in the ataxia due to central lesions. By
the stereognostic sense we mean the ability to recognize the shape,
consistency, surface, and nature of any object placed in the hand or
brought in contact with the skin of any part of the body. This sen-
sation is most readily tested by directing the patient to keep the eyes
firmly closed ; then to select a number of small objects, such as a
pencil, match-safe, coin, key, etc., and place them in his hand and
direct him to name them or describe them. This sense depends upon
a variety of perceptions. The size of the object is recognized by a
combination of the locality and muscle senses ; the nature of its surface
by the tactile sense ; its consistency chiefly by the pressure sense, per-
haps aided by the pain-sense ; its nature — that is, whether of metal,
wood, or any other substance — largely by the temperature sense. The
stereognostic sense is always abolished when tactile sense is absent.
Occasionally in hysteria the patient may declare himself unable to
perceive touch when the stereognostic sense is intact, but this is an
exception. It may, however, be lost when tactile sense is still preserved,
especially if the locality sense and the muscle sense have been greatly
impaired. When due to organic causes its absence usually indicates a
lesion in the parietal lobe or in the projection fibres coming from this
region. It occurs frequently in hemiplegia, in cerebral monoplegia,
and occasionally in peripheral palsy, involving two forms of sensation.
It has also been observed as a transient symptom after brain shock
without disturbance of any other sense.
Disturbance of Motility. These may be grouped under a number
of heads. First, loss of power, which may be either partial, paresis ;
or complete, paralysis. Second, impairment of movement, inco-ordina-
tion, or ataxia. Third, closely allied to this, tremor. Fourth, excessive
muscular movement, spasm, or convulsions.
Paralysis. This is a loss of power in the muscles. It may be
true, in which the loss of power is due to some disease of the muscle
itself or the nervous influence controlling it ; or false, when it is due
merely to an inhibition of the muscnlar function produced by a disease
of the muscle or joint that causes pain upon movement. Paralysis is
classified, according to the part affected, into monoplegia, when one
extremity is involved ; hemiplegia, when half the body is involved ;
paraplegia, when two symmetrical extremities are involved ; para-
plegia, cruralis, if the legs are affected ; paraplegia brachialis, if the
arms are affected (this term is usually restricted clinically to paralysis
of both legs) ; diplegia, when two extremities are affected without
involvement of the trunk. Clinically, this is sometimes restricted,
although incorrectly, to paralysis of both arms {diplegia brachialis) or
of both sides of the face {diplegia facialis). Grossed paralysis is a term
applied to paralysis of one side of the face and the opposite side of the
body. Local paralysis is the term used when only small groups of
muscles are affected. Multiple paralyses is employed when several
parts of the body are involved at the same time. Paralysis is also
classified, according to the cause, into cerebral paralysis, spinal parol-
DISEASES OF THE NERVOUS SYSTEM. 977
ysis, neural paralysis, and muscular or myopathic paralysis. Paralysis
is also classified, according to the type, into spastic paralysis, in which
the muscle tone is increased and the reflexes are exaggerated, and con-
tractures are either present or likely to ensue, and flaccid paralysis, in
which the muscle tone is diminished, in which there is no resistance to
passive movement, and the reflexes are abolished. Spastic paralysis is
usually due to some lesion in the central motor neuron — that is, between
the motor cortex and the terminations of the fibres of the pyramidal
tracts in the anterior cornua of the spinal cord. The lesion, therefore,
may be situated in the cortex, the corona radiata, the internal capsule,
the pons, the pyramids of the medulla, and the lateral columns of the
cord. Spastic paralysis must not be confused with the contractures
that ensue after degeneration of the muscles, as in infantile palsy,
neuritis, etc. In these cases the limbs are in a state of permanent
flexion. The resistance to extension and to passive movement is not
due to increased muscular tone, but to an actual shortening of the
muscle and its tendons, which can only be overcome by rupture of one
or the other. Flaccid paralysis may be produced by cerebral lesions,
but is more commonly due to lesions of the peripheral motor neurons
— that is, from the anterior cornua of the cord to the muscle itself.
It may, therefore, be produced by destruction of the ganglion cells, by
injury to the anterior roots, or the peripheral nerves, or disease of the
muscle. Flaccid paralysis frequently occurs as the result of functional
conditions — for example, it is the type of paralysis that is usually
observed in hysteria. As the trophic centres influencing the muscle
are either cut off or destroyed, atrophy of the latter usually takes place
{atrophic paralysis), which is characterized by decrease in bulk, altera-
tion of the electrical reactions, and fibrillary twitchings. Monoplegia,
or paralysis of one limb, may be caused by small lesions in the cerebral
cortex or the corona radiata. It is rarely produced by lesions of the
internal capsule, where the fibres are placed closely together, or of
the spinal cord, unless the gray matter of the latter is involved. It
occurs in circumscribed forms of infantile paralysis, in lesions of the
peripheral nerves, particularly the roots of the plexuses, but rarely in
disease of the muscles alone, the lesions in this case being more widely
distributed. Monoplegia also occurs in hysteria and in the pseudo-
paralysis due to localized disease of the muscles or joints. Hemiplegia
is commonly due to a lesion of the opposite side of the central convolu-
tions. This lesion may either be extensive and destroy the motor por-
tion of the cortex or corona radiata, or more circumscribed, involving
the internal capsule, the crura, the pons, or the medulla. Spinal lesions,
also, if unilateral, which is rare, and situated above the fourth cervical
segment, may produce paralysis of the same side of the body. ( Vide
Brown-Sequard's syndrome.) In hemiplegia due to lesion of the cere-
brum, the muscles of the trunk, and those supplied by the upper
branch of the facial nerve commonly escape. The lower half of the
face, the arm and leg, and the side of the body opposite the affected
hemisphere are paralyzed. If due to lesion of the pons below the
decussation of the facial fibres —that is, in the posterior half — the arm
and leg of the opposite side and the lower half of the face on the
62
978 SPECIAL DIAGNOSIS.
same side are paralyzed (crossed paralysis, pontine palsy). Lesions of
the medulla ordinarily, in addition to the motor tracts, involve other
important nuclei and tracts. Spinal hemiplegia is characterized by
the absence of facial involvement. Hysterical hemiplegia can only be
recognized in some cases by the discovery of the other stigmata of that
disease. The form of paralysis in organic hemiplegia is ordinarily
spastic, and usually in the course of time pronounced contractures
occur. Paraplegia cruralis is usually produced by a lesion of the spinal
cord. If this lesion is situated above the lumbar portion of the cord,
the type of paralysis is spastic ; if in the lumbar or sacral region, or
involving the cauda equina, there is often abolition of the reflexes and
flaccidity of some of the muscles. Paraplegia, therefore, occurs in trans-
verse or pressure myelitis, in tumor of the spinal cord, in hemorrhage
into the spinal cord, and as a result of traumatism. It is occasionally
produced by multiple neuritis of the legs, particularly that form known
as Landry's paralysis, or in alcoholic neuritis, by bilateral cerebral
lesions, and occasionally as a functional condition. Paraplegia brachi-
alis is a rare condition occurring chiefly as the result of a localized
meningitis in the cervical enlargement, particularly pachymeningitis
hypertrophica cervicalis. As the result of the destruction of the ante-
rior roots there is atrophy and degeneration of the muscles, and the
paralysis is flaccid. It may also occur in syringomyelia, and more
rarely as a result of traumatic injury to both sides of the brachial
plexus. Diplegia facialis is almost invariably the result of bilateral
facial palsy — that is, either neuritis or an injury to the facial nerve
after it leaves the medulla. The paralysis is, therefore, flaccid in
type, characterized by the loss of the normal folds, and the inability to
close the eyes and drooping of the corner of the mouth.
Multiple palsies are usually due to some general condition affecting
the peripheral neurons — thus, in multiple infantile palsy the anterior
cornua of the gray matter of the spinal cord are involved in various
situations. The paralysis is usually flaccid and incomplete — that is,
certain groups of muscles escape. In polyneuritis due to intoxication
or infection there may be paralysis either of certain groups of muscles,
particularly the extensors, or of the entire limb. This occurs most
frequently in poisoning by lead, arsenic, and alcohol, or in infectious
diseases, as beri-beri and diphtheria. The paralysis is nearly always
flaccid ; there is muscular atrophy, and the reactions of degeneration
ultimately appear. Local palsies are usually due also to lesions of the
peripheral neurons. Occasionally, however, a very small lesion in the
cortex will produce this condition. They are commonly the result of
some trauma injuring a single nerve- trunk. The paralysis is, of course,
flaccid, and the reactions of degeneration are present.
A congenital absence of complete atrophy of the muscle gives rise
to myopathic paralysis. In either case the diagnosis must usually be
made by careful anatomical examination, as in the course of a very
short time the patient learns to compensate the defect of the individual
muscle by the excessive action of others in its neighborhood. The
muscles most frequently affected by congenital absence are the pec-
torals, although many others also may be involved. Total atrophy
DISEASES OF THE NERVOUS SYSTEM. 979
occurs in various myopathies, but with extreme slowness. In a special
type of muscular atrophy (type of Duchenne-Aran) atrophy occurs in in-
dividual muscles or in small groups, and compensation is usually acquired
for a considerable time until the progress of the disease renders it no
longer possible.
Paresis is a term used to indicate partial loss of power in the volun-
tary muscles. In addition to the causes given for paralysis, it may be
produced by exhaustion. Paresis is of two kinds — that in which the
muscle is unable to exert its normal force at any time, and that in
which the muscle may exert its normal force for a brief period and
then rapidly becomes exhausted and insufficient. In the former there
is some deformity, such as foot-drop or wrist-drop. In the latter the
symptoms do not appear until some effort has been made. Paresis
may also be temporary, as after fatigue ; stationary, as in cases of
injury to the central nervous system ; or progressive, as in the myop-
athies. In the latter condition the muscles waste and lose their
power, but reactions of degeneration do not occur, and there are no
fibrillary twitchings. Ultimately, the condition may go on to absolute
paralysis. The power of the muscle may be tested very accurately by
means of the dynamometer. This consists of a steel spring with a
staff on one side and a sliding index on the other. The patient com-
presses the spring in the palm of the hand, and the amount of pressure
is indicated in pounds or kilogrammes upon the index. By various
mechanical devices the dynamometer may also be employed for the
other muscles of the body. Care should be taken when it is used that
the patient is not permitted to throw his weight against it. In using
the instrument it is chiefly important to regard not so much the abso-
lute power as the difference between the two sides, the degree of mus-
cular force normally present varying very greatly in different indi-
viduals. Clinically, it is often sufficient to have the patient squeeze
the physician's hand first with one hand and then with the other ; even
moderate differences being readily detected by this means. The patient
may also be instructed to resist passive movements, such as the exten-
sion of the flexed arm ; the flexion of the extended arm ; the lateral
movement of the head ; the opening of the eyelids, or the various
movements of the lower extremities.
Intermittent claudication is a term applied to indicate the occurrence
of transient, partial, or complete paresis or lameness. Sometimes the
patient will suddenly be unable to continue locomotion, and fall to the
ground ; at others, one limb will become weak, causing a m-onounced
limp and necessitating the aid of a crutch ; while in other instances
there is simply discomfort upon continued locomotion. This symptom
occurs in various forms of functional nervous diseases ; thus the peri-
odic paralysis of Goldflam, meralgia paraesthetica, and as an idiopathic
condition in diabetes and arterio-sclerosis.
Disturbances of movement, characterized by excessive or perverted
muscular activity, consist of ataxia, tremor, and spasm. By ataxia
is meant the inability to co-ordinate perfectly — that is, to give each
muscle its due share in the performance of any action. As a result
the movements are irregular and imperfect. Various types of ataxia
980 SPECIAL DIAGNOSIS.
have been distinguished : Spinal ataxia, in which the disturbances of
motion are more pronounced when the eyes are closed, and which is due
to disease of the posterior columns ; cerebellar ataxia, in which the dis-
turbances are equally severe when the eyes are opened or closed, but
disappear when the patient lies down ; cerebral ataxia, in which there
is loss of muscular sense and marked persistent inco-ordination of
movement, occurs as a result of injury to the parietal lobe ; pseudo-
ataxia, due to the weakness of certain groups of muscles, so that they
do not properly oppose the action of other groups. Finally, there is
a form of ataxia apparently due to anaesthesia of the skin and loss of
the muscular sense, in which the patient is able to perform movements
perfectly as long as he can watch the part with the eye, but as soon
as the eyes are closed the ataxia appears Ataxia may be tested in a
variety of ways. Ataxia of the upper extremities may be recognized
by directing the patient to touch the tip of the nose with the tip of
the forefinger, or to extend the arms and bring the tips of the
forefingers together with a rapid motion. In health, after one or
two trials, either of these movements can be done perfectly. When
ataxia is present they are carried out awkwardly, and the forefingers
are only brought in contact with each other or the tip of the nose after
several irregular coarse oscillations. The ataxia of the legs may be
tested by requesting the patient, lying upon his back, to touch some
object held above his feet with one of the toes, or to bring the heel of
one foot against the knee of the other. When the patient is erect the
ataxia may be tested by getting him to place the feet together, when
there may be some swaying that is usually very markedly increased
when the eyes are closed. If the ataxia is very slight it may be neces-
sary to get the patient to stand on one foot with the eyes closed, or
to attempt to step backward under the same conditions. Under these
circumstances a considerable swaying occurs that is more pronounced
than the swaying noticed in a normal person attempting to perform
the same movements. If the ataxia is at all pronounced it produces a
characteristic disturbance in the gait. (See Ataxic Gait.) Ataxia of
the head is difficult to detect. Some observers contend that a peculiar
form of grimacing, whenever the patient attempts to move the lips or
the eyes, or whenever the muscles of the face express some emotion, is
an ataxic condition due to overaction.
Tremor. This is a disturbance of motion characterized by an oscilla-
tion of the part or parts involved. Tremor may be of various kinds.
It may be fine or coarse, constant or irregular. It may disappear
upon voluntary effort or only be apparent when motion is attempted
(intention tremor). It may be the result of paralysis, paralytic tremor ;
of poisoning, toxic tremor ; of some functional nervous disease, as the
hysterical tremor ; or spasm of the muscle, spasmodic tremor ; or it may
occur as a family peculiarity without any discoverable cause, hereditary
or idiopathic tremor. Tremors are also classified as rapid, in which the
movements occur more than five times per second ; and slow, in which
the oscillations may occur at intervals of several seconds. Nearly all
forms of tremor are increased by placing the muscles upon a stretch.
Tremor can usually be recognized by simple inspection. In some cases
DISEASES OF THE NERVOUS SYSTEM. 981
it is necessary to use peculiar methods of detecting it. Ordinarily it is
sufficient, in order to detect tremor of the fingers, to get the patient to
extend them forcibly and keep them in that position. If the tremor,
however, is exceedingly fine, its effect may be exaggerated by attaching
long, light rods to the fingers, such as straws. This procedure is often
exceedingly useful in cases of tremor of the head or the feet. Tremors
may be recorded by attaching to the part affected rods whose ends are
furnished with a pencil or stylet which writes upon a moving roll of
paper. If a chronograph marks off seconds or fractions of a second
at the same time, it is possible to measure very accurately the rate of
oscillation. A more convenient method consists hi allowing the patient
to put the trembling part, for example, the hand, upon a small drum
which conveys each movement to an oscillatory stylet that marks upon
a piece of smoked glass or paper. Seconds should be marked at the
same time. Persistent fine tremor occurs particularly in paralysis
agitans. In this the movements in the fingers are those of flexion
and extension and of opposition in the thumb, and it has, therefore,
been spoken of as the pill-roller's tremor. It also occurs not infre-
quently in exophthalmic goitre and as hereditary or idiopathic tremor.
Irregular tremors occur as a manifestation of ataxia, often with cere-
bral lesions (the paralytic tremor), and after intoxications, as alcohol
and tobacco. The hysterical tremor may be either irregular or regular.
Its character is largely influenced by surrounding circumstances ; thus
if the hysterical patient be in the hospital ward and have an oppor-
tunity of seeing a Case of paralysis agitans, the tremor peculiar to that
condition is often closely reproduced. Ordinarily, however, the hys-
terical tremor, being the result of voluntary and variable effort, is
irregular. Intention tremor occurs particularly in multiple sclerosis.
In this condition no tremor is observed while the parts are at rest, but
as soon as voluntary motion is attempted a violent tremor ensues, and
continues until the effort ceases. Such a tremor can be particularly
well elicited by asking the patient to convey a glass of water to his
mouth. The movements become more and more violent as the lips are
approached, and frequently more or less of the water is spilled. It may
also be tested by asking the patient to touch with the forefinger some
object. It will be observed, as the finger approaches, that the oscilla-
tions become more vigorous and wider. Intention tremor may, of
course, be present in other parts of the body. Generalized tremors
are spoken of as convulsions or convulsive movements (q. v.).
Muscular Spasm. By this is meant a condition in which the
muscle is involuntarily but forcibly contracted, either persistently
(tonic or tetanic spasm) or rhythmically (clonic spasm). Tonic spasms
are characterized by the vigorous contraction of the muscle, which
becomes hard and painful. If only one group of muscles is affected,
as, for example, the calf, the joint controlled by this group is placed in
the position normally assumed when they are active. If all the muscles
of the limb or even antagonistic groups are affected, the flexors usually
overcome the extensors. This, however, is not invariably the case.
When all the muscles of the body are involved, the powerful muscles
of the back usually arch the spinal column, and there is a more or less
982 SPECIAL DIAGNOSIS.
severe opisthotonos. Tonic spasms can usually be diagnosticated by
simple inspection. They occur particularly in tetanus, strychnine-
poisoning, and hysteria, and in these conditions may often be produced
by peripheral irritation. Localized spasms in the upper extremities
may occur as a result of disease of the cord above the cervical enlarge-
ment, or of the brain, producing a spastic condition of the muscles.
This is rare. A more common type is the peculiar form of spasm
seen in tetany, consisting in the closure of the fingers and the opposi-
tion of the thumb, giving rise to the so-called obstetrical hand. Spasms
in certain individual muscles of the hand or arm occur in the occupation
neuroses. Spasms of the lower extremities are also occasioned by the
various conditions giving rise to spasticity of the muscles. An idio-
pathic form of spasm not infrequently occurs in the calf muscles, par-
ticularly on awakening. It appears to be of no clinical significance.
Hysterical spasms are of various types. The tonic forms may affect a
single limb or even a single group of muscles, and may persist for long
periods of time, giving rise either to extension or persistent flexion of
the limb. In the latter case shortening may ultimately ensue and
cause persistence of the deformity. General hysterical spasms usually
can be recognized by the fact that the patient assumes some extraor-
dinary posture, as opisthotonos, pleurosthotonos, and emprosthotonos.
These spasms are often precipitated by pressure upon some sensitive
point (hysterogenic zone, ovaria), and may sometimes be abolished
by pressing upon the same or a corresponding portion of the body. A
peculiar form of localized tonic spasm is that occurring in the masseters,
known as trismus. The myotonic reaction is frequently spoken of as a
form of tetanic spasm. It consists of a sudden, persistent contraction
of the muscle or groups of muscles with which some voluntary move-
ment has been attempted. It occurs, as far as is known, only in Thom-
son's disease. Clonic spasms are of various types. They may affect a
single extremity, half the body, or, in rare cases, the whole body. The
movements are usually rhythmical, and vary greatly in different cases.
The most frequent causes of clonic spasms are the injuries to the brain.
Focal irritation in the motor region will produce at first a spasm in the
part innervated by that area. If the irritation is sufficiently strong, or
acts for a sufficiently long time, its influence will extend to the adjacent
areas in the cortex, and a general unilateral or bilateral convulsion will
ensue. This is the so-called epileptiform attack. If the local spasm
is distinct and precedes by some time the development of the general
twitching, it is spoken of as focal, or Jacksonian epilepsy. As a result
jf the violent irritation in the brain, unconsciousness usually ensues,
but not invariably. Clonic convulsions may possibly be of local origin,
although this is exceedingly doubtful. Ankle clonus, however, and
patellar clonus bear a certain resemblance to this symptom of disease.
A localized form of clonic spasm, due to peripheral irritation in all
likelihood, is facial tic, characterized by occasional or successive light-
ning-like contractions of the muscles of the face. Functional con-
vulsions, particularly those occurring in hysterical patients, are very
frequently clonic in character. Often there will be a preliminary
tetanic spasm, followed in a short time by the development of clonic
DTSEASES OF THE NERVOUS SYSTEM. 983
movements. These assume various forms, the commonest being per-
haps beating with the limbs, throwing of the head from side to side,
and lateral or antero-posterior movements of the body. The attitudes
and movements express fear, threat, ecstasy, eroticism, or other emo-
tional states.
Allied to the clonic spasms, but bearing also close affinity to tremors,
are the irregular movements that occur in chorea and athetosis. The
typical movement of chorea is an irregular innervation of groups of
muscles that appears to be voluntary in character, but that is not under
the control of the patient, is much more rapid, as a rule, than a volun-
tary movement, and recurs at very frequent intervals. Choreic move-
ments may be mild, or so severe that they produce irregular contortions
of the body, causing the patient to throw himself or herself from side
to side, and often producing severe bodily injuries and even death by
exhaustion. Athetosis is a name given to a peculiar, slow, irregularly
rhythmical movement of the extremities, generally spoken of as worm-
like in character. It is ordinarily most marked in the fingers. In
movement these are gradually extended until they form almost a right
angle with the back of the hand, and then slowly flexed and extended
again, each finger moving more or less independently of the others.
At the same time there is movement at the wrist-joint, the elbow, and
sometimes of the trunk. The limbs may be affected, giving rise to a
curious, staggering gait in which the patient seems ever to be about to
lose his equilibrium, but maintains it almost by a miracle. Frequently
the muscles of the face are involved, giving rise to curious, irregular
grimaces and more or less disturbance of speech or dysarthria. The
movements are usually continuous. Athetosis is a very common sequel
to cerebral lesions occurring in early childhood.
The term convulsion is used to designate general spasm with loss of
consciousness. It is often employed, however, to indicate general clonic
spasm of the whole body, even if consciousness be still present. This
use is undesirable, and should be avoided. General convulsions inva-
riably indicate some disturbance in the brain. If this is organic, it
may be either some chronic disease with occasional exacerbation of
cortical irritation, or some acute injury or some disease, such as men-
ingitis. If it is some functional disturbance, it may be hysteria or
epilepsy. (The latter is, of course, usually due to organic lesions.)
The term muscular tone means that condition of the voluntary
muscles of the body by which they are maintained in a state of tension
sufficient to enable them to respond promptly to nervous innervation.
Muscular tone varies slightly under normal conditions. It is less in
profound fatigue, and when the attention is distracted by external
objects ; it is more marked when the patient concentrates his attention
upon the part being tested. It is invariably diminished after lesions
of the peripheral motor neuron, in cases of profound cachexia, in coma,
and during anaesthesia. It is also generally decreased in lesions of the
posterior columns of the spinal cord. It is increased in lesions of the
central motor neuron without involvement of the peripheral neuron, in
neurasthenia, hysteria, and in conditions affecting the brain as a whole,
such as meningitis, brain tumor, etc. It must be remembered that
984 SPECIAL DIAGNOSIS.
flaccid paralysis does not necessarily imply diminished muscle tone ;
thus in the early stages of hemiplegia the muscles are completely
relaxed, but, nevertheless, the reflexes are usually increased. There
are two methods of testing this quality : First, passive movements ;
second, the tendon reflexes. In the former the limb to be tested is
grasped firmly, and, if flexed, is suddenly but not too forcibly ex-
tended, or, if extended, is flexed. If the muscle tone is normal there
may be a transient, involuntary resistance at first, but this disappears
very soon, and then the limb may be moved in any position with com-
paratively slight effort. Any of the joints may be tested independently
in this manner. It is important to inform the patient what is to be
done and what is to be tested. In children, in the ignorant, and in the
insane it is often almost impossible to overcome the tendency to volun-
tary resistance, which is usually increased by the anxiety produced by
the examinatiou. Occasionally it is necessary to take some measures
to distract the attention, such as giving the patient a sum in arithmetic
to perform, requesting him to look at the ceiling or some particular
object, or engaging him in conversation. Increase of the muscle tone
is determined by increased resistance to passive movements. This may
be so great that it is almost impossible to bend the limb at any of the
joints, or so slight that it is difficult to discriminate it from the normal
condition.
The exaggerated forms are usually spoken of as spasticity of the
muscles, and when associated with paretic or paralytic conditions the
term spastic paralysis is employed. Diminution of the muscle-tone is
usually difficult to detect by passive movements alone. When it is
entirely lost the lhnb is spoken of as flail-like. The joints seem to
have no tendency to remain in one position. If the limb is shaken,
with every movement they pass from extension to flexion, or vice versa.
Under these circumstances the passive movements are entirely unre-
sisted, the only effort necessary being that required to overcome the
weight of the limb itself.
The Texdox Reflexes. These were first described by TVestphal
in connection with the reflexes of the knee. They consist essentially
of a rapid twitch or succession of twitches in the muscle when the
tendon by which it is attached to some bony part is struck a sharp
blow. There is some difference of opinion regarding the true nature
of the stimulus required to produce them. According to Gowers, it is
a simple extension of the muscle, and he, therefore, uses the term myo-
tome phenomenon. Sternberg, on the other hand, believes that he has
shown that they are the result of vibrations in the tendon, which are
communicated by it to the muscle. Others contend that they are pure
reflexes produced by the mechanical action of the blow upon the nerve-
fibres in the tendon itself. It is certain, at any rate, that more factors
are required than the mere tone of the muscle, and that afferent im-
pulses to the spinal cord and efferent impulses from it are necessary to
the development of the reflex; and that it is furthermore profoundly
influenced by higher centres that usually have an inhibitory action
(upper reflex arc). The question is complicated by the fact that in
certain cases the reflexes may be elicited by tapping the bony parts, such
DISEASES OF THE NERVOUS SYSTEM. 985
as the periosteal reflexes ; by irritating the skin overlying the muscles,
as the cutaneous reflexes ; or by tapping upon the fascia or the belly
of the muscle itself. In general, it may be said that all conditions pro-
ducing increased muscular tone produce exaggeration of the reflexes,
and that all conditions diminishing muscular tone diminish the reflexes.
In marked contradiction to this, however, are the facts that attention to
the reflex, being tested, will diminish or abolish it completely, whereas
distraction of the attention, which ordinarily diminishes muscular tone,
increases the force of the reflex. Moreover, in certain forms of pro-
found coma, where the muscle tone appears to be at a minimum, the
reflexes appear to be often greatly exaggerated. Thus, in uraemia and
diabetic coma, I have been able on several occasions to detect exaggera-
tion of the reflexes when the limbs were flail-like in their relaxation.
The individual reflexes of the head are practically limited to the chin-
jerk. This is elicited by having the patient open his mouth slightly,
then a flat object, such as a tongue depressor, or the handle of a spoon, is
placed upon the teeth of the lower jaw and sharply tapped with the
finger or hammer. Under normal circumstances there will be a slight
upward jerk of the chin. It may also be elicited with less discomfort
to the patient by placing the finger beneath the lower lip and upon the
mental prominence and striking it sharply with the hammer. This does
not always result in a reflex under normal conditions, but is quite satis-
factory for the purpose of testing pathological exaggeration. The chin-
jerk is nearly always increased in neurasthenia and hysteria, and is
sometimes present in profound coma. In the conditions of general
spasticity that are occasionally met with in severe infectious disease it
is also usually exaggerated. Its absence does not appear to be of any
pathological significance. Allied to the tendon or peritoneal reflexes
is the phenomena known as Chvostek's sign. This occurs only in tetany,
and consists of a sudden lightning-like twitching of the muscles of the
face, particularly the elevators of the angles of the lip and the muscles
of the eyelids. It is elicited by striking the skin below the zygomatic
arch just in front of the ear with the hammer. It was formerly sup-
posed that this was due to mechanical irritation of the trunk of the
facial nerve, but the same phenomenon can also be elicited by striking-
over the malar bone or in the region of the infra-orbital foramen. No
tendon reflexes have as yet been discovered for the muscles of the
trunk.
In the arms the most important are the bicipital, tricipital, and
the supinator reflexes. The bicipital reflex is best obtained by allow-
ing the patient to rest the perfectly relaxed arm upon some support,
for example, the arm of the investigator in a semi-flexed position.
The finger or thumb is then placed upon the tendon of the biceps, and
struck a sharp blow with the hammer or the finger, as in percussing.
In nearly all normal cases a slight twitching or distinct contraction of
the biceps can be obtained in this manner. Sometimes it is possible,
by resting the arm upon a support, to see the tendon distinctly and to
strike it directly, but this is usually much less satisfactory. The tri-
cipital reflex is readily obtained by holding the arm semi-flexed and
relaxed, and then striking just above the olecranon process of the ulna.
986 SPECIAL DIAGNOSIS.
The supinator reflex is obtained by striking the radius just above the
styloid process. These reflexes are particularly distinct in hemiplegia,
upon the paralyzed side. They also occur in the general conditions
above mentioned. Their absence is of no pathological significance, as
it is often impossible to obtain them in normal individuals. In addi-
tion a reflex may be obtained by striking the bodies of the extensor
muscles of the forearm, giving rise to extension of the fingers. A
form of wrist clonus occasionally occurs that may be elicited by sud-
denly flexing the wrist-joint either dorsally or ventrally, and holding
it in the cramped position. The hypothenar reflex is the contraction
produced in the palmaris brevis by pressure upon the pisiform bone.
It does not appear to be dependent upon any diseased condition. Tap-
ping upon the bodies of the muscles sometimes gives rise to a sharp
contraction. This is particularly observed in connection with the
shoulder muscles (Striimpell) and pectoral muscles. An important
reflex, the abdominal reflex, is elicited by drawing the end of a blunt
object obliquely across the skin of the abdomen downward and out-
ward or upward and inward, the object being to make it cross the line
of the intercostal nerves as nearly as possible at a right angle. This
produces contraction in the muscles innervated by these nerves, and
is due to the stimulation of their cutaneous distribution. It may be
exaggerated in functional nervous conditions, and is diminished in
cases of hemiplegia and anaesthesia on the anaesthetic sides. Its absence
at some particular point occasionally serves as an additional factor in
the localization of lesions of the spinal cord. Various reflexes, prob-
ably periosteal or fascial in nature, may be produced by tapping upon
the spinous processes of the ilium. As far as is known, they are hot
of any clinical value.
The reflexes of the lower extremities are the most important of
all. The first discovered, the knee-jerk, is invariably present hi health,
and by its delicacy and constancy is the most valuable reflex for clin-
ical purposes. It may be elicited in a variety of ways. Perhaps
the best method is to have the patient lie upon his back : then placing
one hand under the knee it should be lifted several inches from the
surface of the bed or table until the leg and thigh form an obtuse
angle of about 120°. Then with the finger, the side of the hand,
the edge of the stethoscope, or the percussion hammer 1 it is struck a
sharp blow. The patellar tendon should be struck between the lower
edge of the patella and the tuberculum of the tibia. The stroke should
be delivered with moderate force, and, according to the practice of most
clinicians, a single blow is sufficient, but sometimes the reflex is more
certainly elicited if several strokes are given in quick succession. The
most obvious and vigorous contraction occurs in the quadriceps of the
same side, causing the leg to be tipped upward suddenly and giving
rise to the name knee-jerk. In addition, the adductors of the same side
nearly always contract slightly, and occasionally the flexor muscles —
1 There are various forms of these — one with a heavy metal head and short, wooden
handle, the end of the metal head being covered with leather ; another, composed of a
wedge-shaped piece of rubber set in a light metal handle ; the latter is probably the
better.
DISEASES OF THE NERVOUS SYSTEM. 987
that is, the biceps, the semi-tenclinosus, and the semi-membranosus —
also contract. Frequently the adductors of the opposite side contract
very slightly in health, and sometimes quite vigorously in diseased
conditions {crossed-reflex). Other methods of obtaining this reflex are
to allow the patient to sit on a low chair with the leg extended forward,
until it forms a blunt angle with the thigh, with the heel resting upon
the ground. The patellar tendon is then struck as before. Clinically
it is usually sufficient when the patient is sitting in an ordinary chair
to have one leg thrown over the other, and hanging loosely and freely.
Occasionally it is difficult, on account of extreme relaxation of the
muscles, to stretch the tendon sufficiently to obtain the reflex by this
method, and Gowers suggests that under these circumstances the legs
should be completely flexed upon the thighs. It is often difficult to
discover the tendon, either on account of deformity of the joint or
because of an excess of fat tissue. In one case that I have observed,
in which extensive arthropathies existed, the knee-jerk was present,
but obtained with great difficulty, on account of the distortion of the
parts. The patellar tendon reflex, therefore, is a multiple muscular
reflex, producing phenomena of the opposite side, the so-called bilateral
reflex. It is said to be invariably present in health, but its intensity
varies considerably, and in some apparently healthy persons without
any evidence of disease of the spinal cord it is extremely difficult to
elicit. Under these circumstances it is necessary to use various pro-
cedures in order to make it evident. These consist either in requesting
the patient to look at the ceiling, in order to distract the attention, or
to perform some violent muscular effort, such as an attempt to pull the
hands apart when they are clasped together, to squeeze the dynamom-
eter, etc. Under these circumstances the knee-jerk, if obtained, is
spoken of as reinforced. It is always important to have the muscles
completely relaxed, and to prevail upon the patient not to think of
what is being done. The knee-jerk is sometimes rendered more pro-
nounced by emotion, and sometimes inhibited, as, for example, by
fright. The arc of the knee-jerk is situated in the first lumbar seg-
ment of the cord, but probably occasionally deviates slightly from this
position, being either higher or lower. The knee-jerk is, therefore,
invariably increased in any disease of the pyramidal tracts above this
point. It is diminished in disease of the efferent or afferent fibres.
Its absence in tabes dorsalis was noted early, and has long been con-
sidered evidence of disease of the posterior columns. Closely allied to
the knee-jerk in its clinical significance and mode of occurrence is the
patellar reflex. This is elicited usually by placing the finger transversely
above the patellar, pushing the bone forcibly down, and then striking
the finger with the hammer. Ordinarily a distinct, pronounced con-
traction of the quadriceps alone is produced. In order to elicit this
reflex the leg must be extended and relaxed. Patellar clonus occasion-
ally occurs, and is obtained by placing the thumb and forefinger oil the
upper edge of the patella and pushing it forcibly downward and keep-
ing it in that situation. If clonus occurs it will be characterized by a
series of rapid contractions of the quadriceps, resulting in a vertical
oscillation of the patella. It occurs in disease of the spinal cord, and
988 SPECIAL DIAGNOSIS.
not infrequently in conditions of increased tonicity in general infectious
diseases. 1
In general it may be said that the mechanical effort is dependent
upon the condition of the nutrition of the quadriceps and the amount
of interference of the opposing muscles. Exaggeration of the knee-
jerk is characterized by a more vigorous effort or more extensive con-
traction of the surrounding muscles. The latter, indeed, may, by the
involvement of the flexors, diminish the excursion of the leg. Some-
times in cases of profound emaciation, as in cachexia, although the
knee-jerk is increased and the muscle apparently contracts vigorously,
its power is so greatly diminished that it is unable to move the leg.
Elaborate mechanisms, therefore, that have been devised for meas-
uring the knee-jerk do measure in fact only the amount of movement
of the foot, and are practically worthless. They consist essentially of
an arc of a circle whose radius is approximately equal to the length of
the leg. Either a pencil or a small readily movable index is placed
against the foot, and the knee-jerk is measured by the number of de-
grees marked off on the scale. It is manifest that comparisons are
only valuable when the blow is of exactly the same force, and then
only when the experiments are performed upon the same individual
within a limited period of time. In order to obtain a constant force
of blow various instruments have been devised, the simplest being
weights dropped through a paper cylinder upon the patellar tendon,
and the more complicated having springs for their motive power.
Tendon reflexes may also be obtained by tapping upon the hamstring
tendons. They are of no particular value. Tapping upon the inner
condyle of the tibia often produces contraction of the adductor muscles,
but this is not, as a rule, as pronounced as the contraction produced by
the percussion upon the patellar tendon. Next in importance to the
patellar reflex is the Ackillis tendon reflex, which consists of the contrac-
tion of the gastrocnemius and soleus muscles when the Achillis tendon
is struck. It is most readily elicited by lifting the entire leg from the
bed or table, and holding it by the ball of the foot, which is gently
pressed upward. The tendon is thus moderately stretched, and may
be struck directly. In nearly all healthy individuals this reflex is
present, but is absent in some, and its absence is apparently of no clin-
ical significance. Exaggeration may be indicated in moderate cases by
the more forcible extension of the foot. In more pronounced cases it
gives rise to a peculiar and characteristic phenomenon, known as ankle
clonus. This may be elicited by tapping the tendon once vigorously or
several times in succession when the leg is held in the manner described,
but is more readily produced by slightly flexing the leg and thigh, then
grasping the ball of the foot firmly, flexing it dorsally with considerable
force, and holding it in that position. When ankle clonus exists there
will be violent vibratory oscillations of the foot, as long as the pressure
upon the sole is continued, that vary from two to three up to five or
1 Dr. Mills has devised an ingenious instrument, consisting of a metal ring with a
curved handle, by which the patella may be drawn downward and the jerk or clonus
more certainly elicited.
DISEASES OF THE NERVOUS SYSTEM. 989
ten movements per second. There is usually a rhythmical increase and
decrease in the rapidity , without absolute cessation at any time. Occa-
sionally, in very mild cases, the clonus after a few movements becomes
weaker, and rapidly disappears. Ankle clonus is supposed to indicate
the existence of a lesion above the second lumbar segment of the spinal
cord that seriously interferes with the function of the pyramidal tract.
For a long time there has been doubt as to whether it occurs in func-
tional disease, but it seems now to be established that it does. Its
occurrence in functional conditions is, however, of such extreme rarity
that when it is present organic disease should always be suspected. It
is most characteristic in spastic paraplegia, either due to transverse
myelitis, to lateral sclerosis, or to syringomyelia. It also occurs after
lesions in the motor regions of the brain. It can sometimes be elicited
by supporting the weight of the leg upon the toe. Under these circum-
stances it develops spontaneously in organic conditions, and sometimes
in fatigue, cold, or exhaustion. It may also be produced in normal
persons who continue for a sufficient length of time voluntary oscilla-
tory movements of the foot supported in this manner. A pseudo-ankle
clonus has been described as characterized by a few irregular oscilla-
tions that soon cease. It occurs in functional disease and occasionally
among malingerers. Tapping upon the tendon of the great toe occa-
sionally produces a slight contraction of that member. The other
reflexes of the lower extremities are front tap, dorsal extension of the
toes upon percussion of the anterior surface of the tibia, and the toe
reflex — that is, slight flexion of the toes when the skin of the sole is
irritated. This, according to Babinsky, is replaced by a dorsal flexion
of the toes when the pyramidal columns are involved, and disappears
in tabes dorsalis. The plantar reflex properly belongs to the group of
cutaneous reflexes. It is characterized by the involuntary withdrawal
of the foot when the sole is irritated. It is of course absent in cases
of anaesthesia, and is greatly exaggerated in functional nervous condi-
tions, occasionally giving rise to a peculiar general tremor of the leg or
even of the whole body. It is best elicited by drawing a blunt object
(pencil, handle of a stethoscope) across the surface of the foot.
Allied to the reflexes is the so-called paradoxical contraction of AVest-
phal. This consists in a persistent spasm of the muscle when its two
attachments are suddenly brought closer together. It is most fre-
quently observed in the peroneal muscles of the leg, and may be elicited
by suddenly flexing the foot dorsally. It occurs most frequently in
various functional conditions, and has also been observed in paralysis
agitans.
Next to the functional conditions of the muscles, which is indicated
by the degree of motility that they possess, we arc interested in the
state of their nutrition. It may be suspected that this is impaired
when fibrillary contractions or atrophy are present.
Atrophy of the muscles may usually be detected by simple inspection.
If only certain groups are involved, the latter will appear more or less
distorted. It is always, however, important to measure the injured
limb and compare it with the sound side if the affection is unilateral.
When due to general conditions, such as the muscular dystrophies or
990
SPECIAL DIAGNOSIS.
polyneuritis, it is sometimes more difficult to be certain of its existence.
A general atrophy of the muscular system also occurs in cachectic
states, such as the cachexia of carcinoma. Fibrillary twitchings occur
Thev are characterised
in muscles undergoing degenerative changes
Fir. 226.
M. occipit.
M. retrah. auric
N. auricul. post.
M. splenitis
N. accessorius
M. sternooleidom.
M. cueullaris
N. axillaris (M. deltoid.)
N. thoracic, long. (M. serr.
ant. maj.
Plexus brach.
M. temporal.
M. frontal.
M. corrugator super-
[cilii.
M. orbicul. palp.
> Nasal muscles.
jM. levat. lab. sup.
M. zygomaticus.
M. orbic. oris.
M. masseter. [talis.
]M. levator menti (men-
M. depressor lab. inf.
(quadr. meuti).
M. depressor ang. oris
(triangul. menti).
N. hypoglossus.
Platvsnia
M. sterDohyoideus.
M. omohyoideus.
pllrenicus.
M. sternotbyreoideus.
Erb's point (M. del-
toid., biceps, bracb.
int. supinator long.
N. thoracic ant. (M.
pect. maj.).
Motor points for the head and neck. (Sahli.)
by the sudden, spasmodic contraction of individual fibres in the mass
of the muscle itself, giving rise to a curious trembling of the overlying
skin and a peculiar sensation to the palpating hand, as if minute waves
were passing through the muscular substance. They often occur spon-
taneously, and in degenerating muscles may be elicited by slight median-
DISEASES OF THE NERVOUS SYSTEM. 991
ical stimuli, such as cold, percussion, or shock. Fibrillary twitchings
may also occur in healthy muscles that have either been chilled (tremor
or shivering) or subjected to severe fatigue.
The most reliable method of diagnosis is by an electrical examina-
tion. For this purpose we use two types of apparatus. The galvanic
current is produced by the galvanic battery, consisting of a number of
cells, each containing an electro-positive and electro-negative element
and filled with battery fluid. Long wires are attached to the battery,
through which the current flows when they are brought in contact or
the circuit closed, and ceases when they are kept apart or the circuit
opened. The free end of the wire toward which the current flows
from the cell is called the anode, and the free end from which the
current passes to the cell, the cathode ; then, if any substance is intro-
duced between these ends of the wire, closing the circuit, the current
passes through it from the anode or positive pole to the cathode or
negative pole. It is customary to introduce into the circuit for meas-
uring the amount of electricity employed a galvanometer, which is
graduated in milliamperes. 1 As it is important to employ a definite
number of milliamperes, the apparatus is also provided with a rheostat,
which renders it possible by the introduction of a greater or less degree
of resistance to regulate the amount of electricity passing through the
body. The free ends of the wire are, for medical purposes, supplied
with electrodes. These consist essentially of metal disks or plates
to which the wire is attached, provided with a wooden or hard rubber
non-conducting handle. As the resistance normally offered by the
skin is greatly reduced if it be moistened, the ends of the electrodes
are covered with cotton or gauze and moistened by immersion in either
plain or salt water. The area of the cross-section of the electrode may
vary considerably. Ordinarily, it is customary to have one very large
electrode, from 50 to 100 square centimetres in area, and one exactly
3 square centimetres in area. (Stintzing's standard electrode.) In
addition, for therapeutic purposes, it is customary to have for the
galvanic and faradic apparatus a wire brush and various special elec-
trodes for application to the more inaccessible portions of the body.
If a muscle or nerve is to be investigated the large electrode is thor-
oughly moistened and placed over the back or the sternum. It is
not advisable to place it over the neck nor to allow the patient to hold
it in the hand. The current is so arranged that this large electrode is
at first the anode and the small electrode the cathode. The cathode
is now placed over the muscle or the nerve to be stimulated, locating
it, if possible, exactly over the most sensitive (electrically) point. This
is most readily determined by comparison with the figures on pages 990
et seq. The circuit should be open and the rheostat so placed that the
minimum amount of current flows through the body. The circuit is
1 One milliampere equals 0.001 of an ampere. The ampere is the unit adopted for
the measure of the amount of current. It is determined by dividing the unit of
electromotive force, one volt— that is, 0.0 of the amount of current liberated by a
freshly filled Daniell cell, divided by 1 ohm — that is, the amount of current required
to overcome a unit of standard resistance, or a column pf mercury 1.06 metres in
length and 1 square millimetre in cross-section.
992
SPECIAL DIAGNOSIS.
now rapidly opened and closed, while the cathode is kept in position
and the rheostat gradually moved around until the current is strong
enough to produce a slight twitching of the muscle. This will first
occur at the making of the circuit, and is spoken of as cathodal closing
contraction, or CCC. The current should now be slightly increased,
and by means of a switch the small electrode converted into the anode
and the other into the cathode. It will soon be observed that a con-
traction takes place both at opening and closing the current. This is
spoken of as the anodal closing contraction, or ACC, and the anodal
opening contraction, or AOC. If the small electrode be again made
Fig. 227.
Rectus abdominis.
Intercostal nerves.
Serratus magnus.
Latissimus dorsi.
Intercostal nerves.
Transversus
abdominis.
Diagram of the motor points of the trunk. (Prom Von Ziemssen.)
the cathode, it will be found that there is a vigorous contraction when
the current is closed, but none when it is opened. Finally, if the cur-
rent is made still stronger, it will be found that the closure of the
current produces at the cathode no longer a simple lightning-like con-
traction, but a prolonged cramp of the muscle, spoken of as cathodal
closing tetanus, or CCTe. The contraction produced by both opening
and closing the current at the anode is now much stronger than before,
and there will probably appear a slight contraction at the opening of
the cathode, the cathodal opening contraction, or COC —that is to say,
with gradual, increasing current the order of contraction is as follows
in a normal muscle : cathodal closing contraction, anodal closing con-
traction, anodal opening contraction, cathodal closing tetanus, cathodal
DISEASES OF THE NERVOUS SYSTEM.
993
opening contraction. Under ordinary circumstances the healthy mnscle
contracts suddenly and relaxes almost immediately. Various modi-
fications of these phenomena occur in diseased conditions, and there are
considerable quantitative changes between the different muscles in
health. Thus, in the muscles of the face contraction is always more
Diagram of the motor points of the arm, under side.
1. Musculocutaneous nerve. 2. Musculocutaneous nerve,
triceps. 6. Median nerve. 8. Brachialis anticus. 10. Ulnar nerve,
nerve to the pronator teres.
(From Vox Ziemssen.)
3 Biceps. 4. Internal nerve of
12. Branch of median
rapid than in those of the thigh, and can be elicited with much weaker
currents. In disease we recognize three types of alteration : First,
quantitative changes ; second, quantitative qualitative changes ; third,
pure qualitative changes. Before discussing these it is necessary to
describe the faradic apparatus. This consists essentially of a coil of
wire through which flows an electric current, that forms the core for a
Motor points of the arm, outer side. (From Von Ziemssi v i
1. External head of triceps. 2. Musculo-spinil nerve. 3. Brachialis anticus. -1. Supinator
longus. 5. Extensor carpi radialis longior. 6. Extensor carpi radialis hrevior.
second coil not attached to it. If, now, the current passing through
the inner or primary coil is interrupted, there will be generated, at each
opening of the current, a current in the outer or secondary coil, going
in the opposite direction, and, at each closure, a current going in the
same direction. This is usually the stronger, and, if the interruptions
63
994
SPECIAL DIAGNOSIS.
are sufficiently rapid, dominates the reversed current. The ends of the
secondary coil are attached to the electrodes. The strength of the cur-
rent is altered by moving the inner coil away from the secondary coil.
Fig. 231.
Motor points of forearm, inner surface. Motor points of forearm, outer surface.
(From Vo.v Ziemssen.)
Fig. 230.— 1. Flexor carpi radialis. 2. Branch of the median nerve for the pronator teres. 3.
Flexor profundus digitorum. 4. Palmaris longus. 5. Flexor sublimis digitorum. 6. Flexor
carpi ulnaris. 7. Flexor longus pollicis. 8. Flexor sublimis digitorum (middle and ring fingers).
9. Median nerve. 10. Ulnar nerve. 11. Abductor pollicis. 12. Flexor sublimis digitorum (index
and little finger). 13. Opponens pollicis. 14. Deep branch of ulnar nerve. 15. Flexor brevis
pollicis. 16. Palmaris brevis. 17. Adductor pollicis. 18. Adductor minimi digiti. 19. Lumbri-
calis (first). 20. Flexor brevis minimi digiti. 22. Opponens minimi digiti. 24. Lumbricales
(second, third, and fourth).
Fig. 231.— 1. Extensor carpi ulnaris. 2. Supinator longus. 3. Extensor minimi digiti. 4. Ex-
tensor carpi radialis longior. 5. Extensor indicis. 6. Extensor carpi radialis brevior. 7. Extensor
secundi internodii pollicis. 8. Extensor communis digitorum. 9. Abductor minimi digiti. 10.
Extensor indicis. 11. Dorsal interosseus (fourth). 12. Extensor indicis and extensor ossis meta-
carpi pollicis. 14. Extensor ossis metacarpi pollicis. 16. Extensor primi internodii pollicis. 18.
Flexor longus pollicis. 20. Dorsal interossei.
DISEASES OF THE NERVOUS SYSTEM.
995
This is spoken of as the distance between the coils, and is measured in
inches or centimetres. It is manifest that this method for measuring
is not absolute, but its value must be determined for each particular
machine. This can only be done by the physiological test — that is,
measuring the force required to produce contractions in some muscles
and then comparing it with the known value for this muscle obtained by
a standard machine, and obtaining in this way the ratio. The current
Fig. 232.
Fig. 233.
....5
02 9
Motor points of thigh, anterior surface. Posterior surface.
(From Von Ziemssen.)
Fig. 232. — 1. Tensor vaginae femoris (branch of superior gluteal nerve). 2. Anterior crural nerve.
3. Tensor vaginse femoris (branch of crural nerve). 4. Obturator nerve. 5. Rectus femoris. 6. Sar-
torius. 7. Vastus externus. 8. Adductor longus. 9. Vastus externus. 10. Branch of crural nerve
to quadriceps extensor cruris. 12. Crureus. 14. Branch of crural nerve to vastus externus.
Fig. 233.— 1. Adductor magnus. 2. Inferior gluteal nerve for gluteus maximus. 3. Semi-tendin-
osus. 4. Great sciatic nerve. 5. Semi-membranosus. 6. Long head of biceps. 7. Gastrocnemius
(internal head). 8. Short head of biceps. 10. Posterior tibial nerve. 12. Peroneal nerve. 14. Gas-
trocnemius (external head). 16. Soleus.
is, of course, increased when the secondary coil is directly over the
primary one and diminished when the primary coil is withdrawn. As
the current in the secondary coil is oscillatory — that is, going first in
one direction and then in the other — it is not theoretically possible to
speak of an anode and a cathode. Practically, however, the current
going in the same direction as that of the primary coil is the stronger,
and a difference does exist between the two ends of the wire, which are
996
SPECIAL DIAGNOSIS.
usually spoken of, therefore, as cathode and anode. A contraction pro-
duced by the faradic stream is always tetanic in health, as there are a
series of stimulations constantly passing through the muscle.
Fig. 234.
Fig. 235.
Motor points of the leg, outer side. Inner side.
(From Von Ziemssen.)
Fig. 234.— 1. Peroneal nerve. 2. Peroneus longus. 3. Gastrocnemius (external head). 4. Tibi-
alis anticus. 5. Soleus. 6. Extensor longus pollicis. 7. Extensor communis digitorum longus.
8. Branch of peroneal nerve for extensor brevis digitorum. 9. Peroneal brevis. 10. Dorsal inter-
ossei. 11. Soleus. 13. Flexor longus pollicis. 15. Extensor brevis digitorum. 17. Abductor
minimi digiti.
Fig. 235.— 1. Gastrocnemius (internal head). 2. Soleus. 3. Flexor communis digitorum longus.
4. Posterior tibial nerve. 5. Abductor pollicis.
Alterations in the Reactions of the Muscles and Nerves
to Electricity. Reactions of Degeneration. Quantitative
alterations consist in increase or decrease of the susceptibility of the
muscles or nerves to electrical action. They may be determined in
case the lesion is unilateral by comparison with the normal side of the
body ; in case the lesion is bilateral, only by comparison with a stand-
ard table, such as has been furnished by Stintzing.
If the deviation
DISEASES OF THE NERVOUS SYSTEM.
997
from the normal is slight, the error has very likely been produced by
variation or alteration in the resistance of the skin. Quantitative
increase in the electrical reaction occurs chiefly in tetany, for which
disease it is almost pathognomonic, and has been spoken of as Erb's
sign. It occurs also occasionally in the early stages of hemiplegia, in
paralysis of the facial nerve, and has been noted in certain cases of
tabes dorsalis. Diminished electrical irritability occurs in all the forms
of idiopathic muscular dystrophy. It also occurs in those forms of
atrophy due to lesion of the central motor neuron without involve-
ment of the peripheral motor neuron. It also occurs in those atrophies
secondary to disease of the joints and loss of functional activity on the
part of the muscle. Diminished reaction may occur in hysteria and
profound neurasthenia, and has been observed in some cases of loco-
motor ataxia, and even in some cases of progressive spinal muscular
atrophy of exceedingly slow course. It also occurs in certain nervous
diseases whose nature is not yet understood, as in Goldflam's periodic
paralysis, although it is to be noted that there are other alterations in
the electrical reactions in this disease. The quantitative qualitative reac-
tion consists, first, of a diminution of the reaction of the muscle or the
nerve to the faradic current, and its diminution or exaggeration to the
galvanic current, with distinct alteration of the order in which the
various forms of galvanic irritation produce contractions. Cohn dis-
criminates three types of this form of degeneration : First, the complete
reaction, mild in character, and terminating in recovery ; second, the
complete reaction, severe and incurable; and, third, a partial reaction.
He gives the following table illustrating the various stages of these three
forms :
Total Reaction of Degenekation.
Moderate Form.
Indirect stimulation (nerve).
Direct stimulation (muscle).
1st stage, 1-8 days.
2d stage, 2-15 weeks.
F.
Diminished.
Lost.
G.
Diminished.
Lost.
F.
Diminished.
Lost.
3d stage, 6-30 weeks. Returning. Returning. Returning.
4th stage, later.
1st and 2d stages.
3d stage, after 6 weeks.
Subnormal. Subnormal. Subnormal.
Progressive Incurable Form.
As first and second stages above.
Lost. Lost. Lost.
G.
Diminished.
Increased, con-
traction slow.
AOOCCC.
Diminishing
contraction
more rapid.
AOC = or
>CCC.
Subnormal, no
qualitative
changes
Diminished
or lost.
AOOCCC.
1 By direct stimulation is meant the application of the electrode to the muscle itself-
By indirect stimulation is meant the application of the electrode to the motor nerve-
trunk. The latter term is employed because irritation of the nerve can only be detected
by the activity of the muscle, and the stimulation of the latter is, of course, in this
mode of application, indirect.
998
SPECIAL DIAGNOSIS.
Partial Reaction of Degeneration.
Indirect stimulation (nerve). Direct stimulation (muscle).
F.
G. F.
G.
1st stage.
1-8 days.
Normal or
Normal or Normal or
Normal or
diminished.
diminished, diminished.
diminished.
2d stage,
2-5 weeks.
Normal or
Normal or Normal or
Increased, con-
diminished.
diminished. diminished.
traction slow.
AOCKCCC.
3d stage.
6-12 weeks.
All normal oi
■ progressive form.
3d stage,
6 weeks.
Diminished
Diminished Diminished
Diminished
or lost.
or lost. or lost.
or lost.
Contraction
still slow.
AOC0 £oJ§^ ■■••.•.•.:::■•••-■ MB&Ws II
r V. mot.
I
Relative location of the nuclei of the different cranial nerves. (Edinger.)
behind it, and beneath the posterior corpora, is a small group of cells
for the pathetic nerve. The nucleus of the trigeminus is situated in
the anterior portion of the pons, just to the outer side of the fillet, the
motor group of cells lying inside the sensory group. The Gasserian
ganglion receives the peripheral branches of this nerve and corresponds
to the spinal ganglia. In addition the nerve receives a bundle of fibres
from the lower portion of the medulla. Disturbances of the nucleus
produce anaesthesia on the same side of the face, involving the conjunc-
tiva and the mucous membrane of the mouth. There is loss of taste in
the anterior' two-thirds of the tongue, and there is some disturbance of
smell in the nostril on the same side. At the same time the pterygoid
muscles are paralyzed and mastication is imperfect. Irritative lesions
cause tic douloureux. This may also be the result of disease of the
ganglion. The nucleus of the abducens lies in the posterior portion of
the pons, just beneath the floor of the fourth ventricle. Destructive
lesions cause internal strabismus. The nucleus of the facial nerve is
1020 SPECIAL DIAGNOSIS.
found in the posterior portion of the pons, lying slightly behind and to
the median side of the nuclei for the trigeminus. The fibres from this
nerve pass out first forward, then downward and backward, and arise
from the lateral surface of the medulla at its anterior extremity, pass-
ing forward over the pontine cerebellar tubercles. Destructive lesions
cause paralysis of the same side of the face, usually involving the upper
branch. (See Hemiplegia.) Irritative lesions cause facial tic. The
nucleus of the acusticus is found in the anterior portion of the medulla
oblongata, just beneath the floor of the fourth ventricle, lying just above
the superior olivary body. Lesions produce nerve or mental deafness
on the same side. The nuclei of the vagus and the glosso-pharyngeal
nerves are apparently in the jugular and petrosal ganglia — that is to
say, they are sensory nerves, and correspond to the sensory fibres enter-
ing the spinal cord. From these ganglia fibres pass into the medulla
oblongata at its lateral aspect, and end in a nucleus in the floor of the
fourth ventricle. The motor nucleus of the vagus is supposed to be
the nucleus ambiguus, situated just posteriorly to the olive in the poste-
rior portion of the floor of the fourth ventricle. Close to the median
line is the hypoglossal nucleus. Its destruction produces paralysis and
degenerative atrophy of the corresponding side of the tongue.
The functions of the pons are merely those of the centres and tracts
it contains, and therefore the symptoms are dependent upon the situ-
ation and greater or less amount of destruction that the lesions produce.
On account of the decussation of the central fibres for the facial nerve
in this region, crossed paralysis is usually considered pathognomonic of
pontine disease. The functions of the medulla are also largely dependent
upon the nuclei and tracts it contains. As it contains the centres for
the pneumogastric and some of the centres or tracts of fibres for respi-
ration, lesions in it are ordinarily followed very promptly by death.
Lesions of the restiform bodies — that is, the lower portion of the medul-
lary peduncle to the cerebellum — are frequently associated with nystag-
mus, and may cause the symptoms of cerebellar ataxia. As the medulla
contains the nuclei of the motor nerves to the pharynx, larynx and
mouth, paralysis of the muscles in this region is spoken of as bulbar
palsy.
The cerebellum is supposed to be concerned in co-ordination and
the maintenance of the equilibrium. The hemispheres may, however,
be extensively diseased without giving rise to any symptoms. If the
middle lobe is affected the characteristic manifestations are disturbance
of equilibrium and inco-ordination. The gait resembles that of a
drunken man, nystagmus is frequent, especially in cases of tumor.
Giddiness and vomiting sometimes occur, but are, however, of no
localizing value. The knee-jerk is often absent, but sometimes in-
creased and sometimes variable. If the pyramidal tracts' are pressed
upon it is always increased, and there is then weakness in the extremi-
ties. As a result of pressure there may be paralysis of the cranial
nerves, difficulty in articulation, and occasionally epileptiform convul-
sions. If the medullary peduncle is affected by an irritative lesion,
quite characteristic symptoms result. These are forced movements —
that is to say, the patient may have an irresistible tendency to fall
DISEASES OF THE NERVOUS SYSTEM. 1021
toward or lie upon one side. There are no symptoms diagnostic of
disease of the superior or middle peduncles. Disease of one side of
the pons may cause symptoms similar to those of cerebellar trouble.
Localization of Spinal Lesions. The spinal cord may be re-
garded in two ways : First, as the pathway between the peripheral
nervous system and the brain, containing the tracts running from the
brain to the motor nerves, and from the sensory nerves to the brain ;
second, as a number of groups of ganglion cells arranged in horizontal
layers or segments. These segments are usually classified according
to the nerve-roots that spring from them. There are, therefore, eight
cervical, twelve dorsal, five lumbar, and five sacral segments of the
cord. The white matter of the spinal cord is divided into two regions :
the antero-lateral part, extending from the median fissure to the poste-
rior horns, and the posterior part, lying between the posterior horns.
The antero-lateral part contains the motor fibres or pyramidal tracts,
whose functions have already been described. In addition, there are
certain fibres that pass downward whose functions are not certainly
known. The gray matter of the cord is divided into the anterior and
the posterior horns. It is composed of nerve-cells and nerve-fibres.
The nerve-cells in the anterior horns form a large group, which send
their axis-cylinders into the anterior roots, and comprise the peripheral
motor neurons. In the posterior horns, in the dorsal region, there is a
group of cells on the inner side known as the column of Clarke, which
apparently have something to do with equilibration. Other cells, whose
functions are not definitely known, are also found in the posterior
cornua. The gray matter also contains a large number of nerve-fibres,
some of which pass transversely and apparently are concerned in reflex
action ; others ascend, and convey to the brain the sensations of pain,
heat and cold. Each segment of the cord innervates and receives sen-
sory impressions from an approximately corresponding segment of the
body, and contains the lower reflex arcs. The motor and reflex func-
tions of the various segments are shown in the table and the sensory
functions in Fig. 244 and Fig. 245.
1022
SPECIAL DIAGNOSIS.
Table of Motor axd Beflex Functions of the Segment of the
Spjxal, Coed. Modified feom Gowees and Mullee.
Segments. Motor innervation. Reflex centres.
c.
1 \ Small rotators of head
2 J Depressors of hyoid
3 ) Diaphragm
4 J Platysma (?)
Scaleni.
Lev. ang. scapulse.
Cucullaris.
5 ] Deltoid
Biceps
I Coraco brachialis
}■ Supinator lougus
Spinati
| Serratus major
6 J Pectoral major (clay.) ] Pronators
| Triceps
7 1 Flexors of wrist and [ Extensors of wrist
fingers
I Pectoralis (costal}
I Subscapulars
I Latissimus dorsi
8 J Teres major
D.
1
2
3
4
5
Intercostal muscles
1
8
9
10 j f
I
J
J and fingers
") Muscles of hand
j- Extensors of thumb
I
J
1
Erectors of spine
Abdominal muscles
11
12
L.
1
Quadratus lumborum J
lleo psoas
Cremaster
Sartorius
Pectineus
Adductors
Quadriceps ~)
Gracilis
Obturator
Adductors
Flexors of knee
Gluteal
~| Dilatation of the pupil,
sensory part. (?)
Scapular.
Tendon reflexes of the
muscles of the arms.
Dilatation of pupil,
motor part. (?)
J J
Epigastric.
Abdominal.
Cremasteric.
Knee-jerk.
1
i
j- Gluteal reflex.
J
External rotators of thigh
Extensors of foot
Tibialis anticus
Peroneal muscles
Perineal and anal muscles
Achillis tendon reflex.
Plantar reflex.
Centres for the bladder
and rectum.
DISEASES OF THE NERVOUS SYSTEM.
Fig. 244. Fig. 245.
1023
(From Oppenheim.)
(From Oppenheim )
General Symptomatology of Le.sioxs of the Brain. Lesions
of the brain may be irritative or destructive. The former, if affecting
the motor tract, produce clonic spasms. If destructive, they produce
paralysis without atrophy, and cause increase in the muscle-tone by
the removal of the influence of the superior arc and exaggeration of
the reflexes. All these changes occur in the muscles of the opposite
side of the body. Irritative lesions are most likely to be extra-cerebral
— that is, pressing upon the cortex. Lesions in the brain-substance are
usually destructive, and, therefore, cause paralysis. As motor fibres
are distributed over a considerable area of the cortex, lesions in this
region, if circumscribed, are likely to cause monoplegia. If involving
the area for the face, the upper branch of the facial nerve, which is
innervated from both sides, is rarely involved. Aphasia only occurs
if the left side is destroyed. Lesions in the corona radiata near the
1024 SPECIAL DIAGNOSIS.
cortex usually cause monoplegia ; if near the internal capsule, hemi-
plegia is more common. Lesions in the internal capsule almost invari-
ably cause hemiplegia. If the knee and anterior portion of the posterior
limb are involved, hemiplegia without sensory changes results. If
they also affect the posterior third of the posterior limb, sensory dis-
turbances are present, and there is likely to be hemianopsia. Lesions
in the anterior portion of the anterior limb produce no recognizable
symptoms, and are termed latent. General disturbances of the brain may
be caused by increase of the intracranial pressure. This may be brought
about by growths, traumatism, oedema, or inflammation. There is usually
headache, delirium or coma, and vomiting. If the process is of slow
development, a certain amount of adaptation may occur, and only the
headache and vomiting may be present. The former is occasionally
sharply localized. In addition, if the pressure be long continued, there
is cedema of the optic nerve. (See Disorders of the Special Senses.)
General Symptoms of Disease of the Spinal Cord. These
depend upon the segment of the cord and upon the nerve-tracts in-
volved. Lesions are spoken of as transverse if they involve the whole
cord, unilateral if they involve but one side, and focal if they involve
only a circumscribed portion. Transverse lesions may be produced by
inflammation, by pressure either by a tumor or as a result of deformity
of the vertebral column (Pott's disease). Transverse lesions above
the fifth cervical segment usually cause death by paralysis of the
diaphragm. If the patient survive there is paralysis of all four
extremities and total anaesthesia of the body. There is also paralysis
of the bladder and rectum and abolition of the cutaneous reflexes, and,
in the majority of cases, of the tendon reflexes. Transverse lesions
between the fifth cervical and the first dorsal segments produce atrophy
and degeneration of certain muscles of the arm, according to their
situation. There is spastic paralysis of the legs and total anaesthesia
of the body as far up as the part that transmits sensation to the lowest
intact segment. There is paralysis of the bladder and rectum, aboli-
tion of the reflexes whose arcs are found in the segments involved, and
sometimes exaggeration of all the tendon reflexes that are completed in
the lower segments. The cutaneous reflexes are abolished. Lesions of
the dorsal region produce spastic paraplegia and paralysis of the bladder
and rectum. The arms escape entirely, and respiration is not disturbed.
The anaesthesia extends up to the segment involved. Lesions in the
lumbar region produce atrophy and degeneration of certain groups of
muscles in the legs, with paralysis and disturbances of sensation, dis-
tributed according to their extent. The situation of a lesion may be
roughly determined by a study of the reflexes. If the lesion involve
the segments concerned in any of these, they are, of course, abolished.
If the lesion is above them, they are sometimes exaggerated ; if below
them, they are ordinarily not involved. Lesions of the conus termin-
alis and the cauda, as they involve the large number of nerve-roots,
produce a complexity of symptoms. There are irregular areas of
anaesthesia corresponding to the posterior roots involved, and atrophy
and degeneration of the muscles supplied by the anterior roots. The
bladder and rectum usually are affected.
DISEASES OF THE NERVOUS SYSTEM. 1025
Unilateral Lesion of the Spinal Cord (the syndrome of Brown-Sequard).
This produces paralysis of the same side and anesthesia of the oppo-
site side, both symptoms extending as far upward as the region sup-
plied by the segment that has been affected. Disturbance of sensation
is not total. There is tactile anaesthesia, analgesia, and loss of tem-
perature-sense on the side opposite the lesion, but persistence of the
muscular sense, which, however, is diminished or lost on the same side
as the lesion. Disturbance of motion is complete. Atrophy and de-
generation occur in the muscles supplied by the involved segment ;
below this there is spastic paralysis, with increase in the reflexes.
Above the paralytic area there is a zone of hyperesthesia that has
never been satisfactorily explained. The commonest cause of unilat-
eral lesion is traumatism, particularly bullet and stab wounds. Occa-
sionally the symptoms develop in the early stages of syringomyelia or
as a result of tumor or hemorrhage of the spinal cord. Focal lesions
in the spinal cord produce various symptoms, according to their situa-
tion. Inflammations involving the gray matter are commonly spoken
of as poliomyelitis. They usually attack the anterior cornua and in-
volve only the peripheral motor neuron — that is, they produce paralysis,
atrophy, and degeneration of the muscles. Inflammatory lesions in the
white matter are spoken of as leukomyelitis. They produce symptoms
according to the tracts they involve.
The Cranial Nerves. The olfactory, optic, oculomotor, pathetic,
abducens, auditory, and glosso-pharyngeal have already been described
in connection with the special senses. The trigeminal nerve takes its
origin from the centres in the pons and medulla already described.
Destructive lesions of the motor portion cause paralysis of the ptery-
goid muscles. If they are unilateral it is impossible for the patient
to move the mouth toward the opposite side when the lower jaw is pro-
truded. It is to be assumed that atrophy and degeneration of these
muscles occur, but their electrical examination is practically impossible.
Irritative lesions produce cramp known as trismus. This is, of course,
usually due to central disease. The sensory portion of the trigeminus
supplies the skin of the face and the mucous membranes of the cavities
of the head. The distribution of the three branches is shown in Fig.
246. Irritative lesions produce tic douloureux ; destructive lesions,
anaesthesia in the distribution of the part affected. The facial nerve
arises from the nuclei in the posterior portion of the pons. These are
probably double, each supplying a separate branch of the nerve, and
the superior nucleus is innervated from both sides of the cerebrum. It
is the motor nerve for the muscles of the face, and supplies the tem-
poral, masseter, the orbicularis palpebrarum, the muscles of the lower
part of the face, the muscles of the palate, and the platysma myoides.
Unilateral destructive lesions produce paralysis of the muscles of the
face (Bell's palsy). This can be recognized by the disappearance of
the folds, drooping of the corner of the mouth, and the inability to
close the eye. In addition there may be loss of taste and hyperacusis
in the ear on the same side. Occasionally there is deviation of the
tongue, the palate is oblique, and the uvula is pulled toward the sound
65
1026 SPECIAL DIAGNOSIS.
side. If the peripheral portion of the nerve is involved, usually both
the upper and lower branches are affected, and the paralysis is general.
If the lesion is central the upper branch commonly escapes, or, at least,
instead of being paralyzed, is only paretic. Moreover, in central lesions
lying above the pons the opposite side of the bod} r is paralyzed. Secre-
tion of saliva on the same side is diminished or abolished. This may
be tested on the sublingual glands by raising the tip of the tongue,
carefully drying the sublingual space and getting the patient to inhale
some pungent substance, such as acetic acid or musk. The saliva will
immediately appear on the sound side, but will fail to appear on the
other. In facial paralysis it is impossible for the patient to masticate
on the diseased side, because the food collects between the cheek and
the gums. It is also impossible for him to whistle. Saliva freely
dribbles from the drooping corner of the mouth, and as it is impossible
to contract the orbicularis palpebrarum the eye remains open even in
sleep (lagophthalmus), and the corneal reflex is abolished or imperfect.
When the patient attempts to close the eye the ball rolls upward and
outward. In addition, the palatine reflex also disappears. In facial
paralysis of long standing contractures may occur. In all cases the
muscles show either partial or complete reactions of degeneration. Irri-
tative lesions of the facial nerve cause spasm of the facial muscles,
usually spoken of as facial tic. The vagus nerve supplies motor fibres
to the larynx, sensory fibres to the lungs, and inhibitory fibres, prob-
ably sensory in nature, to the heart. It also probably sends sensory
fibres to the gastro-intestinal tract. Destructive lesions of the vagus
produce, if unilateral, unilateral paralysis of the vocal cords, interference
with deglutition, and transient tachycardia. The laryngeal changes
are most characteristic. (See Chapter I., Part II.) Irritative lesions
produce spasm of the glottis, with dyspnoea or aphonia. The spinal
accessory nerve is the motor nerve for the trapezius and part of the
sternocleidomastoid. Destructive lesions of this nerve are the chief
cause of torticollis. The hypoglossal nerve is the motor nerve for the
tongue, and is, therefore, concerned in chewing, swallowing, and speak-
ing. Unilateral destructive lesions produce paralysis of one-half of the
tongue, which is protruded toward the paralyzed side, with atrophy and
degeneration of the muscle. Fibrillary twitchings are usually present.
The functional disturbance, however, is slight, and the patient may
complain of no discomfort. Bilateral paralysis produces, however, very
severe symptoms. The tongue lies flaccid in the mouth, it is impossible
to protrude it, or even to move it from side to side. Mastication is
impossible and swallowing exceedingly difficult. Speech is at first seri-
ously affected, but, as a rule, the patient in time learns to compensate
the lingual palsy. Paralysis of the tongue as a result of central lesion
almost never occurs.
General Diagnosis of Nervous Diseases. It is necessary to
study the patient according to some fixed plan, otherwise its com-
plexity and the numerous investigations that it is necessary to make
render a thorough examination almost impossible. It is true, of course,
that in actual clinical practice diseases will be met whose clinical symp-
toms are so characteristic that the diagnosis can be made almost by
DISEASES OF THE NERVOUS SYSTEM. 1027
inspection alone, and a prolonged examination will only be useful for
the purpose of excluding or detecting possible complications. On the
other hand, certain cases will occur that almost defy diagnosis, on account
of the multiplicity and contradictory character of the symptoms. In gen-
eral it may be said that, aside from the history and the subjective symp-
toms, the physician will meet with four groups of signs : disturbance
of sensation, disturbances of motility, atrophic and degenerative lesions,
and disturbances of intelligence. These should be taken, up in the fol-
lowing order : 1. Disturbance of intellect. It is often possible to detect
this, when it exists, by simple conversation with the patient. It may
be indicated by the history, or, on the other hand, the history and the
behavior of the patient may exclude it altogether. 2. Disturbances of
motion. It is well to study first the more patent alterations. Thus the
patient should be told to move the arms and legs, in order to detect
paralysis ; he should be requested to walk, in order to study the gait ;
he should be directed to perform some fine, co-ordinated movement, in
order to detect possible ataxia ; and to put the muscles in a state of
tension, in order to exaggerate a possible tremor. Following this the
individual movements should be carefully examined. It must be
remembered that, whether the lesion is in the central or peripheral
nervous system, disturbance of motility is manifested only in the
muscles themselves, and the investigations, therefore, should commence
with these — that is to say, it is not desirable to test the motor functions
of each particular nerve, but rather of each particular group of muscles,
and to deduce from the changes found in them the nerve or segment
involved. The following table from Sahli gives a classification of the
muscles of the extremities, according to their functions, with their
nerve-supply :
Table of the Voluntary Muscles Grouped According to their
Functions, with their Nervous Supply. (From Sahli.)
Upper Extremity.
A. Movements of the shoulder-blade.
1 . Elevators of the shoulder.
Middle part of the cucullaris (N. accessorius).
Rhomboidei (N. dors, scapul., 5th cervical nerve).
Levator scapulse (2d and 3d cerv. nerv. and N. dors. scap. ).
Upper portion of the pectoral major (Nn. thorac. ant., 5th and 6th cerv.
nerves).
2. Depressors of the shoulder.
Pectoralis minor (Nn. thorac. anterior).
Lower portion of the latissimus dorsi (N. subscapulars).
Lower portion of the pectoralis major (N. thorac. ant.).
3. Adduction of the shoulder.
Lower portion of the cucullaris (N. accessor. ).
Upper portion of the latissimus dorsi (N. subscapulars).
4. Abduction of the shoulder.
Upper third of the pectoral, major (N. thor. ant.).
Serratus anticus major (N. thorac. longus, 6th, 7th, 8th cerv. nerv. ).
1028
SPECIAL DIAGNOSIS
B. Movements of the shoulder-joint.
1 . Elevators of the arm.
(a) Laterally, deltoid (K axillaris).
Vertically, serratus anticus major (N. thorac longus )._
(b) Anteriorly, anterior portion of the deltoid (K axillaris).
Coracohrachialis (N. musculocutaneous).
Biceps (N. musculocutaneous).
(c) Posterior portion of the deltoid (N. axillaris).
2. Adduction of the arm.
Pectoralis major (N. thorac. anticus, 5th and 6th cerv. n.).
Latissimus dorsi and teres major (N. subscapularis).
Infraspinatus (N. suprascapular, 5th and 6th cerv. n. ).
Teres minor (N. axillaris).
These muscles also depress the arm.
3. Internal rotation.
Subscapulars (Nn. subscapulares).
4. External rotation.
Infraspinatus (N. suprascapularis).
Teres minor (N. axillaris).
C. Movements of the elbow.
1. Flexion.
Biceps (N. musculocutan.).
Brachialis (N. musculocutan.).
Supinator longus (N. radialis).
2. Extension.
Triceps (N. radialis).
3. Supination.
Supinator brevis 1 (N _ radialis) .
Supinator longus j v
4. Pronation.
Pronator quadratus j (N> medianus) .
Pronator teres I v
Supinator longus (N. radialis).
D. Movements of the wrist-joint.
1. Flexion.
Flex, carpi radialis (N. medianis).
Flex, carpi ulnaris 1 (N _ ulnaris)-
Palmaris longus J v
2. Extension.
Extensor radialis longus and brevis \ ,-^_ ra dialis).
Extensor ulnaris J
3. Abduction.
Flexor carpi radialis _ 1 (K Qiedianis an a N. radialis).
Badiahs longus and brevis j
4. Adduction.
Extensor ulnaris and flexor carpi ulnaris (Nn. radial, and ulnar).
E. Movements of the fingers.
1. Flexion.
Flexor digitor. sublim.; flexion of the 2d phalanx (IS. median).
Flexor digitor. prof.; flexion of the terminal phalanx (Nn. median, ulnar)
Interossei and lumbrical muscles, flexion of the proximal phalanx (Nm
ulnaris, median.
DISEASES OF THE NERVOUS SYSTEM. 1029
2. Extension.
Extensor dig. comni. (N. radialis).
Interossei and lumbrical muscles (N. ulnar, jS". median).
F. Movements op the thumb.
1. Flexion.
Flexor pollicis longus and brevis (N. median).
2. Extension.
Extensor pollicis longus and brevis (N. radialis).
3. Abduction.
Abductor pollicis long. (N. radialis).
Abductor pollicis brev. (N. median).
4. Adduction.
Adductor pollicis (X. ulnaris).
5. Opposition.
Opponens pollicis ) , w ■,. ■,
* jj . ii- • u >N. median).
Adductor pollicis brev. J v
G. Movements of the little fingeb.
1. Flexion.
Flexor communis digitorum profundus and sublimis (N. median and N.
Flexor brevis minimi digiti (N. ulnaris). ulnaris).
2. Extension.
Extensor minimi digiti proprius (N. radial. ).
3. Abduction.
Abductor minimi digiti (N. ulnaris).
4. Opposition.
Opponens minimi digiti (N. ulnaris).
Loweb Extbemity.
A. Movements of the hip- joint.
1. Elevation of thigh.
Iliopsoas (N. plexus lumbalis).
Kectusfemoris| (Kci , urali
oartorius I v
2. Depression of thigh.
Glutseus maximus (Nn. glut. inf. and ischiadicus).
Flexors of the knee (N. ischiadicus).
3. Internal flexion.
Glutseus med. and minim. (N. glut, super.).
4. External rotation.
Quadratus femoris j ( N ischiadicus) .
Obturator int. and Gemelli J v
Obturator ext. CN. obturat. ).
Piriformis (Plex. ischiad. ).
Iliopsoas (Plex. lumbal.).
Glutseus max. (N. glutseus inf. ).
5. Adduction.
Adductores (N. obturator).
Pectineus (N. crural and obturat. ).
Gracilis (N. obturator).
6. Abduction.
Glutseus med. and min. (N. glut. sup. ).
10 30 SPECIAL DIAGNOSIS.
B. Movements of the knee-joint.
1. Flexion,
Sartorius (N. cruralis).
Gracilis (jST. obturat. ).
Semitendinosus )
Semimembranosus > (N. ischiad. ).
Biceps. J
Popliteus (N. tibial, N. ischiad.).
2. Extension.
Quadriceps (N. cruralis).
C. Movements of the askle- joint.
1. Dorsal flexion.
Tibial antic
libial antic. I (N. peron. prof.).
Extensor commun. dig. long. J r
2. Plantar flexion.
Gastrocnemius) (Ntibial) _
Soleus I v
Perineus long. (N. peron. superficial).
3. Adduction.
Tibial postic (N. tibial).
Tibial ant. (N. peron. prof. ).
4. Abduction.
Peroneus long. "j
Peroneus brevis V (N. peron. prof.).
Comm. dig. long J
5. Elevation of the inner side of the foot.
Tibial ant. (]> peron prof. ).
Tibial post. (N. tibial).
6. Elevation of the outer side of foot.
Peroneus long, and brev. \ K n rf> y
Peroneus tertius I
D. Movements of the toes.
1. Flexion.
Flexor comm. digit, long, and brev. \ ,^ tibial).
Interrossei and lumbricales J
2. Extension.
Extensor comm. digit, long, and brev. (N. peron. prof.
3. Adduction.
Interossei plantares (N. tibial).
4. Abduction.
Interossei dorsales (N. tibial).
E. Movements of the great toe.
1. Flexion.
Flexor ballucis long, and brev. (N. tibial).
2. Extension.
Extensor ballucis long, and brev. (N. peron. prof.).
3. Adduction.
Adductor hallucis (N. tibial).
4. Abduction.
Abductor hallucis (N. tibial).
DISEASES OF THE NERVOUS SYSTEM.
1031
F. Movements of the small toe.
1. Flexion.
Flexor minimi digit. (N. tibial).
2. Abduction.
Abductor minimi digit. (N. tibial).
3. Opposition. .
Opponens minimi digit. (X. tibial).
Each movement should be tested by requesting the patient to per-
form it first unimpeded, and then against resistance. (For functions
of motor cranial nerves, see page 1025.) 3. Sensory disturbances. As
in testing the motor disturbances, there is first obtained a rapid orien-
tation of the sensory condition of the patient. For this purpose it is
customary to touch with the finger or a blunt object both sides of the
Fig. 246.
Cutaneous nerves of the head and face.
Vu V* V 3 , first, second, and third branches of the trigeminus ; S 0, supra-orbital : I, lachrymal
tl, supratrochlear ; it, infratrochlear ; e, ethmoidal ; am, malar ; at, auriculotemporal ; 6, buc
cinator ; m, mental ; am, auricularis magnus ; oma and omi, occipitalis major and minor.
face, the arms, the legs, and both sides of the body. If the patient
declares that there is no difference in the sensory perceptions, tactile
anaesthesia may be temporarily excluded. The same regions are tested
for pain and temperature-sense, and it is often desirable to test the
muscle-sense at the same time, although this properly belongs to dis-
turbances of motility. It is often possible, in testing sensation, to decide
whether the lesion is peripheral or central by its distribution. If it
affects the spinal cord it will be segmental in type. (See Fig. 244 and
Fig. 245.) If it affects the peripheral nerves, the area or areas will
correspond to the cutaneous distribution of the nerve or nerves involved.
(See Fig. 246 et seq.) 4. The cutaneous trophic changes occur
1032
SPECIAL DIAGNOSIS.
particularly in the form of panaritis of glossy skin or of bed-sores.
Trophic changes in the joints occur especially in the knee, shoulder, and
hip. Trophic changes in the muscles may occur in any part of the body.
They are, of course, nearly always associated with distinct paralysis.
Having obtained a rough idea of the condition of the patient, it is then
Pig. 247.
Cutaneous nerves of the anterior surface of the trunk. (Sahli.)
necessary to make a more minute examination. 1. The various func-
tions should be carefully studied, particularly those of the cerebral
nerves. These should be taken up in order and all their functions
tested. 2. It is important to note the reflexes, especially those
of the eye> and the tendon and cutaneous reflexes of the body and
DISEASES OF THE NER VO US SYSTEM.
1033
extremities. 3. The position, station, and gait. 4. The disturbances
of speech. 5. The condition of the individual muscles and nerves of
Fig. 248.
N.radia/.
Cutaneous nerves of the anterior surface of the arm. (Sahli.
the body. The diagnosis must then be made by the study of the symp-
toms elicited. It should be, if possible, both topical and pathological,
although it is not always possible to make the latter.
SPECIAL DIAGNOSIS OF DISEASES OF THE NERVOUS
SYSTEM.
The semeiological classification of nervous diseases presents many
difficulties. Many of the diseases that are closely analogous in their
1034
SPECIAL DIAGNOSIS.
symptoms are widely different in their pathology or etiology, and
many diseases present such variations in their symptom-complex that
at one period they could properly be placed in one group and at
another period elsewhere. In general, it may be said, however, that
the diseases of the peripheral motor neurons differ so widely from
those of the central motor neurons that they can be classified as two
separate groups, and in a third group would come the diseases of the
sensory neurons. Combinations of these three groups, producing on
their part rather clearly marked complexes of symptoms, may then be
described, and finally the general and local diseases of the brain and
Fig. 249.
'Medianus
Distribution of the cutaneous nerves in the hand.
cord. An entirely separate group, characterized by peculiar symptoms,
are the so-called functional nervous diseases, or the neuroses. It must
be admitted, however, that this group, as a result of more accurate
methods of investigation, is growing rapidly smaller.
Diseases of the Peripheral Motor Neurons and the Muscles.
Diseases Characterized by Pure Motor Disturbance.
Progressive Muscular Atrophy. Two forms are recognized — the
scapulo-humoral type of Erb and the facio-scapulo-humoral type
of Dejerine-Landouzy. In the former the disease commences in the
muscles of the shoulder, especially the pectorals and the latissimus
dorsi. Next the adjacent muscles are involved, followed by the
muscles of the arms, thighs, and finally the muscles of the calf.
There is gradual loss of power corresponding to the atrophy of the
muscles, but reactions of degeneration do not occur. As a result of the
DISEASES OF THE NERVOUS SYSTEM.
1035
wasting, peculiar alterations occur in the configuration of the body —
that is, the shoulder-blades become prominent, lordosis occurs, and, as
a result of the weakness of the glutei, it may be necessary for the
Fig. 250.
N. cut. brach. est. (From
the N. musculocuta-
neus).
N median.
Cutaneous nerves of the posterior surface of the arm. (Sahli. )
patient to arise, as in the following form, by climbing up his legs.
The gait, as a result of the atrophy of the quadriceps, is waddling in
character. The disease usually presents itself about puberty.
In the latter type the symptoms are essentially the same, excepting
that the first muscles to undergo atrophy are those of the eyelids and
1036 SPECIAL DIAGNOSIS.
mouth. This form usually commences about the third or fourth year
of life.
Pseudo-hypertropliic Muscular Paralysis. The disease usually com-
mences in the muscles of the calves. These become greatly enlarged,
hard, and there is great loss of power. Other muscles of the legs are
Fig. 251.
WfQf
fymiitlM-liiimm 4 N - P ud - conrm. (pl.sacr.)
\fu.ui'b)\ /Hi- N - cut - fem - P° st - (P 1 - (sacr.)
d i
V| N. obturator, (pi. lumb.
X. peroneus
N. peroneus superf.
X. cut. dorsi pedis ext.
N. plant, ext.
^** N. peroneus prof.
N. plant, int.
Cutaneous nerves ol the anterior surface of the leg. (Sahli.)
next involved ; then those of the back, and perhaps the arms. Not all
the muscles that undergo atrophy show a preliminary hypertrophy.
The electrical reactions remain normal, and the loss of power is due
merely to the atrophy of the true muscle substance. The gait is
waddling, and the patient is unable to arise from the ground, except
by getting upon the hands and knees and then gradually climbing up
DISEASES OF THE NERVOUS SYSTEM.
1037
his legs. There is usually lordosis or scoliosis, and occasionally con-
tractures occur, leading to formation of club-foot. In all these three
forms of disease the course is slowly progressive.
Fig. 252.
I'#r
/ r l * \ileoflifpoq.
*<■<■■:■:■. \\Mc(inixMplex.
I lwmb.eiCsacr.)
N. obturatorius
N. saphenus maj.
N. calcan.
N. plant, int.
— X. cut. fem. lat. (pi. lunib.)
N. communicans tibial et
peroneus.
N. peroneus superfic.
N. cut. dorsi pedis ext.
N. plant, ext.
Cutaneous nerves of the posterior surface of the leg. (Sahlt.)
Diseases Characterized by Motor Disturbance, with Degen-
erative Changes in the Muscles.
Progressive Muscular Atrophy Consecutive to Disease of the Nerves.
(The Charcot-Marie-Hoffmann type; the peroneal type of Gowers.j
The first muscles affected are those of the feet and hands, usually in
the former, the peronei, the extensors of the toes, and the small muscles
1038 SPECIAL DIAGNOSIS.
of the foot ; in the latter, the interossei and the muscles of the thenar
and the hypothenar eminences. The affected muscles show distinct
fibrillary twitchings and usually the characteristic reactions of degenera-
tion to the electrical current. These reactions of degeneration are also
present in the nerves. There is usually a coarse, irregular tremor, and
the atrophy of some of the muscles with contractures of others give rise
to various deformities, such as the ape-hand, the main en griffe, or, if
the foot is first affected, to foot-drop. Later the foot assumes a posi-
tion of equino valgus or varus. In this disease there is sometimes
involvement of the sensory fibres, and the patients may complain of
slight paresthesia or even of pain. Hypsesthesia is also occasionally
present. In a form of this disease described by Dejerine under the
title of Infantile Hypertrophic and Progressive Interstitial Neuritis-,
there are, in addition to the above changes, the symptoms of locomotor
ataxia — that is, Romberg's symptom — lancinating pains, atactic gait,
and even disturbance of the pupillary reflexes. The nerve-trunks
become enlarged and can be felt beneath the skin.
Progressive Spinal Muscular Atrophy. (Type of Duchenne-Aran.)
The disease commences usually in the muscles of the hand, particularly
in those of the thenar eminences, giving rise to the formation of the
ape-hand. The interosseous spaces become deeper, the fingers become
gradually weakened, and ultimately become fixed in a semi-flexed con-
dition — incomplete main en griffe. The muscles show fibrillary twitch-
ing and give the reactions of degeneration to the electrical current.
Usually the process is bilateral. As the disease progresses it next
involves the muscles of the shoulder, especially the deltoids, and later
the muscles of the upper arm, and then of the forearm. Finally, the
muscles of the back become involved, and even the lower extremities.
Sensory disturbances are never present. The emaciation is extreme,
but total paralysis occurs only very late in the disease.
Acute Anterior Poliomyelitis. This is really an infectious disease,
commencing with chills and fever and characterized by the rapid ap-
pearance of flaccid paralysis in one or more limbs. The onset is usually
sudden, and the paralysis may occur before the development of the
general symptoms. The legs are more frequently involved than the
arms ; the muscles are usually affected in functionally similar groups,
such, for example, as the flexors of the upper arm, and then very rapidly
begin to undergo contractures. These produce deformities, particularly
various forms of club-foot, scoliosis or lordosis, and contractures of
the hand. The disease usually occurs in children, and the affected
extremity does not grow as rapidly as the other. Occasionally adults
are attacked. Sensory disturbances are absent, the reflexes are abol-
ished, and the electrical reactions are those of degeneration. In the
very early stage pains, usually radiating from some point in the back,
have been noted in a few instances. Ordinarily, the paralysis is more
extensive at first than later — that is to say, many of the muscles
involved recover completely.
Chronic Anterior Poliomyelitis. This is characterized by the slow
development of paralysis in one or more groups of muscles or extremi-
ties of the body. The flexors are more likely to be attacked than the
DISEASES OF THE NERVOUS SYSTEM. 1039
extensors. The muscles show fibrillary twitchings and the reactions
of degeneration, and the paralysis is usually flaccid. The process is
usually self -limited, but bulbar symptoms may appear and cause death.
The disease resembles closely progressive spinal muscular atrophy.
Periodic Paralysis. This is a disease characterized by the occur-
rence from time to time of paralysis of all four extremities. The
paralysis is usually flaccid in type, occurs without pain, and is associ-
ated with extraordinary increase in the electrical resistance of the skin.
The disease usually occurs in several members of the same family, the
paroxysms lasting three or four days.
Diseases Characterized by Disturbance of Motion Occurring
without keference to any definite portion of the cere-
BRAL Nervous System.
Chorea (Sydenham's chorea) is characterized by irregular twitching
movements affecting various groups of muscles in the body that are
usually functionally associated, so that the movements appear to be the
result of voluntary innervation. These movements may be generally
distributed, or more pronounced on one side than the other, or may
even occur only in one part of the body. They may involve the muscles
of the face, the arm, the leg, or the muscles of the trunk, particularly
the diaphragm, giving rise to an irregular, jerking inspiration. They
may vary in severity from slight, almost imperceptible contractions to
severe, general convulsive movements in which the violence is so great
that bruises or even fractures may occur. As a rule, the affected limbs
are slightly weaker, and in some cases this paralysis is very pronounced
(paralytic chorea). The mind is usually clear, but there may be some
irritability of temper. In a few cases with violent movements there is
pronounced insomnia and violent delirium (chorea insaniens). Speech
may be affected either as a result of choreic movements of the lips or on
account of psychic disturbance. Associated symptoms are the presence
of a heart murmur, irregularity of cardiac action, rheumatic pains in
the limbs, which usually disappear as the movements become more
pronounced ; and, occasionally in the violent form, fever.
Huntington's chorea is characterized by the development, between the
ages of twenty and forty, of choreiform movements of moderate degree,
associated with gradually progressive dementia. The disease is strictly
hereditary, occurring only in the offspring of those who have suffered
from it. The twitchings resemble those of chorea, but are rarely vio-
lent, and often associated with a slight rigidity. The first mental
symptom is usually loss of memory. Later, the patient may have
delusions of grandeur or severe melancholia. Usually life is prolonged
to an advanced age, the mental symptoms gradually passing into the
type of severe senile dementia. A curious condition is the tendency
of the patient to avoid society.
Chorea Electrica. There arc various varieties of this condition — one
occurring in children, characterized by lightning-like contractions of
groups of muscles, sometimes those of the trunk or those of the ex-
tremities ; another, Dubini's disease, which appears to be an infectious
1040 SPECIAL DIAGNOSIS.
process, commences with violent pains in the head, neck, and back, slight
fever, and general convulsions. Muscular contractions occur, usually
involving all the muscles of the body that are characterized by their fre-
quent recurrence and brief duration. Death is the usual termination.
Paramyoclonus Multiplex. This is a disease, probably hysterical in
nature, characterized by lightning-like contractions in groups of muscles,
which do not, however, produce movement that would in any way
resemble co-ordinated action. Often the patient from time to time
emits a peculiar sound resembling a grunt, probably the result of
diaphragmatic involvement. The electrical reactions are normal, and
the reflexes are sometimes slightly increased.
Habit spasm is characterized by the repetition of some peculiar,
unnecessary movement, such as shrugging the shoulders, winking the
eye, rubbing the elbow against the side, etc. Emotional disturbances
or the presence of bystanders always increase the symptoms.
Saltatoric spasm (jumper's disease, latah) is a hysterical manifesta-
tion in which the patient, whenever he or she attempts to stand, is
compelled to rise on the toes or even to spring from the ground.
Often after such movements the patient falls. The spasm disappears
if the patient lies down, but may be produced by pressure upon the
soles of the feet.
General Tie (Maladie de Gilles de la Tourette; maladie der tics con-
vulsifs). This is a psychical condition characterized by curious move-
ments of the limbs and grimaces and the utterance of words, that have
no relation to the evironment, that may be profane or obscene (copyro-
lalia), or the imitations of sounds heard (echolalia). The patient becomes
more or less melancholy, and may even be violently insane.
Paralysis Agitans. This is characterized by a peculiar, fine tremor
of the extremities, rigidity of the muscles, disturbance of gait, and
gradually progressive paresis. The first symptom noted is usually a
slight impairment of agility. As the disease commences in advanced
life, this is not regarded with suspicion ; but later the immobility of
the muscles of the face and the complete loss of facial expression sug-
gests the nature of the case. It will now be found that the patient
will have difficulty in rolling over, if lying down, and that there is dif-
ficulty in commencing to walk and afterward a tendency to take quick
steps (festinatioii). The patient, if studied, will be seen to have from
time to time a slight movement forward or backward, which, if stand-
ing or walking, may cause him to fall in one direction or the other
(propulsion, retropulsion). Speech is also involved, difficulty in articu-
lation being characterized at first by slight halting and then the rapid
utterance of the words. The tremor of the hands is spoken of as pill-
roller's tremor (q. v.). Tremor of the head is a nodding movement to
and fro. There may also be irregular movements of the toes or legs.
The tremor is diminished or abolished temporarily by voluntary move-
ment and disappears during sleep.
Tetany is probably an infectious disease characterized by cramp of
the muscles of the arms and the persistence of peculiar nervous and
mental alterations. The attack usually commences with paresthesia or
pain in the limbs ; then the muscles controlling the fingers become stiff.
DISEASES OF THE NERVOUS SYSTEM. 1041
The flexors gradually contract and draw the fingers and thumb together,
the so-called obstetrical hand. This cramp is tonic in character, and
may last for several minutes or even for many hours. It is often asso-
ciated with intense pain During the interval it may be reproduced
by prolonged, severe pressure upon the nerve-trunks, particularly the
median nerve (Trousseau's sign). The muscles show marked irrita-
bility to mechanical stimuli, particularly those of the face, and twitch-
ing may be caused by tapping upon the trunk of the facial nerve, upon
the malar bone, or over the infraorbital foramen (Chvostek's sign).
The muscles show extreme electrical irritability, contract to very weak
currents, and in some cases AOTe and COTe have been obtained
(Erb's sign). Finally, the patient is extremely sensitive to the induced
current (Hoffmann's sign). During the attack, and even during the
interval, there is sometimes slight oedema of the face, hands, and feet,
and the latter have a tendency to assume a partial equino-varus posi-
tion. Often there is slight fever.
Occupation Neuroses. These are characterized by the development
of pain in the limb employed when the attempt is made to perform
some habitual movement. It is most common as a result of writing.
The patient notices at first that he becomes more readily fatigued than
usual, and there may be dull pains in the joints or in the palm of the
hand. The painful sensations may then extend up the arm, often as
far as the shoulder. They are rarely severe, but by their persistent,
dull character are extremely annoying. The motor symptoms are
characterized by a tonic spasm of the muscles employed in grasping
the pen, so that it is held too tightly, and often there is difficulty in
holding it properly. From time to time the spasmodic condition may
increase and cause inaccurate strokes. The writing is usually heavy and
often quite illegible. The muscles apparently never degenerate. The
electrical reactions are normal or only slightly altered. If the patient
learns to write with the left hand, the symptoms of the disease usually
develop in it after a short time. Similar symptoms occur in piano-
players, violin-players, dairy-maids, telegraphists, and various other
persons who are obliged to perform the same movement for long periods.
Thomsen's Disease. This is characterized by the occurrence of tonic
spasm as the result of voluntary innervation of the muscles. The
patient, upon attempting to make a movement, finds the part rigidly
fixed for a longer or shorter interval of time. The spasm then relaxes,
the movement can be performed, and does not recur while the muscles
are kept active. There are occasionally cramp-like pains in the mus-
cles and a peculiar alteration in the electrical reactions. (See Myotonic
Reaction.) The disease is chronic, but subject to exacerbations, partic-
ularly as a result of exposure to cold, previous excessive exercise, or
emotional disturbance.
Diseases of the Sensory Neuron, with Disturbances of
Sensation.
These are generally included under the term neuralgia. Neuralgia
is a condition characterized by pain of a dull, burning, or shooting
66
1042 SPECIAL DIAGNOSIS.
character that occurs in the distribution of some particular sensory
nerve or nerves. The pain may be remittent or intermittent. It is
exaggerated, as a rule, by external irritation or emotional disturbance.
The nerve-trunk is often tender, not only during the attack, but also
during the interval. Associated symptoms are often present. The
most common are the vasomotor disturbances, the area of distribution
of the affected side showing persistent or paroxysmal flushing or occa-
sionally pallor. Secretion of sweat is sometimes increased, and there
may be exaggeration of the activity of glands supplied by the nerve.
Occasionally there is marked oedema of the skin, and sometimes a
herpetic eruption. Very rarely in neuralgia there is local graying of
the hair. Motor symptoms may also occur. These consist of spas-
modic twitching that may be associated with exacerbations of the pain.
Neuralgias due to various general conditions sometimes have a charac-
teristic localization. Thus in diabetes, sciatica occurs ; in malaria,
supra-orbital neuralgia ; in neurasthenia, occipital neuralgia.
Special Forms. Neuralgia of the Trigeminal Nerve (tic douloureux).
This usually occurs in only one branch of the nerve, and is commonly
unilateral. The pain is paroxysmal and very severe, and is often
referred by the patient to some supposed source of peripheral irritation,
as disease of the nose, carious teeth, etc. It is usually associated with
increase in the secretion of various glands, such as the tear glands, the
salivary glands, the nasal mucous membrane, etc. Trophic changes
are not uncommon. These may vary' from herpetic eruptions and
graying of the hair to atrophy of the soft parts and even of the bones
of the face. Occasionally trophic alterations of the cornea also appear.
Occipital Neuralgia^ This involves the occipitalis major nerve, but
occasionally the auricularis magnus and the nerves of the neck are also
affected. The pain is distributed over the occipital region of the head,
and is usually bilateral. The point of greatest tenderness is over the
cervical vertebrae, usually slightly to one side of the spinous processes.
Brachial neuralgia is characterized by pain distributed in the arm of
the affected side. This may be either persistent or paroxysmal. If
the latter, paresthesia? in the hand or arm are frequent during the
intervals. The points of tenderness are found where the nerves pass
over the bones or just behind the clavicle. Occasionally trophic changes
are observed.
Intercostal neuralgia is characterized by pain distributed along the
course of the intercostal nerves. There are three characteristic tender
points — one next to the spinal column, one in the axillary line, and
one over the sternum or rectus abdominus. There are usually trophic
disturbances in the skin over the affected nerve, characterized by red-
dening or especially by a herpetic eruption (herpes zoster).
Lumbar neuralgia is characterized by pain radiating from the lumbar
to the gluteal region. Occasionally the anterior surfaces of the thighs
are also involved. The sensitive points are found over the lumbar
vertebra? along the edge of the crest of the ilium and over the linea alba.
Crural neuralgia is characterized by pains radiating from the front
of the thigh into the feet. Paresthesia? are frequently present during
the intervals of the attacks.
DISEASES OF THE NERVOUS SYSTEM. 1043
/Sciatica is characterized by pain in the posterior surface of the thigh,
often radiating to the feet. It is an exceedingly common form, usually
paroxysmal in character, the attacks being preceded by paresthesia?.
The pain is increased by any movement tending to stretch the nerve,
and as a result the patient walks with a peculiar gait, the thigh of the
affected side being held fixed and parallel to the body. This some-
times results in a slight curvature of the spine. The nerve is often
sensitive through its entire length. The special points of tenderness
are found near the posterior superior spine of the ilium, at the lower
edge of the gluteus maximus, just outside the tuber ischii, and in the
cavity of the knee-joint. The reflexes are usually slightly exaggerated.
There is sometimes slight weakness of the muscles and occasionally
fibrillary twitchings.
Other forms of neuralgia are mastodynia, or irritable breast ; neuralgia
of the phrenic nerve, characterized by deep pain in the thorax and slight
dyspnoea ; coccygodynia ; and various neuralgia-like pains in the viscera.
Diseases somewhat similar to neuralgia are meralgia paresthetica,
characterized by tingling, burning, or tearing in the area of the distri-
bution of the external cutaneous nerve of the thigh, usually unequally
bilateral, and made worse by prolonged exercise, either walking or
standing. Frequently there is a tender point just below the anterior
superior spine of the ilium. Sensory disturbances in the form of
hypesthesia, hypalgesia, and diminished electro-cutaneous sensibility
are very common.
Achropaixesthesice are characterized by tingling or pain in the extremi-
ties. The affected members are usually tender, and there is hyperes-
thesia. Occasionally vasomotor disturbances are present. An allied
condition is the symptom known as tender toes that occurs in the course
of typhoid fever.
Diseases of the Sensory Neuron Characterized by Disturb-
ance op Motion, Sensation, and Trophic Disorders.
Tabes Dorsalis. This is characterized by ataxia, particularly of the
lower extremities, lancinating pains in the legs, loss of the knee-jerk,
and the Argyll-Robertson pupil. It is divided into three stages : the
preatactic, the atactic, and paralytic. The symptoms of the preatactic
stage frequently commence with disturbance in the nerves affecting
the eyeball. There may be paresis of the abducens, giving rise to
diplopia ; of the levator palpebral, giving rise to ptosis ; or sluggish or
absent reaction to light on the part of the pupil, while the reaction of
accommodation still persists (Argyll-Robertson pupil). The symptoms in
the nerves of the lower extremities are particularly the lancinating pains
that are felt in the posterior portion of the thigh. These come on from
time to time, and the patient feels as if he has been stabbed. They are
more frequent in damp weather, and are frequently confused with rheu-
matism. The knee-jerk is absent, and the patient may note that it is a
little bit more difficult to walk in the dark. The station in the early stage
is usually only slightly affected. There is a sense of constriction about
the body (girdle pain), and sometimes hypesthesia of the lower extremi-
J044 SPECIAL DIAGNOSIS.
ties that may be associated with a slight hyperalgesia in the zone just
above it. The patients may also remark that they have slight difficulty
in urination and some diminution of sexual potency. The second
stage, or the stage of ataxia, is characterized by the symptoms of the
preceding stage, all of which are now pronounced. In addition the
patient exhibits inco-ordination of movement, especially in the lower
limbs. Station is so impaired that it is usually impossible for him
to stand alone with the eyes closed and the feet together. Walk-
ing in the dark is difficult and usually associated with frequent falls.
In the daylight, with the aid of the eyes, the patient can usually
walk quite well, but lifts the feet higher than usual from the ground,
and separates them widely. (See Ataxic Gait.) The inco-ordination is
manifested by the difficulty with which the patients perform certain
movements, such as touching some object with the tip of the finger — as,
for example, the nose, ear— or in bringing the heel of one foot against
the knee of the other. There is diminished muscle-tone, and, of course,
absolute loss of tendon reflexes, even when reinforced. There are
paresthesia?, especially in the lower extremities ; analgesia in the same
situation, or sometimes delay in the conduction of pain. Micturition is
sometimes difficult ; at others there is incontinence, but insufficiency
of the sphincter ani rarely occurs. Impotence is complete. The
Argyll-Robertson pupil is present ; there is usually myosis, nyctalopia,
and occasionally atrophy of the optic nerve. In the latter condition
it has been noted that when blindness has fully developed the ataxia
becomes less pronounced or may disappear completely. The visceral
crises are characterized by attacks of intense pain involving usually
the stomach or sometimes affecting the larynx or heart or other viscera.
The laryngeal crises are often accompanied by distressing cough and
dyspnoea. Trophic changes occur, of which the most common are the
arthropathies. These involve particularly the knee, hip, and shoulder-
joints. In addition, the patient may have painless falling out of the
teeth or rapid softening of them. In certain cases a chronic ulcer
develops on the sole of the foot, which usually progresses until it has
produced perforation (jnal perforante). In the paralytic stage of ataxia
the loss of muscle-tone has reached such an exreme degree that loco-
motion is impossible. The patients by this time have usually developed
cystitis, and death occurs either as a result of exhaustion or of general
septicemia.
The Cervical Type of Tabes Dorsalis. This is characterized by
the development of the symptoms chiefly in the arms. The lightning
pains are found in the upper extremities, there is loss of the bicipital
and tricipital reflexes, and the girdle sensation is usually felt in the
upper part of the thorax. The ocular symptoms are the same. The
visceral crises are likely to affect the larynx. In this form ataxia in
the legs, Romberg's symptom, and the absence of the knee-jerk may
not be present until late in the disease.
Friedreich's Ataxia. This is characterized by inco-ordination, loss
of knee-jerk, weakness, irregular speech, and slight deformities. The
disease commences in youth, and is usually hereditary in character.
The first symptom is inco-ordination of the lower limbs. This gradu-
DISEASES OF THE NERVOUS SYSTEM. 1045
ally becomes more severe, the muscles grow weaker, the flexors more
so than the extensors, often giving rise in time to pes equino-varus.
The muscles of the back also grow weaker, giving rise to scoliosis ; the
knee-jerks are absent, the pupillary reflexes remain normal, and intelli-
gence is unaffected. The speech is peculiar, some of the syllables being
pronounced readily and others slowly, with a drawl. The gait becomes
markedly ataxic, the patients keeping the legs widely separated. In
time the paresis and inco-ordination become so severe that walking
is impossible. The disease is progressive and usually affects several
members of the same family.
The cerebellar type of hereditary ataxia differs from the foregoing by
the fact that the knee-jerks are exaggerated, and there is occasionally
absence of the pupillary reflex to light.
Diseases of the Peripheral Motor and the Sensory Neuron.
These are all characterized by disturbances of motion and sensation,
usually associated with more or less severe trophic changes.
Neuritis. Inflammation of the nerves is characterized by pain local-
ized in the nerve affected, tenderness, and perhaps paresis or paralysis
of certain groups of muscles. The pain is made more severe if the
limb is held in such a position that the nerve is stretched. As it is a
true inflammatory condition, there are usually constitutional disturb-
ances, such as fever, malaise, etc. Often the disease is progressive,
extending from the peripheral to the more central nerve-trunks. This
is spoken of as ascending neuritis. Along the course of the nerve there
are often vasomotor and secretory disturbances, or the lesions may be
more severe, such as atrophy of the skin, with glossiness, or trophic
Fig. 253.
c
Alcoholic neuritis. Foot-drop and wrist-drop.
changes in the nails. Multiple neuritis is characterized by the appear-
ance of the symptoms of the disease in a number of nerves at the same
time. The nerves of the limbs are far more frequently affected than
those of the trunk. The symptoms are modified by the cause. In
alcoholic polyneuritis there arc usually slight paresthesia of the limbs,
with marked paresis of the muscles, particularly the extensors, giving
rise to foot-drop and wrist-drop. (See Fig. 2-"):;.) The disease usually
affects all four extremities. In lead-poisoning the disease is sometimes
unilateral, is usually restricted to the arms, and the sensory disturb-
1046 SPECIAL DIAGNOSIS.
ances are very slight or absent. There is paralysis of the extensor
muscles of the arm, which in severe cases goes on to muscular degen-
eration. Neuritis may also be produced by arsenic. Diphtheritic poly-
neuritis is usually characterized by paralysis of the muscles of the
palate, but occasionally the muscles of the limbs are also involved.
In certain of the chronic forms of polyneuritis, instead of loss of power,
there is marked loss of co-ordination. This is spoken of as the ataxic
variety.
Beri-beri, or kakhe, is an infectious disease characterized by the symp-
toms of a peripheral multiple and symmetrical neuritis. The patients
usually present general symptoms, as fever and chills, and then com-
plain of a sense of weakness or heaviness in the legs, paresthesia?, and
diminution of tactile sensation. The electrical examination of the
muscles of the legs usually shows the reactions of degeneration. Later,
the muscles undergo further degeneration and become paralyzed. There
is oedema of the skin, and the anaesthesia becomes more pronounced.
Occasionally pain-sense is preserved, giving rise to anaesthesia dolorosa.
The paralysis becomes more extensive, and the patient may die as a
result of the involvement of the respiratory muscles.
Multiple neuromata sometimes occur very extensively upon the nerves
of the skin, at times producing symptoms of multiple pressure upon the
nerves — that is, paresthesia, paralyses, or loss of sensation. At other
times they produce no symptoms whatever, and can only be recognized
by inspection.
Diseases of the Spinal Cord Involving the Central Motor
Neurons.
Primary spastic paraplegia is characterized by weakness of the legs
without muscular degeneration and with increased reflexes. The dis-
ease was formerly supposed to be the result of the involvement of the
lateral columns of the cord. The first symptoms are weakness or a
feeling of heaviness in the legs ; then spontaneous cramps app ar.
The reflexes are greatly exaggerated, and the muscle tone is so in-
creased, particularly in the extensors of the thigh or knee and foot, that
the patient walks with the leg partially extended, dragging the toe
along the ground ; the arms are rarely involved. The electrical reac-
tions of the muscles are normal. The sphincters are very rarely in-
volved, and sensation is usually unimpaired. If cramps are frequent,
however, the muscles may be sore. In children the adductors become
stronger than the abductors, and a peculiar, crossed-legged gait is there-
by produced.
Amyotrophic Lateral Sclerosis. This is characterized by a spastic
paraplegia, with exaggeration of the reflexes and degeneration of the
muscles. The symptoms consist of weakness in the legs, which at the
same time become stiff. The muscles rapidly atrophy ; there are fibril-
lary twitchings and reactions of degeneration. The arms are usually
involved first, the degeneration commencing in the muscles of the hands
and giving rise ultimately to the production of various deformities, such
DISEASES OF THE NERVOUS SYSTEM. 1047
as the claw-hand. The tendon reflexes are greatly exaggerated j there
are patellar clonus and ankle clonus. The muscles are greatly weakened,
but remain rigid until late in the course of the disease. The sphincters
are rarely involved, the pupillary reflexes are normal, and there are
no sensory disturbances. Bulbar symptoms — that is, paralysis of the
larynx, pharynx, and palate — occur, giving rise to dysphagia, alteration
in speech, and frequently causing an inspiration pneumonia.
Multiple Sclerosis. This is a condition that involves the sensory and
motor tracts in the spinal cord and occasionally in the brain. The
characteristic symptoms are intention tremor, nystagmus, and scan-
ning speech. The patient usually has weakness of the legs, with some
tremor and exaggeration of the reflexes. In the arms the same con-
ditions are present, and in the attempt to grasp any object a violent
tremor is developed, which continues until the movement has been
accomplished. Various areas of anaesthesia are also present, depending
largely upon the localization of the lesions. There is usually persistent
nystagmus, lateral in character ; the speech is slow and drawling, and
the patient has a tendency to laugh or weep without provocation. In
a large proportion of the cases there is more or less complete atrophy
of the optic nerve. Less frequent symptoms are vertigo, occurring in
paroxysmal attacks, diminution of intelligence, and occasionally dis-
turbances of the function of the bladder, and in a few cases atrophy
and degeneration of the muscles. The disease is usually chronic, but
from time to time there are exacerbations. It appears to be frequently
associated with hysterical manifestations. In some cases bulbar symp-
toms appear early and rapidly lead to death.
Hypertrophic Cervical Pachymeningitis. This is characterized by pain
in both arms, followed by muscular degeneration commencing in the
hands. Later, there may be spastic paraplegia of the legs, with anaes-
thesia of the body below the affected segment. Occasionally this
disease, which is usually due to tuberculous meningitis, may occur in
other portions of the spinal cord, giving rise, therefore, to various
symptoms.
Acute spinal meningitis is characterized by intense pain in the back,
radiating into the legs ; rigidity of the spinal column, with opisthot-
onos ; intense hyperesthesia of the skin of the body, and, if the dis-
ease lasts long enough, paralyses. Kernig's symptom — that is, the
inability to extend the flexed leg as a result of flexor cramp — is said
to occur only in this condition and in cerebral spinal meningitis. The
tdche spinale occurs also in other conditions.
Syphilitic spinal meningitis produces a great variety of symptoms.
There are, however, pains due to pressure upon the posterior roots,
girdle pains of the body, and occasionally paralysis of the muscles of
the extremities, with atrophy and degeneration. Often, also, the spinal
cord is involved, giving rise to the symptoms of pressure or transverse
myelitis (q. v.) or Brown-Sequard's syndrome (q. v.). The sensory symp-
toms, aside from the pains, consist of hyperesthesia, hypsesthesia, or
anesthesia. The tendon reflexes of the lower extremities may be lost
and reappear, and this by some is supposed to be pathognomonic of the
disease.
1048 SPECIAL DIAGNOSIS.
Diseases Characterized by the Syndrome of Transverse
Interruption of the Spinal Cord.
Pott's Disease (caries of the vertebras). This is characterized by an
angular deformity of the spine, spastic paraplegia, and various disturb-
ances of sensation in the body below the level of the lesion. In the
earlier stage the only symptoms may be pain in the back, usually radi-
ating around toward the ventral surface. There may be no deformity,
but sudden pressure upon the head, jarring of the spine by coming
down heavily upon the heels, and pressure over the tender point in the
back may elicit sharp pains. In this stage there are usually slight
exaggeration of the reflexes and perhaps a slight weakness of the legs.
Later, the angular deformity becomes apparent, usually in the form of
a sharp projection in the dorsal portion of the spinal column, but it
may appear also in the cervical and lumbar region. The weakness of
the lower extremities becomes more pronounced, and may give rise to an
actual paraplegia. The pains are usually severe, radiate around the
trunk, and sometimes affect other portions of the body. Sensation
may be slightly impaired. There may be distinct dissociation below
the lesion — that is, loss of temperature and pain senses, with preserva-
tion of tactile sense — or there may be total anaesthesia. As in myelitis,
bed-sores or other trophic changes of the skin are very likely to develop,
and the patients suffer severely in general nutrition. In the earlier
stages, and more particularly in the stage of recovery, after the de-
formity has become stationary, ataxia may exist. The reflexes are
sometimes greatly exaggerated, and there is often ankle clonus. When
the paraplegia has become complete all the reflexes are usually abolished.
Girdle sensation is also very common. The course is very variable. At
times the destruction of the body of the vertebra is rapid, and the symp-
toms develop acutely. At others it occurs very slowly, and the symp-
toms, even after years' duration, may be exceedingly slight. Caries of
the upper cervical vertebra? produce pains that involve the neck and
the occipital region of the head. The position of the head is peculiar ;
it is drawn slightly forward and carried very rigidly, and the chin is
elevated. These patients may sometimes die suddenly as a result of
pressure by the odontoid process on the medulla.
Tumors of the Membranes. The symptoms of this condition are ex-
tremely variable, according to the location, nature, and extent of the
growth. Occasionally deformities occur as a result of pressure upon
the arches of the vertebra?. Paraplegia usually develops, sometimes
very suddenly, sometimes gradually. There is usually exaggeration of
the reflexes and ankle clonus ; but this in time may disappear, or may
never occur if the tumor is situated in the lumbar region. When the
posterior roots are pressed upon there are root pains and the girdle sen-
sation. Sensory disturbances are more or less complete according to the
degree of destruction that has occurred in the spinal cord. Dissociation
of sensation rarely occurs, but anaesthesia is very common. After com-
plete destruction of the spinal cord at any point trophic changes occur.
Chronie Internal Meningitis. This is usually characterized by pain
that radiates into various portions of the body, particularly the limbs,
DISEASES OF THE NERVOUS SYSTEM. 1049
and by more or less hyperesthesia. The motor symptoms con-
sist of tremors, spasms, and occasionally, when the anterior roots are
involved, paralyses, with muscular degeneration. In the milder forms
the only motor symptoms may be inco-ordination of movement. Her-
petic eruptions along the course of the nerves arising from the
involved posterior roots are quite common.
Acute Myelitis. There are a number of varieties of this condition,
the most common and typical being transverse myelitis. It is an
acute inflammatory disease associated with constitutional disturbance —
that is, chills, fever, and malaise, and is occasionally ushered in with a
convulsion. The symptoms are those of transverse lesion of the spinal
cord. Ordinarily the dorsal part is affected ; and there are, therefore,
in the earlier stages weakness and paresthesia of the legs, and perhaps
a girdle sensation and hyperesthesia over the spine, the zone sup-
plied by the involved segment. In the course of a few days or hours the
weakness of the legs increases until there is complete paraplegia. The
tone of the muscles is enormously exaggerated, the knee-jerks are in-
creased, and there is both patellar and ankle clonus and often Sinkler's
toe-jerk. The limbs are usually spastic and kept in a position of ex-
tension. From time to time the muscles give violent twitches. There
is complete anaesthesia up to the horizontal line surrounding the trunk,
at which point there is girdle sensation, and above it there is a zone of
hyperesthesia. The muscles supplied by the affected segment atrophy
and give reactions of degenerations. Those in the region below main-
tain their nutrition for a considerable time. There is difficulty in
micturition, usually paralysis of the bladder, and finally overflow from
retention. The urine becomes alkaline, cystitis develops very rapidly,
and is often followed by extensive sloughing of the surrounding parts.
Bed-sores occur early and extend deeply. Trophic lesions also occur
in the legs, the skin becomes thin and glazed, and the toe-nails are
brittle. Even arthropathies have occasionally been observed. After
the acute stage has passed more or less improvement may occur, charac-
terized by gradual return of power in the legs and partial recovery of
sensation.
Acute Focal Myelitis. This gives rise to only part of the symptoms
described above, depending upon the tracts involved by the process
and the various nuclei that have been destroyed. There is, therefore,
usually a monoplegia, associated with exaggeration of the reflexes and
irregular areas of anesthesia, or, if the focus be in the arm or the leg
centre, diminution or loss of the reflexes and degeneration of the muscles.
Disseminated myelitis gives rise to a complicated group of symptoms,
according to the number, situation, and extent of the lesions. It
resembles perhaps most closely transverse myelitis (g. v.).
Chronic myelitis is distinguished from the acute form by the more
gradual development of the symptoms. The patient first notices weak-
ness of the legs, perhaps characterized from time to time by complete
transient loss of power (giving way of the legs). If the reflexes are
examined at this time, they will be found slightly exaggerated ; later
they become very markedly increased, and ankle clonus develops. The
patient also complains, in the early stages, of paresthesie in the limbs
1050 SPECIAL DIAGNOSIS.
that may involve the arms as well as the legs, and sometimes the trunk.
A girdle sensation is also frequently present. Finally, muscular atro-
phies occur, and even severe trophic disturbances ; the picture ulti-
mately resembling that of acute myelitis.
Pressure upon the spinal cord may be produced either by injury to
the vertebral column or by growths in or hemorrhages into the mem-
branes. The symptoms are those of transverse lesion. If due to tumor,
they develop very slowly ; if due to traumatism, as a rule, very rapidly.
There is weakness or paralysis of the legs, with increase of the muscle-
tone and exaggeration of the reflexes. Ankle clonus is almost invariably
present. The pains are usually due to pressure upon the posterior roots,
and are paroxysmal and lightning-like in character. Girdle sensation
is also present. The muscles supplied by the segments of the cord
involved undergo degenerative atrophy.
Landry's Paralysis. This is characterized by progressive paralysis
of the legs, arms, and muscles of the throat, leading ultimately to
death. The first symptoms noted are weakness of the legs, which may
involve both, or at first only one. This gradually ascends, and at the
same time the patient notices paresthetic sensations. There are, how-
ever, few or no objective sensory disturbances excepting occasionally
a slight hyperesthesia. The reflexes are lost, the muscles are without
tone, and the paralysis is, therefore, flaccid. Electrical changes do not
occur, or only in very chronic cases. The paralysis gradually ascends,
involving the muscles of the abdomen, the thorax, and arms. TThen
the thorax is involved the patient usually has rapid respiration, and
complains of dyspnoea. Later there are symptoms of bulbar involve-
ment, difficulty in deglutition, and interference with speech. The
diaphragm becomes paralyzed, and the patients die as a result of
exhaustion. The intelligence remains normal throughout the disease ;
there is never loss of consciousness and there is no disturbance of the
function of the bladder or rectum. Fever does not occur.
Hemorrhage into the Cord (spinal apoplexy). This is characterized
by the sudden interruption of the functions of the cord at a certain
level. There is usually, at the time the hemorrhage occurs, severe
pain, then rapidly developing paralysis of the legs, which may be
flaccid if the lumbar region is involved, or spastic if the lesion is
higher up. Hasmatomyelia into the cervical region may cause paralysis
of the arms, but death usually occurs suddenly. The sensory dis-
turbances are irregular in character. At times there is dissociation of
sensation, more frequently complete anaesthesia up to the level of the
hemorrhage. The patient has no fever, consciousness is not disturbed,
but there is interference with the functions of the bladder and rectum.
Occasionally the hemorrhage involves particularly one side of the cord
or only one-half of the gray matter, producing the syndrome of Brown-
Sequard (q. v.). The diagnosis can frequently be made from the subse-
quent course of the case. If death does not occur, rapid improvement
is usually the rule. The sphincters regain their functions, power
returns in the limbs, and ultimately the patient may recover com-
pletely. In some cases, however, the recovery, although pronounced,
is only partial.
DISEASES OF THE NERVOUS SYSTEM. 1051
Syringomyelia (cavity in the spinal cord). This is characterized by a
group of symptoms whose occurrence together is almost pathognomonic.
First, dissociation of sensation ; pain and temperature senses are lost ;
tactile and muscle senses are retained. Second, degenerative atrophy
of the muscles, associated with fibrillary twitchings and alteration of
the electrical reactions. Third, trophic lesions which may involve the
skin, particularly that of the fingers or the joints. The disease appears
to develop with extreme slowness. The earliest symptoms may be the
occurrence of painless whitlows — that is, inflammation around the
finger-nail, with perhaps the ultimate destruction of the nail itself.
These may recur in one finger after another for several years and
without the presence of any other symptoms, excepting perhaps a
slight disturbance of sensation in the fingers. Later, muscular atro-
phies appear. These involve particularly the muscles of the shoulder
or the hand. In the latter situation they may give rise to the appear-
ance that occurs in progressive spinal muscular atrophy. At the same
time the sensory disturbances become more pronounced, gradually
ascending the arm and perhaps involving the trunk. The upper
border forms a horizontal line about the body — that is, the alterations
are segmental in type. The trophic changes may then assume a more
severe form, giving rise to deep, painless ulcerations in the fingers, and
perhaps loss of the terminal phalanges. For a long time the symp-
toms may remain almost exclusively unilateral, and it is rare for the
two sides to be equally affected. The motor symptoms, aside from the
weakness resulting from the muscular atrophy, consist of weakness of
the legs with exaggeration of the reflexes — that is, spastic paraparesis.
At times the lower portion of the cord is particularly affected, and then
the sensory and trophic changes are found in the legs. Station may
be slightly altered in the latter stages of the disease, but this is by no
means a characteristic symptom. Ultimately the patient develops scoli-
osis, trophic changes affect other parts than the hands, giving rise to
arthropathies, or to a form of dry arthritis with absorption of the bone.
There may be vasomotor disturbances, and in some cases inequality of
the pupils. The intellect is undisturbed. The patients ordinarily die
as a result of exhaustion or pulmonary involvement, but occasionally
in the latter stages of the disease bulbar symptoms occur.
Morvan's Disease. This is characterized by the appearance of painless
whitlows in the fingers, sometimes associated with deep ulcerations of the
soft parts. There are usually sensory disturbances similar to those
found in syringomyelia, with the addition of tactile anaesthesia, but
muscular atrophy rarely exists. The disease is exceedingly chronic.
It is possibly only a variety of syringomyelia.
Traumatism of the Spinal Cord. This may either produce destruc-
tion, partial or complete, of the tissue of the cord itself, giving rise to
the syndrome of transverse interruption, or else give rise to a group
of indefinite motor, sensory, and mental disturbances that have been
grouped under the term traumatic neuroses. (See Hysteria.) The
symptoms, the result of organic lesion, may come on gradually or
immediately. They are similar to those produced by pressure upon
the cord.
1052 SPECIAL DIAGNOSIS.
Diseases of the Brain Characterized by General Symptoms and
Sensory and Motor Disturbances.
Diseases Characterized by Mental, Motor, Sexsory, and
Sometimes Trophic Disorders.
External pachymeningitis is a rare condition, usually secondary to
traumatism or abscess, characterized by fever, headache, often sharply
localized, and convulsions. Frequently the symptoms are masked.
If there is much thickening of the membrane, evidence of focal dis-
ease in the form of paralyses or convulsions may be present. Hcema-
toma of the dura mater is a condition usually occurring in cases of
chronic disease. There may be slight fever and headache without
other symptoms. In some cases, however, the onset is sudden and
apoplectiform in type. The patients develop hemiplegia, unconscious-
ness, and occasionally unilateral convulsions.
Internal or Leptomeningitis. The symptoms vary according to the
nature of the process, its localization, and extent. The patient may
for a few days preceding an attack complain of malaise and headache,
then there is often a chill followed by fever, convulsions, and delirium.
The headache becomes more intense, and frequently there is vomiting,
sometimes without associated nausea. The headache is usually severe,
and often localized to the frontal or occipital regions ; occasionally,
however, it is more general. From time to time there are acute exacer-
bations, causing the patient to cry out — the hydrocephalic cry. The
skin is hypersesthetic ; all the sensory nerves have their functions
increased ; there is photophobia and inability to tolerate noises. Fre-
quently there is paresis of the vasomotors of the skin, so that localized
cutaneous irritation, such as may be produced by drawing the end of
a blunt object across the surface, gives rise to a persistent red mark
(tache cerebrate). The patient usually lies with the head drawn far back
and the muscles of the neck tense and rigid. This, however, occurs
only when the cervical portion of the spinal cord is also involved. It
is an exceedingly important and an almost pathognomonic symptom.
Any attempt to straighten the head causes intense pain. Examination
of the eye-grounds usually shows intense congestion and more or less
perineuritis. Sometimes there is very distinct choked disk. The
pupils are often unequal, and strabismus and even nystagmus fre-
quently occur. Paralysis of any of the cranial nerves indicates that
the process is chiefly localized at the base, as in tuberculous meningitis.
Paralysis of the oculomotor or some of its branches is exceedingly com-
mon. The facial nerve may also be paretic. The tendon reflexes are
usually somewhat exaggerated, muscular tone is increased, and occa-
sionally there is distinct monoplegia or hemiplegia. Fever, headache,
and delirium usually persist throughout the course of the disease ; and
the former is often very high. The different forms of meningitis are
often difficult to discriminate. By means of Quincke's lumbar puncture
it is sometimes possible to make a bacteriological diagnosis from the fluid
withdrawn. Meningitis due to certain pyogenic micro-organisms, such as
the pneumococcus, staphylococcus, etc., may be suspected ; when the
DISEASES OF THE NERVOUS SYSTEM. 1053
fever is high there is marked retraction of the head, indicating spinal
involvement, and the course is steadily progressive to death. Some
other disease may often be associated with the meningitic symptoms,
or it may have occurred previously, as pneumonia, typhoid fever, etc.
Epidemic cerebro-spinal meningitis may simulate the symptoms of
purulent meningitis exactly. In some cases, however, the course is
more prolonged, and even when the termination is fatal there is apt to
be a remission of longer or shorter duration. Tuberculous meningitis
is usually characterized by the presence of paralyses of some of the
cranial nerves, particularly those of the eye muscles, and the absence
of symptoms of spinal involvement. This disease may run an exceed-
ingly slow course, and the diagnosis is often for a time impossible.
Kernkjs sign is said to be pathognomonic of menhigitis. It consists
of the inability of the patient to straighten the leg when the thigh
has been flexed upon the abdomen and the leg upon the thigh.
Cerebral Hemorrhage (apoplexy). This is characterized by a great
variety of symptoms, depending largely upon the location of the lesion.
They may be divided into those of the attack and those that are perma-
nent. The symptoms of the attack consist of prodromata — that is, head-
ache, tendency to vertigo, a sense of fulness in the head, roaring in the
ears, and perhaps some thickness of speech. These may pass off without
an attack or may lead directly to it. The attack itself is usually char-
acterized by the sudden occurrence of complete unconsciousness. The
patient falls to the ground, and there is at first a temporary pallor.
This is succeeded by flushing of the face, which may become almost
purple. The pulse is full and bounding and with difficulty compress-
ible. The breathing is stertorous, the eyes are partially opened ; the
pupils are usually contracted and often unequal. Often there may be
vomiting, or involuntary micturition or defecation. The limbs remain
completely paralyzed, or in some cases there are unilateral convulsions.
If, as is commonly the case, the hemorrhage has involved the motor
tract, there is complete flaccid paralysis of one side, with, however,
increased reflexes. If death does not occur in the course of the first
twenty-four hours, the patient usually begins to show signs of con-
sciousness, and may be aroused from his comatose condition by sharp
questioning. The patient then may go into a still more deeply coma-
tose condition, with rise of temperature, followed by death, or there
may be no further indications of hemorrhage, and recovery may set in.
As a rule, in those cases in which the prognosis is favorable no rise of
temperature occurs. It may now be found that the patient has hemian-
opsia, usually the visual fields on the same side of the lesion being
blinded. Conjugate deviation may or may not have existed from the
first, the patient ordinarily looking toward the sound side. If the
speech centre has been involved, there is absolute aphasia ; but even
when it is not directly affected partial aphasia is very common.. The
hemiplegic limbs remain paralyzed ; the others regain their power. It
is now necessary to determine the extent of the damage and to locate
as nearly as possible the situation of the lesion. Complete hemiplegia
may involve the lower branch of the facial, the arm, and the leg. The
upper branch of the facial and the muscles of the trunk commonly
1054 SPECIAL DIAGNOSIS.
escape, although the former may show slight paresis. Sensory disturb-
ances may or may not be present. There is sometimes loss of all forms
of sensation and sometimes disturbance of only the tactile or the mus-
cular sense. Occasionally when tactile sense is preserved there may
be loss of the stereognostic sense. Complete hemiplegia with disturb-
ance of sensation almost invariably indicates destruction of the internal
capsule upon the opposite side. Motor disturbances hi the form of clonic
convulsions may also occur in the paralyzed limbs, and occasionally,
probably as the result of a double lesion, in the limbs of the sound
side. They are commonly the result of cortical lesion, irritating in
character, either infarction, or else some growth pressing upon and
involving the cortex. As the case progresses there is usually more
or less return of motor power and almost complete return of sensation.
This may, however, be exceedingly gradual, several weeks elapsing be-
fore the sensory disturbances have entirely disappeared. The muscles
that remain permanently paralyzed gradually atrophy, but nearly always
give normal qualitative electrical reactions until the muscular substance
disappears, leaving contracted fibrous tissue. The muscles themselves
may show early contractions, the flexors ordinarily overcoming the
extensors. Repeated attacks of apoplexy are by no means uncommon,
and the double lesions thus produced may give rise to very complex
symptom-groups. (See, also, Cerebral Localization and Aphasia.)
Cerebral Embolism and Thrombosis. This is a condition characterized
by symptoms very similar to those of cerebral hemorrhage. Prodromal
symptoms, in the form of headache, vertigo, weakness, and malaise, are
often present. At times there also may be slight impairment of speech,
or the patient may be dull and apathetic. The attack usually comes
on more gradually than hemorrhage, although this is not invariably
the case. In some instances consciousness is not entirely lost, and as
a result the hemiplegia may develop before the coma. When uncon-
sciousness does occur there is usually less congestion of the face and
not such marked evidence of increased arterial tension as we find in
hemorrhage. Among the other general symptoms may be mentioned
convulsions, vomiting, and occasionally delirium. The permanent
symptoms resemble exactly those produced by hemorrhage, but
recovery is usually more rapid and more complete than in the former
condition. Apoplexy occurring iu children differs from that occurring
in adults only by the fact that the initial symptoms are more severe, and
the convulsions are frequent and may be repeated. The permanent
symptoms differ slightly, inasmuch as aphasia rarely persists. The
paralysis may be partial, and may in some instances be replaced by
athetoid movements. Sensation is rarely impaired.
Bulbar paralysis is a disease of the peripheral motor neurons arising-
iu the medulla. It is characterized by the degeneration of the muscles
of the lips, tongue, and pharynx. The course is slowly progressive.
The earliest symptom is dysarthria, then difficulty in swallowing,
chewing, and phonation. The face becomes expressionless, the mouth
remains open, saliva dribbles from it, and occasionally the eyelids are
involved and the eye remains open (logophthalmus). The cardiac
action and respiration may be rapid. Death usually occurs as a result
DISEASES OF THE NERVOUS SYSTEM. 1055
of inspiration pneumonia, or exhaustion. In the variety known as
asthenic bulbar paralysis there may be long remissions or even per-
manent recovery.
Encephalitis. This is a condition that rarely can be diagnosed during
life. It may be suspected, however, if, in the course of some other
acute infectious disease, the patient develops intense headache, severe
delirium, and perhaps local palsies. There may be general exaggera-
tion of all the reflexes, with ankle clonus, and usually hyperesthesia of
the skin, and exaltation of the special senses. Examination of the
eye-grounds usually fails to reveal optic neuritis.
Abscess of the Brain. This is a local disease, giving rise to local
and general symptoms. General disturbances are chiefly fever, chills,
leukocytosis, headache, and delirium. The symptoms of focal dis-
ease depend, of course, upon the location of the abscess. The com-
monest seat is in the temporo-sphenoidal lobe, as a result of infection
following ear disease. This often gives rise to mind-blindness or
amnesia. Sometimes there are no general symptoms if the abscess is
located in the blind regions of the brain. The focal symptoms may
not be manifest until rupture has occurred. This often gives rise to
an epileptiform attack.
Tumors of the Brain. Like the preceding lesion, these give rise to
two groups of symptoms : general, which are merely those of increased
intracranial pressure ; or local, due to the involvement of centre and
tracts. The general symptoms of brain tumor are (1) headache. This
is usually very severe, of a boring character, and subject to exacer-
bations ; (2) vomiting. This is paroxysmal, and often occurs without
nausea ; (3) papillitis. It usually occurs early, is intense, and often
leads rapidly to blindness. The local symptoms are, of course, numer-
ous. Tumors in the frontal lobe give rise to none, or at most to some
disturbance of intelligence and perhaps a tendency to make puns.
Tumors in the motor region may cause irritative or destructive changes
in the tissue. Irritation is manifested by local spasms, which may or
may not be succeeded by general convulsions (Jacksonian epilepsy).
Paralytic lesions are those of monoplegia or hemiplegia. Tumors in
the parietal lobes may cause interference with the muscle sense or
some disturbance of vision or speech centres, according to their situa-
tion. Tumors in the occipital lobes usually cause mind-blindness —
that is, inability to recognize objects, and preservation of the pupillary
reflexes. Tumors in the different fossa of the skull often give rise to
symptoms dependent upon pressure upon the cranial nerves. In the
anterior fossa there may be loss of the power to smell upon one side.
In the middle fossa the nerves chiefly affected are the optic, giving
rise to unilateral blindness, or, if the tumor involve the chiasm, to
bitemporal hemianopsia ; the oculomotor nerves, the abducens and
the pathetic, giving rise to more or less complete ophthalmoplegia.
Tumors in the posterior fossa commonly involve the facial and
auditory nerve, and it is said that facial paralysis with nerve-deafness
on the same side is characteristic of tumor in this situation. The
hypoglossal nerve may also be involved. Tumors may, of course,
grow slowly, rapidly, or cease to increase in size, and the symptoms
1056 SPECIAL DIAGNOSIS.
show a corresponding rate of development. In rapidly growing
tumors apoplectiform attacks are frequent, but a certain amount of
compensation occurs, and remissions are not uncommon. In slowly-
growing tumors the symptoms may remain apparently stationary for
long periods. Tumors are sometimes entirely latent, and are simply
discovered accidentally at the autopsy.
Sclerosis of the Brain. This is usually a diffuse or a multiple lesion
that gives rise to a great variety of symptoms, more or less indefinite
in character. Ordinarily the lesion is congenital, or develops shortly
after birth. The patient remains an imbecile or an idiot, and soon
develops epileptic convulsions. If the sclerosis is more pronounced
on one side than the other there is usually a tendency to fall toward
the opposite side. There may be arrest in development in these limbs,
and more or less muscular paralysis. Occasionally, apparently as a
result of foetal thrombosis or embolism, the sclerosis may be limited
to one portion of the brain or even to one hemisphere. In this case
there is always arrest in the growth of the opposite side of the body.
Hydrocephalus (chronic infantile form). This is characterized by an
extraordinary alteration in the contour of the head, which becomes
greatly enlarged and globular in shape, while the face remains small
and infantile in appearance. The symptoms are sometimes exceedingly
pronounced ; at other times entirely absent. Persons with a moderate
degree of hydrocephalus have displayed through life a normal intelli-
gence. In other cases the head is heavy and the muscles of the neck
unable to support it. The child is an imbecile or an idiot, and epileptic
convulsions are very common. Occasionally ocular symptoms may be
present. These consist of ptosis, strabismus, or nystagmus, and some-
times of atrophy of the optic nerve, and blindness.
Acute Delirium. This is a disease characterized by prodromata and
a stage of excitation, and usually terminates in death. The prodromata
consist of disturbances of the general health, loss of appetite, and in-
somnia. The patient is restless, anxious, and may show diminution of
intelligence, and become more or less violent. He then rapidly
passes into the stage of excitation, is restless, noisy, and frequently
homicidal, shouting disconnected words or sentences, singing or shriek-
ing. Sometimes there are delusions of persecution, and he attempts to
escape. In addition, there are the symptoms of the so-called typhoid
state, high fever, profound prostration, dry tongue, and rapid and weak
pulse. The patient refuses all food, is continually active, and emaciates
very rapidly. Among the objective symptoms are increase of the
reflexes, narrowing of the pupils, and hyperesthesia, with more or less
hypalgesia. From this stage the patient passes into a state of collapse,
lies in a condition of muttering delirium, with carphology, and usually
dies from exhaustion.
General paralysis of the insane is a form of progressive dementia
characterized by delusions of grandeur or states of depression associ-
ated with exacerbations of maniacal character. There are, in addition,
weakness and tremors of the muscles of the face, paresis of the extremi-
ties, the Argyll-Robertson pupil, and peculiar disturbances of speech.
It is usual to recognize three stages. The prodromal stage, character-
DISEASES OF THE NERVOUS SYSTEM. 1057
ized by irritability or sometimes by depression ; diminution or loss of
the moral sense ; impaired judgment, particularly in business affairs ;
and a tendency to extravagance and dissipation. Frequently symptoms
associated with degeneration, such as intolerance for alcohol, intense
egotism, etc., appear. The sexual function in this stage is often greatly
increased. Memory fails and the intellectual capacity is considerably
diminished. There are often slight disturbances of speech, and some-
times paralytic pupils. Frequently there is insomnia and occasional
attacks of migraine. In the second stage, which usually develops
gradually, the attacks of migraine are replaced by apoplectic or epileptic
attacks or by distinct maniacal conditions ; memory is greatly impaired,
the intellect is considerably disturbed, the patient becoming unable to
do easy mathematical problems, to comprehend his environment, or
to sustain a simple conversation. Usually there are delusions of gran-
deur, the patient believing himself rich, beautiful, successful, intelligent,
and reiterating constantly his advantages, although from time to time
there will be states of depression and partial recognition of the failure
of power. In other cases, however, particularly chronic alcoholics,
there is distinct melancholia ; the patient is hypochondriacal, or may
have delusions of persecution, or a sense of misfortune. The disturb-
ances of speech are characteristic ; the most common is the omission
of syllables. This may best be tested by asking the patient to repeat
certain words, particularly those containing a number of r's and l's, as
" third riding artillery brigade," " truly rural," etc. There is marked
tremor of the lips and of the tongue, producing a sort of ataxia in the
speech, with the disturbance of the formation of nearly all the sounds.
The pupillary changes are similar to those described in the prodromal
stage, but usually are more pronounced. The extremities are weak,
and often exhibit distinct tremors. Finally, the patient becomes com-
pletely demented, usually lies quietly and placidly in bed, or occasion-
ally mutters unintelligible sounds. Sensation, either as a result of
impaired perception or because of degenerative changes in the periph-
eral nervous system or the spinal cord, becomes greatly impaired,
particularly the pain-sense. The patient is unable to stand, and has
involuntary or rather unperceived micturition and defecation, and fre-
quently develops bed-sores or cystitis. A curious and quite common
symptom is the gnashing of the teeth, which in some cases is almost
persistent. Death usually occurs from exhaustion. Among the less fre-
quent symptoms are a curious unsteadiness of gait, exaggeration of the
reflexes, rapid diminution in weight, particularly in the last two stages.
Epilepsy. This is a condition characterized by attacks of clonic
convulsions, associated with loss of consciousness and usually some
impairment of intelligence. In the characteristic epileptic fit we can
usually distinguish three stages : the prodroma, the attack, and the
postepileptic stage. In the prodromal stage aura? are frequently
present. These may be of the most varying character. A patient
may either have a curious sensation in the epigastrium, paresthesia?
in a limb, and the subjective sensation of movement, or disturbance of
the special senses, particularly an unpleasant odor or a whirring sound.
Sometimes the sensations are painful or distressing, as a sense of con-
67
1058 SPECIAL DIAGNOSIS.
striction about the throat. At other times there is giddiness, vertigo,
or nausea, or the recurrence of some particular idea. Occasionally the
aurse consist of some imperative movement, such as whirling about,
running, or jumping. At the commencement of the attack there is
usually a cry — the epileptic cry. Ordinarily this is a curious sort of
gasping, due to the forcible contraction of the thorax and partial closure
of the glottis. In some cases, however, it may be a loud shriek. The
patient then falls to the ground, and the convulsive movements com-
mence. These are rarely of equal vigor on both sides ; the head and
eyes show conjugate deviation ; the face is bluish and pallid ; the mouth
is filled with frothy fluid, which is often blood-stained, on account of
biting the tongue ; the limbs may be extended or flexed in tonic con-
traction. This is soon replaced by a violent to-and-fro tremor. The
patient is completely unconscious, and may, in falling, cause himself
serious injury. There is no conjunctival reflex, the pupils are widely
dilated ; frequently the urine is passed during the attack, and there is
occasionally profuse sweating. Toward the end the convulsions become
less frequent. Respiration is re-established ; at first irregular, then gradu-
ally it becomes more and more steady. The cyanosis disappears, and
the patient usually passes into a profound sleep. This may last several
hours, and he then awakes, feeling dull and fatigued, but otherwise
normal. At other times, immediately after the attack, there is vomit-
ing or nausea, and sometimes a feeling of excessive hunger. He may
become maniacal, usually with homicidal mania, or the postepileptic
stage may be manifested by nothing more serious than some imperative
movement, such as running or shouting. The convulsive stage may be
replaced by purely sensory phenomena, without complete loss of con-
sciousness, or there may be merely a fine tremor, or the patient may
simply run or be otherwise violent, while wholly unconscious.
Petit Mai. In this condition the loss of consciousness is so transitory
and the motor symptoms are so slight that its nature often escapes
detection. The patient, if talking, will suddenly stop for a moment ;
there is a peculiar rigidity of the expression and perhaps slight sway-
ing. This will disappear almost immediately, and the patient will
resume the conversation. Sometimes after these attacks there will be
a feeling of drowsiness for a short period. Aurse may be present in the
form of giddiness or twitching of the limb. The attack may also occa-
sionally be ushered in with a scream or a peculiar gasping expiration.
Immediately after the attack automatic movements may be performed.
Attacks of petit mal often occur during sleep, and the only symptoms
then that point to the existence of the disease are a feeling of heaviness
in the morning, perhaps a sore and bitten tongue, and nocturnal enuresis.
Focal epilepsy (Jacksonian epilepsy). This form resembles general
epilepsy, with the difference that the motor or the sensory disturbances
always commence in the same part of the body, and from this part
gradually extend until they become general. Thus, the thumb may
first be affected, showing a tonic and then a clonic spasm ; then the
hand, the arm, the whole of that side, or both sides ; or the disturbance
may commence in the foot. The disease almost invariably indicates
the existence of a focal lesion in the brain.
DISEASES OF THE NERVOUS SYSTEM. 1059
General Symptoms in Epilepsy. Epileptics are usually dull, apathetic,
having a tendency to excess in eating. An excess of indican is often
present in the urine. Often there is distinct mental impairment, or,
when the disease occurs early in life, there may be congenital imbe-
cility or idiocy. The temper of epileptics is usually irritable, and they
are likely to commit acts of violence.
Migraine (hemicrania). This is a disease characterized by parox-
ysmal attacks of headache associated with nausea and vomiting, and
frequently with disturbances of the special senses. The attacks are
usually followed by prolonged sleep. The headache is peculiar, in that
it commences slowly as a dull but severe pain that gradually increases
in intensity, with occasional exacerbations or throbbing, and is limited
to one side of the head. Occasionally, however, it is bilateral, but is
then usually unequal. At the same time the patient experiences a
sensation of intense nausea that may be followed by vomiting. The
special senses are affected in various ways. There may be photophobia,
hyperacusis, and occasionally the appearance of peculiar scotomata,
which commence as a bright spot that spreads, the outer edge being of
an irregular, jagged character, and finally disappears at the periphery
of the field of vision. New lines constantly form at the centre, and
follow those first appearing. Sometimes the patient complains of dim-
ness of vision, and this may affect only part of the visual field. Occa-
sionally there is temporary aphasia, particularly if the pain occurs in
the left side of the head. In addition, the patients may observe vaso-
motor symptoms, paresthesia, or occasionally stiffness or spasms in the
limb. The paroxysm usually terminates in sleep, which may be pro-
longed, and when the patient awakens all symptoms have disappeared.
Sometimes there is a severe attack of polyuria.
Meniere's Disease. This is characterized by attacks of vertigo, asso-
ciated with nausea. The attack usually begins with tinnitus, then
intense vertigo, which may come on so suddenly that the patient falls
to the ground, or else he is obliged to lie down, and remain hi this
position until the attack is over.
Hysteria is a disease due to disturbance of the self-control, producing
a curious complex of symptoms that appear to be the result of imitation
or of a desire to attract attention or sympathy, associated with certain
disturbances of the special senses and of sensation. The psychical symp-
toms are a certain tendency to self-consciousness, so that the patient is
anxious to describe his or her sufferings to surrounding persons ; is in
the habit of performing ludicrous or startling acts for the purpose of
attracting attention ; is emotional, weeping or laughing readily, and
is often irritable and suspicious. Among the sensory symptoms are
areas of tactile anaesthesia or analgesia. These may involve exactly
one-half of the body, including the accessible mucous membranes, or
they may be symmetrical in distribution on both sides of the median
line, and often form geometrical figures. These are not the result
apparently of simulation on the part of the patient, because they remain
unchanged for a number of days. Tenderness — that is, hyperalgesia
— may be present over the ovaries and the spine. The areas of anaes-
thesia may be transferred from one part of the body to the other,
1060 SPECIAL DIAGNOSIS.
either spontaneously or as a result of suggestion. The latter is most
effectual when the transfer is made by means of a magnet or metals.
The special senses may have their function exalted, so that the
patients have an extraordinary acuteness of smell or hearing, or find
it difficult to endure strong lights.
Depression of the function of the special senses is perhaps more
common, particularly loss of the sense of smell and taste. Hysterical
deafness is exceedingly rare. Hysterical blindness not infrequently
occurs, is characterized by widely dilated pupils, that usually react
to light, and, of course, by normal eye-grounds. The hysterical stigmata
associated with the eye are of great importance, partly on account of
their peculiarities, partly on account of their persistence. The most fre-
quent is simple contraction of the formed field. This, however, occurs in
other conditions, and is, therefore, not as characteristic as contraction of
the formed field with inversion of the color field — that is to say, a red
object will be seen further from the central visual point than a blue one.
Monocular diplopia, in the absence of structural defect in the eyeball, is
pathognomonic of hysteria. In rare cases three images may be perceived.
The motor symptoms are paresis, or occasionally complete paralysis.
The commonest form of this is hysterical aphonia, in which the patients
are unable to contract the vocal cords for the purpose of producing
sound, but may be perfectly able to cough or perform any other func-
tion with them. In these cases speech usually returns suddenly under
the influence of a strong emotion or suggestion. The paralysis in other
parts of the body occurs in imitation of some form of organic disease.
Thus there may be paraplegia, hemiplegia, or monoplegia. Loss of
power is rarely complete, and occasionally patients move the limbs
when they believe themselves unobserved. The electrical reactions
remain normal, although the degree of resistance in the skin may be
greatly increased. The reflexes are exaggerated, especially those due
to cutaneous irritations, such as the plantar reflex, but ankle clonus
does not occur. The gait may be staggering, imitating cerebellar
ataxia or the ataxia due to intoxication ; sometimes there are tremors,
coarse and irregular, and rarely constant. In some cases of hysteria
actual contractures of the muscles occur, indicating the existence of
trophic disorders. Spasmodic contractions sometimes occur in the
muscles of the abdomen, giving rise to an apparent or hysterical
abdominal tumor. Actual trophic changes may also occur in hys-
terical patients, but these are rare in this country. There may be
hemorrhages into or from the skin, particularly from the forehead,
palms of the hands, and the soles of the feet (stigmata of the passion),
or there may be localized areas of gangrene in the skin.
The attack (prise hysterique) may be divided into the prodromal period
and the convulsive. The aura? consist of a variety of sensory disturb-
ances, of which the most common is the sensation of a ball rising in
the throat (globus hystericus). The patient may also have a sensation
of heat or cold, or moisture of the skin, or various painful impressions.
Occasionally the tenderness over the ovary is greatly increased (ovaria),
and the attack may be precipitated by pressure in this region. It is
impossible to describe all the movements that occur in the grande crise.
DISEASES OF THE NERVOUS SYSTEM. 1061
The convulsion may be tonic or clonic. The patient may assume the
most extraordinary positions. Among the most characteristic is opis-
thotonos, in which the heels and the back of the head rest upon the
floor or bed, while the body forms an arch ; or the patient may assume
attitudes that suggest or are characteristic of mirth, sorrow, fear, pas-
sion, etc. Consciousness is rarely entirely lost, although there may be
subsequently total amnesia for the period of the attack, and, no matter
how violent the movements of the patient, injury to any part never
occurs. Gradually the movements become less violent, the patient be-
comes quiet, and consciousness returns. During the attack the pupils
are usually dilated, the reflexes may be increased, and respirations are
commonly extremely rapid, in one case that I observed they reached
100 per minute. Occasionally the attack may be cut short by pressure
upon one of the hysterogenic zones. After the attack the patient may
be perfectly normal. At times there may be persistent, curious, per-
verse tendencies, such as unwillingness to eat, or, at least, a simulation
of fasting.
Neurasthenia is a disease characterized by an exceedingly complex
symptomatology. The symptoms may be divided into the general and
special groups : the former including those common to all forms of
neurasthenia, the latter those associated particularly with subjective
and objective functional disturbance of the various organs. The mental
symptoms are various. The patients are usually querulous, depressed,
and hypochondriacal. They are very irritable, but incapable of
prolonged emotional exaltation. They find difficulty in concentrat-
ing their attention, particularly upon those subjects with which they
have previously been familiar. Memory is impaired and the intellec-
tual capacities apparently diminished. It must be remembered, how-
ever, that careful testing of the memory or judgment rarely shows
that it is seriously affected. An important symptom is the insomnia.
This may be of all varieties, but ordinarily the patient, after sleeping
in the early part of the night, will awaken and be unable to sleep again
for some hours. The statements by the patients in regard to this symp-
tom are very unreliable. Frequently they complain of unpleasant or
frightful dreams when they actually have slept. Among the sensory
symptoms the most important is headache. This is of a peculiar but
almost typical form. The patient complains of a heavy, dull feeling,
as if wearing some heavy object, the usual simile being a lead helmet.
Occasionally the pain is localized ; sometimes to the occipital region
and sometimes to a circumscribed area, the latter usually the result of
suggestion. Another symptom that is very common is pain in the
back. This is usually felt in the neck or the lumbar and sacral region ;
it is of a dull, persistent character, and may be associated with points of
tenderness over the spine. Occasionally there arc disturbances of the
special senses. The patient may complain of inability to see sharply,
or there may be muscre volitantes. At other times lie will fail to hear
distinctly or may complain of roaring or tinnitus. Actual diminution
of the visual power or of the sense of hearing does not occur. The
patients may complain, however, of paresthesia? in the limbs and of
various symptoms usually the result of suggestion. Sensation is other-
1062 SPECIAL DIAGNOSIS.
wise normal. There is usually a general decrease in muscular power.
Sometimes this may be preserved for short periods of activity, but
fatigue, as a rule, comes on very rapidly. At other times it is impos-
sible for the patient to exert the amount of force that would be normal
for his muscular development. Occasionally this weakness is localized
to one limb or side of the body. When the patient is directed to hold
a limb rigid or to extend the fingers forcibly a fine tremor of the
extremities occurs. This may be persistent or readily exhausted ; in
addition, fibrillary twitchings of the muscles not infrequently occur.
The tendon reflexes are generally exaggerated. Ankle clonus, however,
excepting the form spoken of as pseudoclonus, is exceedingly un-
common. Absence of the knee-jerk does not occur in neurasthenia.
The cutaneous reflexes are sometimes greatly exaggerated, sometimes
depressed. Vasomotor symptoms are very common. The patient
flushes easily, and there is often dermographia ; he complains of palpi-
tation and occasionally of irregularity of the heart's action. Often
perspiration is produced by slight exertion.
In addition to these symptoms, the neurasthenic may complain of
various local disorders of the nervous system ; he usually suspects that
he has locomotor ataxia, and he will probably have learned the symp-
toms of this condition sufficiently well to imitate them more or less
accurately, or he may believe himself suffering from general paresis or
brain tumor, or any other condition with which he may be familiar.
From general paresis the diagnosis is sometimes quite difficult unless the
Argyll-Robertson pupil, which never occurs in neurasthenia, is present.
Another common form is gastro-intestinal neurasthenia. The patient
may complain of excessive acidity, and, in fact, vomit from time to
time masses of acid material, or there may be difficulty with digestion
and hypochlorhydria or anacidity. Constipation is an exceedingly fre-
quent symptom. From time to time the patient may also evacuate
large quantities of mucus, and sometimes there may be persistent
mucous diarrhoea. This is one of the most intractable forms of the
disease. Finally, the patient may be a sexual neurasthenic and be-
lieve himself to be suffering from organic or functional disease of the
genital organs. To this variety is usually, but I believe incorrectly,
reckoned the various types of sexual perversion. The degree of neu-
rasthenia is spoken of as mild or severe, according as the symptoms
are slight or pronounced.
INDEX.
A BASIA, 74
i\- Abdomen, aspiration of, 358
color of, 727
enlargement of, general, 729
local, 733
inspection of, 727
markings on, 727
palpation and percussion of, 735
retraction of, 735
shape of, 729
topography of, 725
Abscess of brain, 1055
fecal, 743
of kidney, 966
pelvic, 744
pericecal, 743
perinephritic, 913
in precordial region, 584
retropharyngeal, 717
subdiaphragmatic, 753, 764
Acetonemia, 958
Acetonuria, 936
Achromia of red corpuscles, 375
Acroparesthesia, 1043
Acne, 143
Acromegalia, 169
Actinomyces, 352
in sputum, 536
Actinomycosis, 350
of mouth, 694
pulmonic type of, 351
Addison's disease, 124
Adenoid vegetations in nasopharynx, 714
Adherent pericardium, 648
iEgophony, 513
in pleurisy, 571
iEsthesiometer, 974
Age in the etiology of disease, 24
Ague, dumb, 285
Albumin in urine, tests for, 921
quantitative estimation of, 926
Albuminuria, 927
in renal calculus, 905
Albumosuria, 929
Alexia, 1000
Alkaptonuria, 937
Allochiria, 974
Alveolar cells in sputum, 523
Amaurosis, uremic, 966
Amnesia, 1010
Amceba dysenterie or coli, 344
in feces, 830
in pus, 363
in sputum, 528
Amcebic dysentery, 342
Amyloid degeneration of kidney, 968
Anemia, 389, 401
blood in, 394
classification of, 390
from disease, 391
fever in, 209
in gastric disease, 794
from hemorrhage, 391
local, 402
from malnutrition, 392
murmurs in, arterial, 641
cardiac, 637
venous, 641
in nephritis, 959
neuralgia in, 48
parasitic, 391
pernicious or idiopathic, 393
in phthisis, 558
splenic enlargement in, 392
symptoms of, 370
toxic, 390
Anesthesia, 972
dolorosa, 973
Analgesia, 972
Anarthria, 1006
Anasarca, 153
Aneurism, 674
of heart, 656
thoracic, 674
diagnosis of, 681
hemorrhage in, 467
pain in, 584
physical signs of, 678
sphygmogram in, 612
Angina Ludovici, 706, 717
pectoris, 585
in aortic regurgitation, 657
arterial tension in, 606
in coronary artery disease, 654
Angle of Ludwig, 472
Ankle clonus, 988
Ankylostomum duodenale, 838
Anorexia, 772, 799
Anosmia, 419
Anthracosis, 327
Anthrax, 277
bacillus of, 278
distinguished from carbuncle, 279
intestinal form of, 277
wool- sorter's type of, 278
Antrum, abscess of, 429
Aorta, aneurism of, 674. See also Aneu-
rism.
1064
INDEX.
Aorta, atheroma of, murmurs in, 637
pain in, 584
pulsation of, 596
Aortic area, 632
obstruction, 659
distinguished from atheroma of
aorta, 639
thrill in, 603
regurgitation, 657
presystolic murmur in, 665
pulsation in, distinguished from
aneurism, 683
pulse in, 639
sphygmogram in, 612
thrill in, 603
Apex-beat. See Heart, impulse of.
Aphasia, 1000
Aphonia, hysterical, 1060
in pericardial effusion, 645
Apoplexy, 1053
relation of arterio-sclerosis to, 673
Appendicitis, 738
abscess formation in, 741
catarrhal, 738
decubitus in, 69
distinguished from acute intestinal
obstruction, 851
from hip-joint disease, 742
from perinephritic abscess, 743
from typhoid fever, 302, 740
gangrenous, 742
pain in, 818
palpation in, 737
perforating, 741
distinguished from acute tubercu-
lous peritonitis, 743, 755
recurrent, 740
tuberculous, 755
Appetite, alteration of, 772, 799
Apraxia, 1006
Aprosexia, 715
Arcus senilis, 96
Argyria, 126
Arrhythmia, 587
in auto-intoxication, 203, 211
Arsenic-poisoning, 216
Arteries, murmurs in, in arterial sclerosis,
673 _
palpation of, 605
pulsation of, visible, 596
in aortic regurgitation, 658
sclerosis of, 672
tension of, 606
Arterio-capillary fibrosis, 672
pulsation of arteries in, 598
Arthritis, gonorrhoea^ 178
rheumatoid, 185
hand in, 113
tuberculous, 178
Ascaris lumbricoides, 833
symptoms of, 815
Ascites, 729
character of fluid in, 730
distinguished from enlargement of
liver, 871
from hydronephrosis, 912
Aspiration, technique of, 357
Astasia, 74
Asthma, 459
causes of, 460
decubitus in, 69
in nasal disease, 420
sputum of, 524
Atavism, 29
Ataxia, 979
Atelectasis, 548
Atheroma of arteries, 672
murmurs in, 641
Athetosis, 983
Auscultation of chest, 502
sounds in health, 503, 505
of voice, 512
Auto-intoxication, 760
BACELLI'S sign of empyema, 572
Bacilli of Booker, 836
Bacillus of anthrax, 278
of cholera, 338
coli communis, 363, 835
of diphtheria, 333
general characteristics of, 221
of influenza, 536
of leprosy, 349
mallei, 336
mucous capsulatus, 535
of pertussis, 536
smegmse, 532
in gangrene of lung, 530
of syphilis, 363
of tetanus, 353
of tuberculosis, 530, 836
of typhoid fever, 298
of yellow fever, 305
Backache, 57
in infectious fevers, 201
Bacteria, general characteristics of, 220
Bacteriological diagnosis, 229
methods, 230
apparatus, 231
collection of material, 232
cover-slip preparations, 244
culture media, 242
examination of blood, 232
hanging-drop preparations, 241
identification of organisms, 245
inoculation of animals, 244
plate culture, 243
smear culture, 244
staining, 240
of capsule, 535
of tubercle bacillus, 532
sterilization, 231
Bacteriuria, 948
Bamberger's sign of pericardial effusion,
648
Baruch's sign of typhoid fever, 301
Belching, 802
Bell tympany in chest, 412
Beri-beri, 1046
oedema in, 152, 153
Bile in urine, test for, 936
INDEX.
1065
Bile-ducts, cancer of, distinguished from
hepatic cancer, 882
inflammation of, 885
obstruction of by gallstones, 886
Biliousness, 855
bad taste in, 764
Black tongue, 696
Blasts, 375
Blepharospasm, 92
Blood, alkalinity of, 386
bacteriological examination of, 232
color index of, 385
counting the corpuscles of, 376
cover-slip preparations of, 372
in gastric contents, test for, 782
haemoglobin of, 384
leucocytes of, 379
parasites in, 388
physical appearance of, 371
pigment in, 386
pressure of, 414
red corpuscles of, 375
number of, 379
serum as culture media, 242
specific gravity of, 387
staining of, 373
in stools, 820
in urine, 928, 940
Boils in diabetes, 934
Bones, the, 169
in osteitis deformans, 170
in rickets, 172
Bothriocephalus latus, 833
symptoms of, 814
Boulimia, 772
Bradycardia, 609
in jaundice, 861
in typhus fever, 249
Bradylalia, 1006
Brain, abscess of, 1055
general symptoms of disease of, 1024
sclerosis of, 1056
tumors of, 1055
choked disk in, 100
Brawny induration, 157
Breath, fetor of, 687, 708
Breathing. See also Respiration.
amphoric, 508
bronchial, 503, 507
in pleural effusion, 571
broncho-vesicular, 504, 509
cavernous, 508
jerking inspiration in, 506
prolonged expiration in, 506
tubular, 508
vesicular, 503
exaggerated, 505
feeble or absent, 505
Broadbent's sign of adherent pericardium,
596
Bronchi, obstruction of, 458, 488
Bronchiectasis, 566
distinguished from phthisis, 567
Bronchitis, acute, 542
diagnosis of, 543
capillary, 545
Bronchitis, chronic, 544
fibrinous coagula in, 524
lithaemic, 856
plastic, 546
putrid, 547
Bronchophony, 513
Bronchorrhcea, 545
Bronzing of skin, 124
Brown-Sdquard's syndrome, 1025
Bulbar paralysis, 1054, 1056
rtJECUM, abscess about, 743
\J inflammation of, 742
Cachexia, cancerous, 412
in gastric cancer, 810
malarial, 289
varieties of, 67
Calculus, biliary, 885
renal, 902
Cancer. See Carcinoma.
Cantering rhythm of heart, 627
Capillary pulse, 598, 659
Caput Medusa?, 728, 877
Carbuncle in diabetes, 934
distinguished from anthrax, 279
Carcinoma, cachexia of, 412
fascies of, 81
gastric, 808
pain in, 771
supraclavicular glands in, 159
general symptoms of, 411
of larynx, 441
of lung, 567
haemoptysis in, 467
of oesophagus, 722
of peritoneum, 754
of skin, 158
Cardialgia, 770
Cardio-hepatic triangle, 615, 646
Carreau, 736, 758
Case-records, 22, 536
Casts in urine, 941
in renal calculus, 905
without nephritis, 944
Cataract, 99
Catarrh, nasal, 427. See also Rhinitis.
suffocative, 545
Catarrhe sec, 544
Cavities, pulmonary, 514
bronchophony in, 413
distinguished from pneumotho-
rax, 578
physical signs of, 514
Cercomonas intestinalis, 831
Cerebellar gait, 73
Cerebellum, symptoms of affections of,
1020
Cerebral localization, 1011
basal centres, 1018
cortical, 1015
medullary, 1019
hemorrhage, 1053
thrombosis and embolism, 1054
( 'erebro-spinal fever. See Meningitis.
Chalicosis, 551
1066
INDEX.
Charcot-Leyden crystals in nasal discharge,
426
in sputum, 526, 546
Chest in adenoid disease, 715
angles of, 471
auscultation of, 502
barrel-shaped, 477
bilateral diminution in size of, 480
enlargement of, 477
in chronic interstitial pneumonia, 550
pleural effusion, 576
counting the ribs of, 472
deficient expansion of, 487
deformities of, 483
fluoroscopic examination of, 488
fluctuation in, 492
inspection of, 473
local changes in size and shape of, 485
mensuration of, 515
movements of, 476
in disease, 486
palpation of, 490
percussion of, 492
phthisical, 480
regions and landmarks of, 471
respiratory capacity of, 516
rhachitic, 172, 480
shape of normal, 475
topographical anatomy of, 472
transverse groove in, 483
unilateral changes in shape of, 583
Cheyne-Stokes respiration, 487
Chickenpox, 253
Chills, 191
malarial, 280
Chin-jerk, 985
Chlorosis, 392
Choked disk, 100
Cholangitis, 862, 885
Cholecystitis, 888
Cholera, Asiatic, 336
diagnosis of, 338
spirillum of, 338
fascies in, 81, 337
infantum, 839
bacilli of Booker in, 836
morbus, 839
nostras, 840
spirillum of, 835
Cholesterin crystals in pus, 363
in sputum, 327
in urine, 954
Choluria, 935
Chorea, 1039
as a sequel to rheumatism, 181
in heart disease, 589
movements in, 983
Choroiditis, 100
Chvostek's sign of tetany, 985, 1041
Chyluria, 948
Claudication, intermittent, 979
Clonic spasms, 982
Clonus, ankle, 988
patellar, 987
wrist, 986
Clubbed fingers in thoracic aneurism, 677
Coin test in pneumothorax, 577
Colic, hepatic, 817, 885
intestinal, 816
lead, 817
renal, 817, 902
uterine, 562
Colitis, chronic ulcerative, 841
Collapse, 65
Colon, dilatation of, 732, 824
Color index of blood, 385
Coma, diabetic, 958
in heart disease, 589
uraemic, 956
Comma bacillus, 338
Congestion. See Hyperemia, 402.
Conjunctiva, the, 96
Constipation, 822
Consumption. See Tuberculosis, pulmon-
ary, 555.
galloping, 552
Convulsions, 983
in heart disease, 589
uraemic, 956
Coprolalia, 1040
Cor bovinum, 657
Cornea in general diagnosis, 96
Coronary arteries, disease of, 653
Corrigan's pulse, 658
Coryza, acute, 427
syphilitic, 429
Costal angle in rickets, 481
Cough in aneurism of aorta, 676
in bronchiectasis, 566
in capillary bronchitis, 546
characteristics of, 465
in chronic bronchitis, 544
dry, 465
in gastric disease, 773
in heart disease, 588
laryngeal, 435
in mediastinal disease, 684
moist, 465
in nasal disease, 420
nervous, 436
in pertussis, 466
in phthisis, 560
in pleurisy, 575
of puberty, 465
in pulmonary affections, 464
reflex and central, 464
Coxalgia distinguished from appendicitis,
743
Cracked-pot sound, 501
in pneumothorax, 577
Cramps in uraemia, 957
Cranial nerves, location of nuclei of, 1020
symptoms of affections of, 1025
Craniotabes, 87
Cranium, auscultation and percussion of, 87
Crepitation, 510
Cretins, facial appearance of, 82
Crises of pain, 44
in tabes dorsalis, 45, 800
Croup, diagnosis of, 442, 443
Culture media, 242
Curschman's spirals, 525, 546
INDEX.
1067
Cyanosis, 122
in capillary bronchitis, 546
in emphysema, £64
Cylindroids, 945
Cyrtometer, 515
Cysticercus of skin, 158
Cystin in urine, 953
Cysts, hydatid, 366
of kidney, 367
ovarian, 367
pancreatic, 367
DEAF-MUTISM, hysterical, 109
Deafness in adenoid disease, 714
hysterical, 109
in nasal affections, 420
nervous, 108
Decubitus, 68
(abed-sore), 409, 1007
Degeneration, fatty, amyloid, etc., 410
Delirium, 1010
acute, 1056
in uraemia, 956
Delusions, 1011
Dengue, 267
Dental arch in thumb-sucking, 687
Dermatitis distinguished from erysipelas,
311
Diabetes insipidus, 916
mellitus, 933
acetonemia in, 958
asthma in, 461
bronzing in, 126
neuralgia in, 48
Diaceturia, 936
Diagnosis, bacteriological, 229
conditions rendering it impossible, 19
data upon which based, 18
Diaphragm, movements of, 476
paralysis of, 461
phenomenon of Litten, 477
Diarrhoea, catarrhal, 819
chronic, 822
in gastric disease, 773
membranous, 822
nervous, 821
stools in, 820
uraemic, 957, 965
Diatheses, varieties of, 66
Diazo-reaction in typhoid fever, 294
Dietl's crises, 908
Diphtheria, 330
bacillus of, 333
diagnosis of, 333
distinguished from scarlet fever, 260
from tonsillitis, 713
false membrane in, 332
heart in, 333
laryngeal stenosis in, 332
sequelae of, 333
uraemia in, 332
Diplococcus intracellularis meningitidis,
329
pneumoniae. Sec Micrococcus Lanceo-
latus.
Diplophonia, 433
Diplopia, 94
Dipping in abdominal palpation, 730
Distoma hepaticum, 833
Dropsy. $ee (Edema.
ovarian, 745
Drowsiness in dyspepsia, 773
Dulness on percussion, 496
Duodenal catarrh, 839
ulcer, 841
Dupuytren's contraction, 115
Dysentery, amoeba of, 344
amoebic or tropical, 342
catarrhal, 341
diphtheritic and gangrenous, 345
Dyspepsia, atonic, 803
flatulent, 804
in heart disease, 589
nervous, 803
reflex, 805
Dysphagia, 435
in aneurism of aorta, 720
in disease of larynx, 430
of pharynx, 708
of oesophagus, 721
from foreign body in oesophagus, 722
mediastinal tumor, 720
from paralysis of oesophagus, 724
in pericardial effusion, 645
from pressure on oesophagus, 720
Dysphasia, 1006
Dysphonia, 432
Dyspnoea in adenoid disease, 716
in aortic aneurism, 677
in asthma, 459
in capillary bronchitis, 545
causes of, 456
dyspeptic, 463
in emphysema, 564
expiratory, 435, 464
in gastric disease, 773
in heart disease, 588
inspiratory, 434
in laryngeal disease, 433 ■
in mediastinal tumor, 684
in nephritis, 962
in obstruction of trachea or bronchi,
456
in pericardial effusion, 645
in pharyngeal disease, 708
in phthisis, 560
rate of respiration in, 463
in retropharyngeal abscesses, 717
uraemic, 957, 965
Dystrophies of connective tissue, 156
muscular, 163
EAR-cough, 465
discharge from, 107
hsematoma of, 107
tophi in, 107
Echolalia, 1006
Eczema distinguished from chickenpox,
255
Elastic fibres in sputum, 523
1068
INDEX.
Electrical diagnosis, 991
Elephantiasis, 162
Embolism, in aortic obstruction, 659
in arterio-sclerosis, 403
capillary, 404
fat and air, 404
in malignant endocarditis, 651
of mesenteric arteries, 815
pulmonary, 541
Embryocardia, 627
in dilatation, 672
Emphysema, 564
atrophic, 566
barrel-shaped chest in, 479
breath-sounds in, 505
distinguished from pneumothorax, 578
interlobular, 566
physical signs of, 565
subcutaneous, 155, 719
Emprosthotonos, 70
Empyema, 572
necessitatis, 572
pulsating, 574
distinguished from aneurism, 683
Encephalitis, 1055
Endocarditis, 650
chronic, 653
malignant, 651
from pneumococcus infection, 318
in rheumatic fever, 180
in septicaemia, 227
simple, 650
Enophthalmos, 92
Enteralgia, 816
Enteritis, membranous, 822
Entero-colitis, 840
Enteroptosis, 748
Enuresis in adenoid disease, 715
Eosinophilia, 382
Ephemeral fever, 212
Epiglottis, inflammation of, 435
Epilepsy, 1058
focal or Jacksonian, 982, 1059
Epistaxis, 426
Ergotism, 215
Eructations, 802
Eruption in measles, 261
in pharynx, 709
in scarlet fever, 259
in syphilis, 269
in typhoid fever, 296
in typhus fever, 248
in varicella, 254
in variola, 251
Erysipelas, 309
Erythema, 135
of infectious diseases, 139
medicinal, 139
multiforme, 137
nodosum, 138
non-contagious, causes of, 136
Erythromelalgia, 115
Exophthalmic goitre, 88
pulse in, 608
Exophthalmos, 92
Exploratory puncture. See Aspiration.
Exudations, 360
chylous, 365
hemorrhagic, 364
purulent, 360
seropurulent, 364
serous, 365
Eye, affections of muscles of, 92
in scurvy, 188
Eyelids, oedema of, 91
FACE in acromegalia, 169
in adenoid disease, 82, 714
in erysipelas, 310
hemiatrophy of, 83
in hereditary syphilis, 82
in hydrocephalus, 82
in nervous diseases, 82
in osteitis deformans, 170
in peritonitis, 751
in scurvy, 188
in tetanus, 352
in uraemia, 959
in yellow fever, 304
Family relations in the etiology of disease,
26, 27
Farcy, 335. See also Glanders.
Fascies of various diseases, 81
Fat in stools in pancreatic disease, 894
in urine, 947
Fauces, examination of, 708
Fecal abscess, 743
impaction, 737, 824 _
epigastric pulsation in, 597
Feces, 825 _
bacteria in, 835
blood in, 827, 829 _
chemical examination of, 836
gallstone in, 827
microscopical examination of, 828
protozoa in, 830
vermes in, 831
Feigned disease, detection of, 33. See also
Pain, Simulated.
Festination, 1040
Fever, arterial, tension in, 199
aseptic, 209
ataxic state in, 200
in auto-intoxication, 211
in carcinoma, 228
cerebral symptoms in, 199
cerebro-spinal, 326
clinical causes of, 203
course and stages of, 196, 204
daily range of, 198
defervescence of, mode of, 197, 204
eruptive, 247
glandular, 265
hepatic intermitting, 206
influence of age on, 204
intermittent, 280
in phthisis, 558
in intoxication, 209
malarial, 279
Malta, 305
miliary, 272
INDEX.
1069
Fever, in morphinism, 212
onset, mode of, 197
pathology of, 191
in phthisis, 558
pulse-rate in, 199, 211
in reaction from apoplexy, 202
recrudescence of, 198
relapsing, 274
renal, paroxysmal, 905
respiration in, 199, 211
rheumatic, 178
scarlet, 255
in septicaemia, 210
simple continued, 212
sudden fall of, 205
onset of, 204
in sunstroke, 211
in suppuration, 408
symptoms of, 19S
in syphilis, 206, 229
tongue in, 701
in trichinosis, 354
in tuberculosis, 205
types of, 195
typhoid, 289
in typhoid fever, 204
typhoid state in, 199
typhus, 247
urinary intermitting, 206
yellow, 303
Fibrinous coagula in sputum, 524
Fibroid change in tissues, 411
tumors of uterus, 745
Filaria sanguinis hominis, 388
in urine, 948
Fits, 64
Flagellar, staining of, 158
Flat-foot, pain in, 54
Flatulency, 769
in diarrhoea, 821
Flint, murmur of, 658
Fluctuation in abdomen, 730
Fontanelles, 87
Foot-and-mouth disease, 273
Freckles in rheumatoid arthritis, 126
Fremitus, friction, 491
.hydatid, 883
peritonea], 754
vocal, 490
Friction fremitus, 491
in pericarditis, 643
sound, 511
distinguished from pleural fric-
tion, 642
from rales, 510
from vascular murmur, 642
mediastinal, 650
in pericarditis, 629, 641
pleural, 511
Friedreich's ataxia, 1044
respiratory change of sound, 515
Funnel- breast, 483
Gall-bladder, cancer of, 889
enlargement of, 887
palpation of, 868
tumors of, 888
diagnosis of, 889
distinguished from movable kid-
ney, 909
Gallstones, 885
accidents resulting from, 887
colic due to, 817
obstruction of common duct by, 886
Gangrene, 409
of lung, 563
haemoptysis in, 467
from trophic disturbance, 1007
Gastralgia, 770, 771, 779
neurasthenic, 800
Gastrectasis, 807
Gastric crises, 769
Gastritis, acute, 795
pain in, 771
chronic, 805
distinguished from ulcer and can-
cer, 811
mycotic and diphtheritic, 796
phlegmonous, 796
toxic, 796
Gastrodiaphany, 774
Gastrodynia, 770
Gastroxynsis, 802
Gerhardt's change of sound, 515
Girdle pain, 55
Glanders, 335
bacillus of, 336
diagnosis of, 336
mallein test for, 336
Glands, lymphatic, enlargement of, 159
Glandular fever, 265
Glenard's disease, 748
Globulin in urine, 937
Globus hystericus, 769, 1061
Glossitis, 696
dissecting, 698
Glycosuria, 933, 935
in pancreatic disease, 894
Goitre, exophthalmic, 88
Gonococcus, 363
in blood, 308
Gonorrhoeal septicaemia, 307
Gout, 183
acute articular, 184
blood in, 184
chronic, 184
gastric symptoms in, 762
hand in, 114
relation to lithreinia, 856
retrocedent, 184
teeth in, 691
Gram's stain, 241
Gums in cachexia, 690
in lead-poisoning, 691
in scurvy, 189, 691
GAIT in disease, 70
Gall-bladder, aspiration of,
II
ABIT spasm, 1040
Habits in etiology of disease, 25
1070
INDEX.
Hematemesis, 792
distinguished from haemoptysis, 793
in gastric ulcer, 812
cancer, 810
in hepatic cirrhosis, 676
Hematocele, pelvic, 744
Hematoidin crystals, 364
in pus, 527
Hematokrit, 378
Hematoporphyrinuria, 936
Hematuria, 928, 940
malarial, 288
from overexertion, 904
in renal calculus, 904
cancer, 911
Hemocytometer, 376
Haemoglobin, 384
Hemoglobinometers, 384
Hemaglobinuria, 929
Hemopericardium, 648
Haemophilia, 129
diagnosis of, 130
Haemoptysis, 468, 521. See ako Hemor-
rhage, pulmonary.
Hemothorax, 593
Hair in diagnosis, 85
Hallucinations, 1011
Hands in acromegaly, 170
deformities of, 110, 113
swelling of, 113
Hanging-drop, method of making, 241
Harrison's groove, 172
Hay-fever, 420, 547
Head in rickets, 173
Headache, anemic, 42
character of pain in, 52
chronic, causes of, 52
in indigestion, 770
in infectious fevers, 201
in inflammation of frontal bones, 49
lithemic, 770, 856
ocular, 51
in syphilis, 52
in uremia, 956
Hearing impaired by drugs, 108
tests for, 107
Heart, aneurism of, 656
area of absolute dulness, 614
change in, 615
graphic record of, 619
in pericardial effusion,
646
of deep dulness, 616
arrhythmia of, 587
auscultation of, 619
dilatation of, 670
acute, 671
area of dulness in, 616
valve, shock in, 603
disease of, etiological factors in, 582
bradycardia in, 609
cough in, 588
dropsy in, 588
dyspeptic symptoms in, 589
dyspnea in, 588
general pathology of, 580
Heart, disease of, hemoptysis in, 467, 588
inspection in, 592
kidneys in, 589
nervous symptoms in, 588
pain in, 583, 585
precordia in, 592
retraction of interspaces in, 595
in emphysema, 565
fatty overgrowth of, 656
hypertrophy of, 667
area of dulness in, 616
diagnosis of, 670
impulse in, 593, 602
epigastric, 597
physical signs of, 668
in valvular disease, 657
impulse of, 592
absence of, 594
additional, 595
area of, 595
changes in position of, in health,
593
in dilatation, 671
displacement of, 593
palpation of, 601
strength of, 602
inflammation of muscles of. See Myo-
carditis,
irregular, in pericardial effusion, 645
irritable, 587
murmurs. See Murmurs,
neuroses of, 581
palpitation of, 586
percussion of, 614
pleximetric, 617
repercussion of, 618
physiology of, 591
in pleural effusion, 571
right side of, hypertrophy of, 669, 670
rupture of, 656
sounds, aortic accentuated, 625
diminished, 626
mitral, diminished, 626
normal, 620
diastolic, 623
differentiation of, 623
systolic, 621
transmission of, 623
pulmonary, accentuated, 625
diminished, 626
reduplication of, 627
false, 629
systolic, accentuation of, 624
topography of, 590
valves of, position of, 591
valvular disease of, chronic, 656
effects on heart and pulse, 639
gastric symptoms in, 761
weakness of, sphygmogram in, 612
Heat exhaustion, 212
Heberden's nodes, 114
Hemianopsia, 102
Hemiplegia, 977
Hemorrhage, 405
in central nervous disease, 131
cerebral, 1053
INDEX.
1071
Hemorrhage, gastric, 792
distinguished from pulmonary
hemorrhage, 469
gastro-intestinal, in portal congestion,
858
internal, symptoms of, 406
intestinal, 824
in duodenal ulcer, 841
from mucous membrane of mouth, 687
from cesophagus, 719
from pharynx, 709
pulmonary, 466
in capillary bronchitis, 546
character of blood in, 468
in chronic interstitial pneumonia,
551
distinguished from other forms,
469, 793
in heart disease, 588
in infarction of lung, 542
in phthisis, 553, 560
symptoms of, 468
in scurvy, 189
in thoracic aneurism, 677
into skin, 126
in anaemia, 127
in fever, 127
in jaundice, 862
in septicaemia, 227
toxic, 131
in uraemia, 959
Hemorrhoids, 853
Hepatic colic, 885
fever, 864
Hepato- pulmonary abscess from dysentery,
346
Heredity, transmission of nervous diseases
by, 961
pulmonary diseases by, 455
Hernia as a cause of intestinal obstruction,
859
Herpes labialis, 138
zoster, 187, 1006
Hiccough in gastric diseases, 773
Hippocratic fascies, 81
Hippus, 97
Hodgkin's disease, 160, 399
Hutchinson's teeth, 270, 691
Hydatid cyst of liver, 883
of lung, 568
Hydrocephalus, 1056
physiognomy of, 86
Hydronephrosis, 911
distinguished from hydatid cyst of
liver, 884
Hydropericardium, 648
Hydrophobia, 273
Hydrothorax, 573
Hypaesthesia, 971
Hypalgesia, 972
Hyperacidity, gastric, 801
Hyperaemia, active, 401
passive or venous, 402
Hyperaesthesia, 971
of stomach, 798
Hyperalgesia, 972
Hyperorexia, 799
Hyperpyrexia, 194
Hyperthermoaesthesia, 973
Hysteria, 1059
detection of, 89
joint in, 189
pseudo-angina in, 586
Hysterical mimicry of disease, 33
[DIOCY, 1010
L Impetigo, 255
Impulse of heart, 592. See Heart, im-
pulse of.
Indicanuria, 935
in empyema, 573
in gastric cancer, 810
in intestinal obstruction, 849
Indigestion, gastric, 797
intestinal, 836
Infarction, 404
of lung, 467
infections, classification of, 219
etiology of, 218
fever in, 203
history in diagnosis of, 246
pulse in, 608
terminal, 228
Inflammation, 407
of mucous membrane, 408
of serous membrane, 408
Influenza, 323
bacillus of, 536
diagnosis of, 325
ophthalmic neuralgia in, 48
Inheritance in the etiology of disease, 27
Inoculation of animals, 244
Intermittent fever. See Malarial Fever,
280.
Intestines, amyloid degeneration of, 841
cancer of, 852
catarrh of, acute, 837
chronic, 840
disease of, physical signs in, 825
obstruction of, acute, causes of, 843
symptoms of, 846
chronic, causes of, 844
symptoms of, 846
diagnosis of, 847, 850
parasites in, 814
tuberculosis of, 842
ulceration of, 841
Intoxication, alcoholic, 214
fever in, 209
by food, 213
by grain, 214
by lead, 215
Intussusception, 744, 844, 849
Iritis, 97
"JAUNDICE, 121
J acute febrile, 271
bradycardia in, 609
catarrhal, 862, 866
in cholelithiasis, 886
1072
INDEX.
Jaundice, in congestion of liver, 859
fever in, 864
hematogenous, 863
hepatogenous, 862
infantile, 865
malignant, 864
symptoms of, 861
Joints, crepitus in, 177
enlargement of, 176
fluctuation in, 177
hysterical, 189
movability of, 177
pain in, 176
pathological processes in, 177
position assumed, 177
in rheumatic fever, 179
in tabes dorsalis, 189
trophic lesions of, 1008
tuberculosis of, 178
KERNIG'S sign of cerebro-spinal fever,
330, 1053
Kidney, abscess of, 913
congestion of, 960
cystic, 911, 967
degeneration of, 967
enlargement of, 910
distinguished from enlarged spleen,
892
granular, 964
in heart disease, 589
horseshoe, 909
hydatid cyst of, 914
inflammations of. See Nephritis,
movable, 907
distinguished from tumor of gall-
bladder, 889
pain in disease of, 901
palpation of, 906
percussion of, 907
sarcoma and carcinoma of, 910
topography of, 906
Knee-jerk, 986
Koch's postulates, 218
Koplik's sign of measles, 261
"I AGOPHTHALMOS, 92, 1026, 1054
JL Landry's paralysis. 1050
Laryngismus stridulus, 434
in rickets, 174
Laryngitis, acute, 441
with stenosis, 442
chronic, 432
membranous and diphtheritic, 443
spasmodic, 443
submucous, 445
Laryngoscopy, 437
Larynx, color of mucous membrane in, 439
cough in disease of, 435
dysphagia in disease of, 435
dyspncea in disease of, 433
foreign bodies in, distinguished from
whooping-cough, 445
hemorrhage from, 436
Larynx, inco-ordination of muscles of, 436
lupus of, 440
cedema of, 443
distinguished from membranous
laryngitis, 444
pain in, 431
paresthesia, hyperesthesia, and anes-
thesia of, 432
paralysis of muscles of, 445
perichondritis of, 431
syphilis of, 439, 440, 448
tuberculosis of, 439, 440, 447_ _
distinguished from syphilis, 448
tumors of, 440, 447
Lathyrism, 215
Lead- poisoning, 215
colic in, 817
Leprosy, 349
in mouth, 694
organism of, 349
Leptomeningitis, 1052
Leptothrix buccalis, 690
in sputum, 529
Leucin in urine, 953
Leucocythemia, 396
acute, 399
blood in, 397
lymphatic form of, 399
spleen in, 892
splenomedullary form of, 396
Leucocytosis, 381
absence of, in typhoid fever, 299
in infectious disease, 238
in pneumonia, 315
Leucopenia, 382
Leukemia. See Leucocythemia, 396
Linea albicantes, 728
Lipemia, 386
Lipomata, peritoneal, 733
Lips in diagnosis, 85
Lipuria, 947
Lithemia, 855
neuralgia in, 48
Liver, abscess of, 346, 872
diagnosis of, 874
distinguished from cancer, 882
acute yellow atrophy of, 864
amyloid disease of, 866, 880
arterial pulsation of, 604
auscultation of, 868
cancer of, 880
palpation in, 867
cirrhosis of, atrophic, 876
collateral circulation in, 877
gastric symptoms in, 762
hypertrophic, 878
distinguished from cancer,
882
syphilitic, 879
congestion of, 857
constriction of, from lacing, 867
diminution in size of, 869
enlargement of, 869
conditions with which confounded,
870
etiological factors in disease of, 859
INDEX.
1073
Liver, fatty, 866, 880
floating, 867
functional disturbances of, 855
hydatid disease of, 883
tumor in, 867
pain in, 873
palpation of, 866
syphilis of, 879
topographical anatomy of, 860
Localization of lesions of nervous system,
1011
Locomotor ataxia. See Tabes dorsalis,
1043
Logorrhoea, 1006
Ludwig's angina, 717
Lumbago, 167
Lumbar puncture, 359
in cerebro- spinal fever, 3'28
Lung or lungs, abscess of, 563
boundaries of, in disease, 498
collapse of, 548
congestion of, 540
cough in diseases of, 464
diminution of air space in, 458
embolism and thrombosis of, 541
gangrene of, 521, 563
general symptomatology of disease of,
452
history in disease of, 455
hydatid disease of, 568
neuroses of, 540
oedema of, 540
percussion sounds in disease of, 498
relationship of. to heart, 453
size of, in phthisis, 561
topographical anatomy of, 473
tuberculosis of, 552. See Tuberculosis,
pulmonary.
tumors of, 567
Lupus of larynx, 440
Lymphadenoma, 399
Lymphangitis, 161
in septicaemia, 227
Lymphatic glands in leucocythaemia, 399
Lymphatism, 162
Lymphocytosis, 382
Lymphosarcoma, 158, 160
"WACROGLOSSIA, 700
IU Main en griffe, 1009
Malarial cachexia. 289
neuralgia in, 48
spleen in, 892
fever, 279
diagnosis of, 283
intermittent, 285
irregular forms of, 285
pernicious, 287
Plasmodia of, 282
remittent, 287
Mallein test for glanders, 336
Malta fever, 305
Mania, 1010
McBurney's point, 739
Measles, 260
Measles, distinguished from scarlet fever,
259
Meat- poisoning, 213
Mediastinal friction, 650
tumors, 684
Mediastinitis, 683
Mediastino-pericarditis, [indurative, 650
Medicinal rashes, 139
Melaena, 825
Melanaemia, 386
Melancholia, 1011
Melanuria, 954
Meniere's disease, 108, 1059
station in, 74
Meningitis, 1052
chronic internal spinal, 1048
epidemic cerebro-spinal, 326, 1047
complications and sequela? of, 328
distinguished from typhoid fever,
302
Kernig's sign of, 330
lumbar puncture in, 328
organism of, 329
symptoms of, 327
temperature in, 326
from pneumococcus infection, 318
syphilitic, 1047
Mensuration of chest, 515, 517
Mental disturbances, 1010
Meralgia paraesthetica, 1043
Merycismus, 803
Metallic tinkling in chest, 512
in pneumothorax, 578
Metatarsalgia, 54
Micrococci, general characteristics of, 220
Micrococcus lanceolatus, 363, 534
.Micturition, frequent, 906
Migraine, 49, 1059
Miliaria, 140
Miliary fever, 272
Milk-poisoning, 214
sickness, 273
Mitral area, 632
insufficiency, 660
broken compensation in, 661
physical signs of, 662
stenosis, 663
physical signs of, 664
pulmonary second sound in, 626
thrill in, 603
Monoplegia, 979
Morphinism, 212
Morphoea, 157
Morton's painful affection of foot, 54
Mor van's disease, 1051
Motor points of muscles, 994
Mountain fever, identitv with typhoid, 303
Mouth-breathing, 417, 426
color of mucous membrane of, 687
dryness of, 686
hemorrhage into mucous membrane
of, 687
Mumps, 84, 265
Murmurs of anaemia, 637
in aortic aneurism, 680
area, 633, 634
68
1074
IXDEX.
Murmurs in aortic obstruction, 659
regurgitation, 658
arterial, 640
double, 641
from pressure, 641
cardio-muscular, 638
-respiratory, 638
character of, 635
combined, 640, 667
disappearance of, 637
of Flint, 658
influence of pressure on, 638
loudness of, 636
at mitral area, 633, 634
of mitral insufficiency, 662
stenosis, 664
position of maximum intensity of, 631
presystolic, 664, 665
at pulmonary area, 634
in relative incompetency, 637
time of, 632
transmission of, 635
in tricuspid stenosis, 666
at tricuspid area, 633, 634
vascular, 629
Muscular atrophy, 164, 989
diagnosis of, 164
peroneal type of, 164
progressive, 1034
consecutive to disease of
nerves, 1037
spinal, 1038
table of, 165
hypertrophy, 166
ossification, 167
paralysis, pseudohypertrophic, 1036
tone, 983
Muscles, extra-ocular, actions of, 92
affections of, 93
disturbed balance of, 95
functional classification of, 1027
lack of tone in, 78
Myalgia, 167
distinguished from neuralgia, 45
occipital and frontal, 47
Mydriasis, 98
Myelitis, acute, 1049
chronic, 1049
disseminated, 1049
Myelocytes, 383
Myocarditis, 654
Myoidema, 163
Myosis, 98
Myositis, 166
Myotonia congenita, 166
Myotonic reaction, 999
Myxoedema, 154
"VTAILS in diagnosis, 116
IN disturbed nutrition of, 1007
Nasal discharge, a portent of uraemia, 418
Nasopharynx, adenoid vegetations in, 714
Nausea in gastric disease, 764
in headache, 52
ursemic, 957
Necrosis of tissue, 409
Nephritis, acute exudative or glomerulo,
961
with pus formation, 962
productive, 962
chronic productive, 962
without exudation, 964
erythema in, 140
gastric symptoms in, 762
interstitial, 964
retinitis in, 100
suppurative, 966
tubercular, 967
Nephrolithiasis, 902
colic in, 817
Nervousness, 34
Neuralgia, 1041
causes of, 53
character of pain in, 47
distinguished from myalgia, 45
intercostal, distinguished from pleu-
risy, 470, 576
from local irritation, 47
malarial, 285
points of tenderness in, 45
reflex from eye, teeth, or tongue, 48
secondary, 49
symptoms of, 52
from systemic conditions, 48
trigeminal, 47
Neurasthenia, 1061
Neurasthenic gastralgia, S00
Neuritis, 1047
of optic nerve, 100
Neuromata multiple, 1046
Neurons, motor, lesions of, 1013
sensory, lesions of, 1012
Neuroses, gastric, 797
of lungs and bronchi, 540
of occupation, 1041
reflex, 420
Neusser's granules, 383
Night-blindness, 189
restlessness in adenoid disease, 716
sweats of phthisis, 559
Nigrities, 696
Nodes on bone, 175
Nose, 426
appearance of mucous membrane of,
423
auxiliary cavities of, disease of, 429
deformity of, 421
examination of, 421
obstruction of, 420
polypi in, 424
relation of disease of, to asthma, 420
ulceration in, 424
Nucleo-albumin in urine, 928
Nyctalopia, 189
Nystagmus, 95
OBJECTIVE symptoms, methods of ob-
serving, 60
Obstipation, 822, 825
Occipital neuralgia, 1042
INDEX.
1075
Occupation in etiology of disease, 26
neuroses of, 10-11
(Edema, angio-neurotic, 153
of arms and thorax, 151
diagnosis of, 150
of feet, 151
general, 153
in heart disease, 5S8
inflammatory, 150
local, 150
significance of, 152
of lungs, 540
mode of recognition of, 149
in nephritis, 961
pathology of, 148
in trichinosis, 151, 354
in uraemia, 959
Oesophagitis, 721
Oesophagus, abscess of, 721
carcinoma of, 722
dilatation of, 723
examination of, 719
foreign body in, 722
obstruction of, 720
spasm of, 723
stricture of, 721
Oidium albicans, 690
in sputum, 529
Oligochromasia, 585
Oligocythemia, 379, 395
Ophthalmoplegia, 105
Ophthalmoscopy, 99
Opisthotonos, 70
Opium habit, 212
Optic atrophy in tabes dorsalis, 101
Osteitis deformans, 170
Osteo-arthropathy, pulmonary, bones in,
171
Osteomalacia, 174
Osteomyelitis, 175
Ovarian cysts, 367
diagnosis of, 745
Oxaluria, 952
Oxyuris vermicularis, 833
symptoms of, 815
Ozsena, 425
in glanders, 335
PACHYMENINGITIS, external cere-
bral, 1052
hypertrophic cervical, 1047
Pain in abdomen, 726
in appendicitis, 739, 818
in arms, 54
character of onset of, 41
in chest in phthisis, 360
crises of, 44
deep seated, 44
definition of, 36
in diarrhoea, 821
duration of, 41
in epigastrium, 584, 770
in relapsing fever, 275
in uraemia, 957
estimation of, 38
Pain, etiology of, 37
in extra-uterine pregnancy, 817
in foot in flat-foot, 54
in gastric disease, 771, 775, 818
ulcer, 812
general, 43
in rickets, 173
girdle, 55
in heel in gout, 54
indicating location of disease, 43
nature of disease, 42
inframammary, 56
intermittent or remittent, 41
in intestinal obstruction, 818
in joints, 176
kinds of, 42
in larynx, 431
in legs, 53, 54
in cerebral hemorrhage, 54
in loins, 57
measurement of, 40
modes of expression of, 37
in mouth, 686
muscular in trichinosis, 354
in nasal disease, 419
in oesophagus, 718
in otitis media, 49
in pancreatic disease, 818
paroxysmal, 42
in pericarditis, 643
periodic, 42
peripheral of central origin, [36, 44,
54
in peritonitis, 750, 818
in pharynx, 707
in pleurisy, 469, 569, 575
in praecordia, 583
in rectum, 817
referred, 43, 44
in scalp, 46
sense, 973
in shock, 40
simulated, 39. See also Feigned dis-
ease,
in spine, 55, 56
in and behind sternum, 55, 175
superficial, 43
sympathetic, 43
in thoracic aneurism, 676
in vertebral disease, 819
visceral, 973
Palpitation of heart, 586
in gastric disease, 773
in litha?mia, 856
Palsies, local and multiple, 978
Pancreas, cancer of, 894
distinguished from hepatic can-
cer, 882
cysts of, 898
distinguished from enlarged liver,
871
fluid in, 367
diseases of, 893
hemorrhage into, 895
tumors of, 746, 894
Pancreatitis, acute hemorrhagic, 895
1076
INDEX.
Pancreatitis, acute hemorrhagic, distin-
guished from acute intestinal ob-
struction, 851
gangrenous, 897
suppurative, 897
Papillitis, 100
Papilloma of larynx, 440
Paradoxical contraction of Westphal, 989
Paresthesia, 970
Paralysis, 976
agitans, 1040
bulbar, 1054, 1056
crossed, 1014
diphtheritic, 333
Landry's, 1050
local, in uraemia, 957
myopathic, 978
of orbital nerves, 106
periodic, 1039
pseudo-hypertrophic muscular, 1036
gait in, 72
station in, 74
Paramyoclonus multiplex, 166, 1040
Paranoia, 1011
Paraphasia, 1001
Paraplegia, 978
hysterical, gait in, 72
primary spastic, 1046
gait in, 71, 72
from Pott's disease, 1048
Parasites, anaemia due to, 391
in intestines, 814
in mouth, 693
in sputum, 528
Paresis, 979
general, of the insane, 1057
Parosmia, 419
Parotitis, epidemic, 84
symptomatic, 718
Pectoriloquy, 413
Peliosis rheumatica, 129
Pellagra, 215
Percussion, 492
auscultatory, 497
of chest, amphoric sound in, 501
cracked-pot sound in, 501
dulness in, 500
hyper-resonance, 498
impaired resonance, 499
normal sounds in, 494
tympany in, 499
respiratory, 497
superficial and deep, 497
Pericardial friction sound, 603, 629
distinguished from pleural, 630
Pericarditis, 641
acute fibrinous, 641
adhesive, 648
with effusion, 644
impulse in, 593
pain in, 584
physical signs of, 645
from pneumococcus infection, 318
Pericardium, aspiration of, 358
Perinephritic abscess, 913
Periostitis, 175
Peristalsis, visible, 729, 774
Peritonitis, 750
chronic, 754
diagnosis of, 752
in dysentery, 347
hysterical, 753
localized, 753
tuberculous, 755
Perspiration in crisis of pneumonia, 145
diminished, 146
increased, 145
local, 146
in miliary fever, 272
in phthisis, 559
in rheumatic fever, 145, 180
in rickets, 173
in tuberculosis, 145
Pertussis, 265
bacillus of, 536
cough in, 466
Petit mal, 1058
Phantom tumor, 734, 1061
Pharyngitis, acute, 716
chronic, 717
lithsemic, 856
phlegmonous, 717
rheumatic, 717
Pharynx, adenoids of, 714
anaesthesia of, 710
color of mucous membrane of, 709
examination of, 708
pseudomembrane on, 710
spasm of, 708
ulcers in, 709
Phlebitis in septicaemia, 227
Phlegmasia alba dolens, 403
Phosphates in urine, 950
Phosphorus-poisoning, 865
Photophobia, 92
Phrenic nerve, paralysis of, 461
Phthisis. See Tuberculosis, pulmonary,
555.
Physical signs, pictoric record of, 536
Pica, 772
Pigeon-breast, 715
Pigmentation of skin, 124
Plague, bubonic, 347
bacillus of, 348
Plasmodia of malaria, 2S2
staining of, 284
Plate cultures, 243
Plethora, 401
Pleural friction sound, distinguished from
pericardia], 630
Pleurisy acute, 569
distinguished from intercostal neu-
ralgia, 470, 576
from pleurodynia, 469, 576
from pneumonia, 575
physical signs of, 570
chronic, 576
with thickening, 576
cough in, 465
diaphragmatic, 574
etiology of, 569
with effusion, 570
INDEX.
1077
Pleurisy, with effusion, segophony in, 513
aspiration of, 358
character of fluid in, 365
distinguished from consolidation,
575
from enlarged liver, 870
from hydatid cjst of liver,
884
heart in, 571
shape and size of chest in, 484
movements of chest in, 487, 488
pain in, 469
from pneumococcus infection, 318
tuberculous, 574
Pleurodynia, 167
distinguished from pleurisy, 469, 488,
576
Plumbism, 215
Pneumatosis, 802
Pneumococcus, 363
septicaemia due to, 31 8
Pneumokoniosis, 550
Pneumonia-broncho-, 549
distinguished from collapse of
lung, 549
physical signs of, 549
tuberculous, 550
bronchophony in, 513
chronic interstitial, 550
crepitant rales in, 510
croupous or lobar, 311
bacteriological diagnosis of, 318
central variety, 311
cerebral symptoms in, 314
chlorides in urine in, 315
critical sweats in, 145
diagnosis of, 317
distinguished from collapse of
lung, 548
in drunkards, 317
duration and course of, 316
heart and pulse in, 314
massive, 315
organism of, 534
physical signs of, 315
respiration in, 312
sputum in, 312
varieties of, 316
in infants, 317
movements of chest in, 487
pulmonary second sound in, 625
sputum of, 521
Pneumopericardium, 648
Pneumoperitoneum, 751
Pneumothorax, 577
diagnosis of, 578
distinguished from emphysema, 566
Poikilocytosis, 375
Poisoning. See Intoxication, 209
Poliomyelitis, anterior, 1038
Polyphagia, 803
Polypi, nasal, 424
Pons, lesions of, 1019
Portal vein, obstruction of, 858
pysemia, 858
Pott's disease, paraplegia in, 1048
Prsecordia, prominence of, 592
Previous disease, bearing of, on diagnosis,
29
Pregnancy, pigmentation in, 125
vomiting in, 767
Pressure, sense of, 975
Proctitis, 839
Pruritus, 134
in jaundice, 861
in uraemia, 957
Ptosis, 91
Ptyalism, 694
Pulmonary disease. See Lung.
valve disease, 666
area, 632
Pulsation of arteries, 587, 596
a subjective symptom, 590
epigastric, 596, 7^8
of veins, 599
Pulse in aortic aneurism, 681
capillary, 598, 659
Corrigan's, 658
in fever, 199
frequency of, 604, 608
high tension, sphygmogram in, 613
irregular, sphygmogram in, 614
low tension, sphygmogram in, 613
method of taking, 604
in peritonitis, 752
in rheumatoid arthritis, 186
rhythm of, 607
tension of, 606
in fever, 199
venous, 600
volume of, 606
Pulsus paradoxus in adherent pericarditis,
649
in pericardial effusion, 645
Puncture, exploratory, 357
Pupillary reflex, 97
Purpura, 128
Pus, bacteria of, 240, 360
chemical examination of, 364
physical characteristics of, 360
staining of, 240
tubercular, 362
in urine, 936, 941
Pyseinia, 224
Pyelitis, 912
Pylephlebitis, suppurative, 875
Pylorus, stenosis of, 808
Pyonephrosis, 912
Pyopneumothorax, 577
subphrenicus, 578, 747
Pyorrhoea alveolaris, 691
Pyrosis, 772, 802
Pyuria, 936
absence of in renal calculus, 905
RHACHITIS. See Rickets, 172
Rales, 509
distinguished from friction sound,
510
Ranula, 697, 700
Rashes, medicinal, 139
1078
INDEX.
Ray fungus, 351
Raynaud's disease, 115, 1006
Reactions of degeneration, 996
atypical, 999
Records of cases, 21
Rectum, diseases of, 852
Reflex, abdominal, 986
patellar, 987
plantar, 989
reinforcement of, 987
tendo-Achillis, 988
tendon, 985
Regions of chest, 471
Regurgitation of food, 772
in disease of oesophagus, 723
Reichman's disease, 801
Relapsing fever, 274
serum diagnosis in, 276
spirillum of, 275
Renal calculus, 902
colic, 902
Residence in etiology of disease, 26
Resistance to finger in percussion, 496
Resonance, pulmonary, 494
Respiration, Cheyne-Stokes, 487
in fever, 199
rate of, 476, 486
ratio of inspiration to expiration, 486
types of, 476
Restlessness, 70
Retinitis, 100
albuminuric, 959, 965
Retraction of interspaces in adherent peri-
cardium, 649
Retroperitoneal sarcoma, 754
Retropharyngeal abscess, 717
Rhabdenoma intestinale,.834
Rheumatic fever, 178
complications and sequelae of, 181
diagnosis of, 181
endo- and pericarditis in, 180
temperature in, 180
Rheumatism, acute articular. See Rheu-
matic fever,
chronic articular, 183
gastric symptoms of, 762
gonorrhceal, 178
hand in, 113, 114
muscular, 167
relation of, to lithaemia, 856
subacute articular, 182
subcutaneous nodules in, 158
Rheumatoid arthritis, 185
diagnosis of, 187
fingers in, 114
pulse in, 186, 608
Rhinitis, atrophic, 425
caseous, 425
chronic hypertrophic, 424, 428
idiopathic, 420
sicca, 429
simple acute, 427
syphilitic, 429
Rhinoscopy, 421
Rickets, 172
diagnosis of, 174
Rickets, fontanelles in, 87
shape of chest in, 480
sweating of head in, 146
Rigidity of abdomen in peritonitis, 751
Roseola, 139
Rotheln, 264
Rubella, 264
distinguished from scarlet fever, 259
Rumination, 803
OALIVA, 687
O in disease, 689
Salivation, 687
Saltatoric spasm, 1040
Sarcina, 220
in gastric contents, 784
in urine, 948
Sarcoma, retroperitoneal, 754
of skin, 157
Scalp, pain in, 46
Scanning speech, 1006
Scaphoid abdomen, 735
Scarlet fever, 255
complications and sequelae of, 258
diagnosis of, 258
pulse in, 608
tongue in, 701
varieties of, 257
Scars, significance of, in diagnosis, 146
Sciatica, 53, 1043
Scleroderma, 157
Sclerosis, amyotrophic lateral, 1046
multiple or insular, 1047
gait in, 71
Scotoma, 102
Scurvy, 188
gums in, 691
hemorrhage in, 128
-rickets, 189
Seitz's sign of cavity, 515
Sensation, 971
delayed, 975
dissociation of, 973
of locality, 974
muscular, 975
of pain from induced current, 975
of pressure, 975
stereognostic, 976
tactile, 971
of temperature, 973
Septicaemia, 225
fever in, 210
Septico-pysemia, 334
Serum diagnosis, 233
dilution and time limit in, 236
the appearance of the reaction, 236
in relapsing fever, 276
in typhoid fever, 235, 299
value of, 237
with dried blood, 236
with fluid serum or blood, 234
Sex in etiology of disease, 25
Shell-fish poisoning, 214
Shock, 65
effect of, on pain, 39, 40
INDEX.
1079
Shock from hemorrhage, 406
Shortness of breath, 462. See Dyspnoea.
Siderosis, 551
Skin, color of, 119
hemorrhage into, 126
lesions of, artificial, 41
classification of, 132
general diagnosis of, 141
syphilitic, 142
traumatic, 141
ulcerative, 144
malignant nodules under, 157
nutrition of, 144
pigmentation of, 125
Skodaic resonance, 499
in pleural effusion, 570
in pneumonia, 315
Smallpox. See Variola, 250
Smell, disturbance of sense of, 419
Spasm, habit, 1040
muscular, 981
saltatoric, 1040
Speech, disturbances of, 1000
Spermatozoa in urine, 946
Sphygmograph, 609
Spinal cord, general symptoms of disease
of, 1024
hemorrhage into, 1050
pressure on, symptoms of, 1050
traumatism of, 1051
tumor of membranes of, 1048
localization, 1021
Spirilla, general characteristics of, 222
Spirillum of cholera Asiatica, 338
nostras, 835
of relapsing fever, 275
Spirometry, 516
Spleen, amyloid, 893
diseases of, 890
enlargement of, 891
in cirrhosis of liver, 877
in Hodgkin's disease, 161
in infants, 893
in leucocythsemia, 396
in malaria, 289
in pneumonia, 314
in simple anaemia, 392
floating, 890
hydatid cyst of, 893
malignant tumors of, 893
palpation of, 890
percussion of, 890
puncture of, 360
syphilis of, 893
topography of, 890
Splenitis, acute, 891
Spores of bacilli, 221
Sputum, 519
in bronchiectasis, 566
in bronchitis, capillary, 546
plastic, 546
chemistry of, 536
in gangrene of lung, 563
from larynx, 441
in liver abscess, 529
in lobar pneumonia, 312
Sputum, method of collecting, 519
micrococcus lanceolatus in, 534
microscopic examination of, 522
in phthisis, 561
physical characteristics of, 520
tubercle bacilli in, 530
Staining of bacteria, 240
Staphylococci, 361, 362
Station in disease, 74
Stelwag's sign, 89
Sterilization in bacteriology, 231
Stethoscope, 502
Stiff neck in oesophagitis, 719
Stigmata of the passion, 1061
Stokes- A dams' syndrome in myocarditis,
589, 655
Stomach, absorptive power of, 790
anaesthesia of, 803
atony of, 803
auscultation of, 778
auscultatory percussion of, 777
carcinoma of, 808
distinguished from ulcer and
chronic gastritis, 811
gastric contents in, 810
cirrhosis of, 806
catarrh of. See Gastritis.
contents, acetic acid in, 788
alcohol in, test for, 788
anacidity of, 791
bile in, 782
blood in, 782
butyric acid in, 788
carbohydrates in, 789
chemical examination of, 784
clinical value of examination of,
791 _
free acid in, test for, 784
hydrochloric acid in, test for, 785
hyperacidity of, 791
lactic acid in, significance of, 792
test for, 787
method of securing, 779
microscopical examination of, 783
mucus in, 782
pepsinogen in, 789
rennin in, 789
syntonin in, 789
total acidity of, 784
cough, 465
digestive power of, 789
dilatation of, 777, 807
diminution in size of, 777
general condition in disease of, 793
history in disease of, 763
hyperacidity and hypersemia of, 801
inspection of, 774
internal exploration of, 775
motor power of, 790
neuroses of, 797
nervous mechanism of, 760
in other diseases, 761
palpation of, 775
percussion of, 776
position of, 776
relaxation of orifices of, 803
1080
INDEX.
Stomach, tumor of, 775
ulcer of, 811
Stomatitis, 692
aphthous, 693
catarrhal, 693
gangrenous, 694
materna, 693
mercurial, 694
parasitic, 693
ulcerative, 693
Stools in amoebic dysentery, 343
in catarrhal dysentery, 345
in cholera, 337
in diarrhoea, 820
Streptococcus pyogenes, 362
Strongylus, symptoms of, 815
Stuttering and stammering, 1006
Subdiaphragmatic abscess, 746
Sublingual ulcer, 695
Succussion, Hippocratic, 512
in pneumothorax 577
splash in stomach, 778
Sudamina, 140
Sugar in urine, 931
Sulphocyanide of potassium in saliva, 689
Sunstroke, 211
fever in, 203
Suppuration,- symptoms of, 408
Suprarenal capsules, disease of, 734
Sweat. See Perspiration.
Symptoms, evolution of, 31
objective, definition of, 17
subjective, definition of, 17
valuation of, 32
Syncope, 64
Synovitis, 178
Syphilis, acquired, 269
caries of frontal bone in, 87
coryza in, 429
effect of mercury on haemoglobin in,
271
fever in, 206, 229
headache in, 49, 592
hereditary, 270
of larynx, 439, 448
of liver, 879
lymphatic glands in, 159
nasal ulceration in, 424
neuralgia in, 48
of pharynx, 709
skin lesions in, 142
teeth in, 691
Syringomyelia, 1050
TABES dorsalis, 1043
cervical type of, 1044
gait in, 70
joints in, 189
pain in, 55
pulse in, 608
mesenterica, 748
Tache ce"r6bral, 1052
Tachycardia, 608
in exophthalmic goitre, 89
Taenia, 831
Taenia, symptoms of, 814
Teeth, 691 _
Hutchinson's, 271
in rickets, 172
time of eruption of, 692
Teething, 692
Temperature. See also Fever.
danger limit of, 194
determination of, 192
influence of age and sex on, 208
normal variation in, 194
pathological variations in, 194
sense of, 973
subnormal, 201
when to take, 193
Tendon reflexes, 985
Tenesmus, 42
in diarrhoea, 821
Tension in arteries, 606
Tetanus, 352
bacillus of, 353
Tetany, 1040
in dilatation of stomach, 807
in rickets, 174
Thermoansesthesia, 973
Thirst in gastric disease, 764
Thomsen's disease, 166, 1041
Thorax. See Chest.
Thrill in aortic aneurism, 679
obstruction, 659
cardiac, 603
in mitral stenosis, 664
in tricuspid stenosis, 666
Throat in scarlet fever, 256
Thrombosis, 403
in arterio-capillary fibrosis, 673
cerebral, 1054
Thrush, 690
Thumb-sucking, effect on dental arch, 687
Thyroid gland, enlargement of, 88
Tic douloureux, 47, 53, 1042
facial, 982
general, 1040
Tinea, 143
Tinnitus aurium, 107
Tongue, 695
atrophy of, 700
coating of, 700
cysts of, 700
diagnostic significance of, 704
discoloration of, 695
dryness of, 704
furrows in, 697
geographical, 700
hypertrophy of, 700
movements of, in disease, 706
in prognosis and treatment, 705
of scarlet fever, 257
ulcers of, 698
white patches on, 699
Tonsillitis, acute, 711
chronic, 714
distinguished from diphtheria, 713
follicular, 712
suppurative, 712
Tonsils, the, 710
INDEX.
1081
Tonsils, foreign body in, 714
leptothrix in, 711
pseudoniembraue on, 711
ulcers of, 711
Tooth-cough, 465
Tophi in gout, 184
Tormina ventriculi, 803
Torticollis, 168
Toxaemia, fever in, 203
Toxins and toxalbumins, 221
Trachea, obstruction of, 457
Tracheal tugging in aneurism, 88, 681
Transudations, 365
Traube's semilunar space, 776
Tremor, 980
in exophthalmic goitre, 90
Trichina spiralis, 354, 834
Trichinosis, 354
eosinophilia in, 356
face in, 84
oedema in, 151
Trichoaesthesia, 973
Trichomonas in genito-urinary tract, 949
Trichterbrust, 483, 715
Tricocephalus dispar, 834
Tricuspid area, 632
regurgitation, 665
venous pulse in, 600
stenosis, 666
Trismus neonatorum, 353
Trophic disturbances, 1006
Trousseau's sign of tetany, 1041
Tubercle bacillus, 530
Tuberculin test, 321
in tubercular adenitis, 161
Tuberculosis, 319
acute miliary, 322
distinguished from typhoid fever,
302, 555
pulmonary type of, 554
bacillus of, 530
cervical glands in, 159
fever in, 205
hereditary tendency to, 320
of intestine, 842
of kidney, 967
of pharynx, 709
pulmonary, acute, 552
distinguished from pneumo-
nia, 554
chronic, 555
diagnosis of, 319
excursion of diaphragm in,
477
fever in, 558
gastric symptoms in, 761
haemoptysis in, 467, 560
inspiratory capacity in, 518
modes of invasion in, 556
movements of chest in, 488
pain in chest in, 560
physical signs of, 561
sputum in, 561
sweats in, 559
of tongue, 699
Tuberculous peritonitis, 755
Tuberculous peritonitis, acute, distin-
guished from perforating ap
pendicitis, 743
diagnosis of, 758
tumors in, 757
Twitching, fibrillary muscular, 989
Tympany, a percussion sound, 495
Tympanites in peritonitis, 732, 751
Typhlitis, 742
stercoral, 824
Typhoid fever, 289
absence of leucocytosis in, 299
bacillus of, 298, 300
Baruch's sign of, 301
complications and sequelae of, 298
diagnosis of, 301
distinguished from appendicitis,
740
from malignant endocarditis,
652
from typhus fever, 249
eruption in, 296
heart-sounds in, 294
incubation of, 289
nervous symptoms of, 294
pulse in, 291
spleen in, 290
temperature in, 290
tongue in, 702
urine in, 294
varieties of, 297
Widal reaction in 233. See
Serum diagnosis,
without fever, 229
without intestinal lesions, 298
state, 199
Typhus fever, 247
Tyrosin crystals, in sputum, 528
in urine, 953
ULCER in mouth, 694
of skin, diagnosis of, 144
of stomach, 611
sublingual, 695 .
of tongue, 698
trophic, 1008
Umbilicus in tuberculous peritonitis, 728,
755
Unconsciousness, 64
Uraemia, 956, 965
asthma in, 461
cardio-vascular symptoms of, 958
dropsy in, 959
dyspnoea in, 957, 965
gastro-intestinal symptoms in, 965,
977
hemorrhage in, 959
latent, 95S
nervous symptoms in, 956, 965
retinal changes in, 959, 965
temperature in, 956, 965
Urates in urine, 950
Urea, estimation of, 920
Ureters, catheterization of, 955
Uric acid in blood, test for, 386
1082
INDEX.
Uric acid diathesis, 184. See Gout.
Neusser's granules in, 383
in urine, 949
Urine, acetone in, 936
albumin in, causes of, 927
quantitative estimation of, 926
tests for, 921
albumose in, 929
alkapton in, 937
bacteria in, 948
bile-pigments and bile-acids in, 935
blood in, 928, 940
cancer cells in, 949
casts in, 941
centrifugation of, 938
chemical examination of, 919
chlorides in, 920
in gastric cancer, 794
in pneumonia, 315
cholesterin in, 954
color of, 914
cylindroids in, 945
cystin in, 953
diacetic acid in, 936
entozoa in, 948
epithelium in, 946
extraneous matter in, 938
fat and chyle in, 947
in gastric disease, 794
globulin in, 937
indican in, 935
leucin and tyrosin in, 953
in lithsemia, 856
melanin in, 954
in nephritis, acute exudative, 961
productive, 962
chronic productive, 963, 964
nucleo-albumin in, 928
odor of, 919
oxalates in, 952
phosphates in, 950
pus in, 936, 941
reaction of, 918
in rheumatic fever, 180
sediments in, 918
solids in, estimated from specific grav-
ity, 918
specific gravity of, 917
spermatozoa in, 946
sugar in, test for, 936
quantitative estimation of, 932
suppression of, 916
urates in, 950
urea in, 919
quantitative estimation of, 920
uric acid in, 949
volume of, 914, 916
Urticaria, 138
Uvula, 710
VALLEIX, points of, 45
Valve-shock, 602
Varicella, 253
Variola, 250
varieties of, 252
Varioloid, 252
Vasomotor changes in hysterical joints, 190
mechanism, 415
symptoms in migraine, 50
in neuralgia, 53
Veins, diastolic collapse of, 601
in adherent pericarditis, 649
distention of, 598
murmurs in, 641
pulsation of, 599
thrombosis of, 614
Venous hum, 641
pulse, 600
Vertebral canal, aspiration of, 359
Vertigo in dyspeptic headache, 52
paralyzing, 109
Vision, field of, 101
Vocal resonance, 513
Voice in adenoid disease, 715
in central nervous disease, 449
Volvulus, 843
Vomiting, 764
cerebral, 768
cyclic, 768
in gastric cancer, 767, 809
ulcer, 767, 812
in gastritis, 766
in migraine, 50
in peritonitis, 751, 768
in phthisis, 561
of pregnancy, 767
reflex, 767
in toxaemia, 768
uremic, 768, 957, 965
Von Graefe's sign, 89
WATERBRASH, 872
Weight of body in disease, 76
Weil's disease, 271
Wernicke's sign, 104
Whooping-cough, 265
Widal reaction, 233. See Serum diagnosis.
Williams' tracheal tone, 514
Wintrich's change of note over cavity, 414
in pneumothorax, 577
Wool-sorter's disease, 278
Word-blindness and word-deafness, 1000
Wrist-drop, 113
Writer's cramp, 1041
XANTHELASMA, 695
Xerostoma, 686
X-ray examination of chest, 488
of stomach, 775
YELLOW fever, 303
I bacillus of, 305
general diagnosis of, 305
serum diagnosis of, 305
COLUMBIA UNIVERSITY
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Musser
A Dractical
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