C HEALTH SCIENCr SSI ANDARD j "' !l HX641 22425 l RC71 .H141881 Differential diagnos | ■ i ' !;'i''l ,i ■ ■ i [ RECAP 1 I, 11B1| ; i B RC7/ Ml Columbia IHnitier^ttp mtijeCttpofBrmgork College of 3&w&it\m& anb burgeons lUbrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/differentialdiagOOhall HALL'S DIFFERENTIAL DIAGNOSIS. Differential Diagnosis : A MANUAL OF THE COMPARATIVE SEMEIOLOGY OF THE MORE IMPORTANT DISEASES. By F. de HAVILLAND HALL, M. D., ASSISTANT PHYSICIAN TO THE WESTMINSTER HOSPITAL, LONDON. SECOND AMEKICAN EDITION. EXTENSIVE ADDITIONS. EDITED BY FRANK WOODBURY, M. D. PHYSICIAN TO THE GERMAN HOSPITAL, PHILADELPHIA. PHILADELPHIA: D. G. BRLNTON, 115 SOUTH SEVENTH ST. 1881. Entered according to Act of Congress, in the year 1881, by D. G. BRINTON, in the Office of the Librarian of Congress, in "Washington, D. C. All rights reserved. n-ws\. Press of Wm. F. Fell & Co., 1220-24 Sanson Street, Philadelphia. CONTENTS. PAGE Introductory 12 PART I. GENERAL DISEASES. CHAPTER I. THE FEVEES. The Febrile State 14 Inflammatory, or Symptomatic and Essential Fever 19 The Exanthematous or Eruptive Fevers 21 Typhoid and Typhus Fevers 28 Typhoid and Malarial Fevers 34 The Typhoid State 37 Malarial Fevers 38 Cerebro- spinal Fever 43 Acute Tubercular Meningitis 48 Yellow Fever 49 Relapsing Fever 52 CHAPTER II. DISEASES OF THE BLOOD. The Dyscrasise 54 The Arthritic, Dartrous, or Rheumic Dyscrasia 54 The Scrofulous, or Strumous Dyscrasia 56 The Syphilitic Dyscrasia 58 The Tuberculous Dyscrasia 59 Rheumatism , 61 Chronic Rheumatism 62 Gout 65 Rheumatoid Arthritis 66 Pernicious Anaemia and Leukaemia 66 Remarks on the Germ Theory and Zymotic Bowel Affections 68 v VI CONTENTS. PART II. LOCAL DISEASES. CHAPTER I. DISEASES OF THE NERVOUS SYSTEM. PAGE Nervous Symptoms 73 Cerebral Congestion and Cerebral Anaemia 75 The Symptoms of Cerebral Apoplexy Contrasted with those of Drunkenness, Narcotic Poisoning, Urasmia, Hysteria, Syncope and Asphyxia 75 Cerebral Hemorrhage rs. Thrombosis and Embolism 77 Acute Cerebral Inflammations 78 The Ophthalmoscope in Nervous Disorders 80 Headache 82 Chronic Cerebral Disorders 84 Hypertrophy of Brain and Hydrocephalus 84 Brain Tumors, Softening, Abscess, Meningitis and Thrombosis 85 Cerebral Sclerosis vs. Defective Development of Intelligence 85 Localization of Brain Disease 86 Lesions of Cerebral Cortex (with Diagram) 86 Disease of Brain Centres other than Cortical 88 Tabular View of Paralysis 89 Spinal Diseases 91 Location of Spinal Lesions 93 Tabular View of Spinal Paralysis 93 Myelitis, Meningitis and Congestion Compared 96 Chronic Spinal Disorders 97 Degenerative Diseases 98 Sclerosis of Cord 99 Tendon-reflex Symptom of Westphal 1 03 Cerebro-spinal Sclerosis, Paralysis Agitans and Locomotor-ataxia 104 Paraplegia, from Reflex Irritation and Myelitis 105 Pseudo-hypertrophic Paralysis 107 Paralysis, from Lead Poisoning and Hysteria 109 General Paralysis of the Insane 109 General Paralysis and Locomotor-ataxia 112 General Paralysis and Syphilitic Paralysis 113 Spinal Irritation and Spinal Weakness 114 Hysteria 115 Epilepsy and Hystero- epilepsy 116 Neuralgia .' 117 Neuralgia and Myalgia 118 CONTENTS. VII / PAGE Cerebral Abscess vs. Cerebral Neuralgia 119 Insanity 120 Mania and Melancholia 122 CHAPTER II. DISEASES OF THE RESPIRATORY APPARATUS. Symptoms of Laryngeal Diseases 125 Diagnostic Table of Acute Laryngitis; Chronic Laryngitis; Syphilitic Laryngitis ; Tubercular Laryngitis 120 Perichondritis ; Benign Growths ; Malignant Growths ; Neuroses of the Larynx ... 128 Croup and Diphtheria 130 Spasmodic Croup 130 Inflammatory Croup 130 Membranous Croup 131 Diphtheria 131 Tonsillitis, Catarrhal and Parenchymatous 132 The Regions of the Chest 133 Normal Differences between the two Sides of the Chest 134 Methods of Physical Examination 135 Normal Respiratory Sounds 136 Normal Voice Sounds 136 Abnormal Percussion Sounds 137 Abnormal Respiratory Sounds 138 Amphoric Sound 140 Abnormal Voice Sounds 141 General Rules for Diagnosis 142 The Forms of Phthisis (Catarrhal, Fibroid, Tubercular) 143 The Diagnosis of Incipient Phthisis 145 Diagnosis between Incipient Phthisis and Bronchitis 148 Clinical History of Phthisis 149 Acute Phthisis (Acute Miliary Tuberculosis) 150 Syphilitic Phthisis 152 Bronchitis, Acute and Chronic 152 Capillary Bronchitis compared with Pneumonia 155 Pneumonia and Pleurisy 156 Pleurisy and Hydrothorax 157 Pleurisy with Effusion and Pneumonia with Consolidation Compared 160 Diagnosis between Pneumonia and Pulmonary Apoplexy 161 Pulmonary Thrombosis 161 Asthma , 162 Pneumothorax and Pneumo-hydrothorax 163 Emphysema, Vesicular and Interlobular 164 Cancer of the Lung 165 VI ll CONTENTS. CHAPTER III. DISEASES OF THE CIRCULATORY APPARATUS. PAOl The Precordial Regions K>7 The Ana of Cardiac Dullness 1C.8 Normal Sounds and Impulse of Heart L69 Endocardial Marmora 170 Genera] Rules for the Diagnosis of Heart Disease 170 Constitutional Symptoms of Heart Disease 171 Clulil ling of the Fingers 172 Differential Signs between Anemic and Organic Blood Murmurs 173 Pain at and near the Heart 173 Aphorisms Regarding Angina Pectoris 174 Differential Signs of Aortic Obstruction and Aortic Incompetency 175 Differential Signs between Mitral Obstruction and Mitral Incompetency 176 Differential Signs between Pulmonary Obstruction and Tricuspid Regurgitation... 178 Pericarditis 178 Diagnosis between Acute Endocardial and Exocardial Sounds 180 Differential Signs of Cardiac Dilatation and Pericarditis with Effusion 180 Differential Signs of Simple Hypertrophy, Hypertrophy with Dilatation, and Simple Dilatation 181 Fatty Degeneration of the Heart 181 Slow Heart 183 CHAPTER IV. DISEASES OF THE DIGESTIVE SYSTEM. Principal Symptoms 184 The Tongue 184 The Appetite 185 Acidity (1) from Fermentation; (2) from Hyper-Secretion 186 Pain 187 Flatulence and Eructation * 188 Vertigo, (1) Stomachal; (2) Cerebral 188 Vomiting, (1) Stomachal; (2) Cerebral 189 Comparison of Atonic Dyspepsia, Chronic Gastritis, Gastric Ulcer and Gastric Cancer 191 Indigestion and Dyspepsia 195 Abdominal Phthisis 195 Obstruction of the Bowels, Enteritis and Colitis 196 Method of Examination of the Liver 198 Significance of Pain in the Liver 199 Significance of Jaundice 200 Jaundice with Obstruction 201 Jaundice without Obstruction. 201 CONTENTS. IX PAOE Diseases Characterized by Enlargement with Smooth Surface 202 Enlargement with Uneven Surface 20:; With Diminution of the Organ 20-'i Hepatic Abscess 204 Internal Parasites 205 Tape-worm , 205 Hydatids 206 Round Worms 206 Thread Worms 200 Trichinosis , 206 CHAPTER V. DISEASES OF THE UKINAKT SYSTEM. The Early Signs of Bright's Disease 208 Comparative Diagnosis of the Different Forms of Bright's Disease (Acute Paren- chymatous Nephritis, Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Contraction of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albuminoid or Amyloid Renal Degeneration, Parenchymatous Renal De- generation) 210 Diabetes Mellitus and Glycosuria 212 Diabetes Insipidus and Hydruria 215 Bile in the Urine 215 Urinary Calculi 216 PUBLISHER'S NOTE SECOND AMERICAN EDITION The present work is founded upon Dr. F. De Havilland Hall's Synopsis of the Diseases of the Larynx, Lungs, and Heart. The plan adopted by De. Hall has, however, been extended to embrace all the more frequent and important diseases. In the preface to the first American edition the editor stated that he had held especially in view (1) the early and often overlooked signs of the presence of disease ; (2) the collection of whatever symptoms are alleged on good authority to be pathognomonic of pathological conditions; (3) any peculiar features which diseases have been found to present in this country. " Preference has been given to American over European authorities, as every year adds confirmation to the opinion, now widely received, that diseased conditions assume very different aspects under dif- ferent climatic and sociological surroundings." As the editor of the first edition could not revise the present one, the publisher was fortunate enough to complete an arrangement with De. Feank Woodbuey to give it a thorough revision, and to add to it what was lacking to make it a complete work within the limits which it aims to cover. XI INTRODUCTORY. The nomenclature of diseases adopted by the best authorities divide them into two great classes — General Diseases and Local Diseases. General diseases may be said to comprehend those which pervade the whole system, and in which any local affection may be regarded as acci- dental ; while local diseases are those which particularly affect certain organs, and in which the involvement of any other part of the body is but a sequel of the primary lesion. This classification, having much to recommend it, from a clinical stand- point, is the one most practically useful to the physician. The first question he should put to himself on examining a patient is, Have we here a general or a local disease ? He reaches the answer by excluding those organs whose form and functions present nothing abnormal, and by distinguishing among such as are implicated those which indicate primary and essential lesions, from those which are affected accidentally or second- arily. Where no primary lesions are discoverable, he may conclude that he has to do with a general disease. For the purpose of diagnosis, General Diseases are best divided into the two classes of (1) Fevers and (2) Diseases of the Blood. These also are each divisible into two or more classes marked by one or two leading and prominent symptoms, which are the guides to the diagnostician. Thus, The Essential Fevers are usually acute in their course, and either characterized by an eruption of a well-defined character (the Exanthe- mata) ; or by a recurrent marked diminution (remission) or total cessation (intermission) of the symptoms (Periodic fevers) ; or else by a persistent course not manifesting either of these phenomena (Continued fever). Blood Changes are rarely acute, and are either constitutional (the xiii XIV INTRODUCTORY. Dvs.rasi.e); or else characterized by definite organic lesions (Rheumatism, Gout); or by a physical and generally recognizable change in the blood itself (Anaemia, Leuksemia, Scurvy and Purpura). Local Diseases are more conveniently classified with reference to the physiological than the anatomical divisions of the body. The functions of life are carried on by the Nervous, Respiratory, Circulatory, Digestive and Urinary systems ; and the impairments of each of these form classes of diseases which are broadly discriminated by signs easy of recognition. The niceties of diagnosis are needed rather to distinguish between the varied diseases peculiar to each of these systems than to locate the disturbance in one or the other of them. PART I. G-ENEBAL DISEASES. CHAPTER I. THE FEVERS. Contents. — The Febrile State — Inflammatory, or Symptomatic, and Essential Fevers — The Exanthematous or Eruptive Fevers — Typhoid and Typhus Fevers — Typhoid and Malarial Fevers — The Typhoid State — Malarial Fevers — Cerebrospinal Meningitis — Acute Tubercular Meningitis — Yellow Fever — Relapsing Fever. THE FEBRILE STATE. The most common of all forms of disease is that which is presented by the Febrile State. The chief objective symptoms which it offers are found in I. The temperature. II. The pulse. III. The tongue and uvula. IY. The urine. V. The state of the skin. I. The temperature is one of the most prominent of the phenomena in fever, and by many is regarded as the essential feature of the febrile condition; yet its correct appreciation was never understood previous to the labors of Wundeklich. Now, the clinical thermometer is considered as indispensable to the practitioner, as the lancet used to be. In using the clinical thermometer, Dr. Sydney Ringer, of London, lays down the rule that in order to insure correctness in the observations, the following conditions must be fulfilled : — 1st. That the patient should be in bed, otherwise the temperature of the surface will be much below that of the internal organs. 1-5 16 DIFFERENTIAL DIAGNOSIS. 2d. That the patient be in bed at least one hour before the observations are made, since that time is necessary for the surface of the body to regain tlic heal ln.-t by previous exposure. 3d. The position of the person examined should be such that the anterior and posterior edges of the axilla are relaxed, for otherwise a cup-shaped cavity is formed, in which the thermometer moves freely* without being in contact with its walls. This occurs especially in emaciated persons. 4th. The temperature should be taken twice daily, say at eight in the morning and eight in the evening. If but one observation is possible, then the evening should be preferred, since the morning temperature, abnormal though it may be, rises in the evening. 5th. The thermometer should remain in the axilla at least five minutes. As regards the peripheral parts, such as the hands and feet, accord- to Dr. H. Wegscheider,* the following propositions should be received in reference to the distribution of temperature in febrile diseases: — 1st. There is no constant relation between the internal temperature, as measured in the axilla, and the general temperature of the surface. 2d. Two completely symmetrical parts of the skin, as between the toes, show no proportionate course in their temperature ; not only do they differ by not rising or falling to the same level, but one may rise while the other remains stationary or falls, or vice versd. 3d. There is greater variation in the temperature curves in the same part of the skin in the same person in fever than in health ; but in fever there is a striking fall of temperature, notably lower than in the healthy state. However, in those people who suffer from cold feet the tempera- ture is often as low, or somewhat lower. 4th. It follows, from the last, that there is a greater difference, in fever, between the temperature of the axilla and that of the periphery than any changes of local temperature which may occur in health. Although the axilla is generally selected, on account of convenience, the temperature is often taken with the thermometer in the mouth, rectum or vagina, and it is believed that such observations give more correct indications of the heat of the body than those taken on the surface. The temperature fluctuations in the various zymotic diseases have now * Archiv. filr Pathologie, Feb. 1877. FEVERS. 17 been carefully studied by many clinical observers, who have deduced observations which are of great service in diagnosis, as some of them are characteristic. A pretty constant increase and decrease of temperature exists in the several specific fevers, a close observation of which, in accordance with the foregoing rules, will often serve as a valuable aid both in diagnosis and in prognosis. Dr. Wunderlich, in his work, gives useful tables for this purpose, and we subjoin a valuable comparative table of the pulse as well as the temperature in seven of the more frequent febrile diseases, drawn from recent English observations. COMPARATIVE TABLE OF THE TEMPERATURE AND PULSE IN THE LEADING FEBRILE DISEASES. Day. Typhus Fever. Typhoid Fever. T. P. 108 113 114 122 124 122 113 117 119 108 106 100 98 92 90 85 T. 102. 103.1 103.4 102.7 103.2 103.7 102.5 103. 102.6 103. 102.5 102.2 102.4 101.8 102. 101.4 98.8 101.4 102.2 98.8 P. 98 98 110 107 104 107 108 108 111 111 112 108 109 107 100 100 98 105 100 98 1st 104.8 103.6 103. 103.2 104.2 103.8 103. 102.7 102.4 102.2 100.5 100. 99.4 98.7 98.4 98.2 2d 3d 4th 5th 6th 7th 8th 9th 10th 11th 12th 13th 14th 15th 16th 17th 18th 19th 20th 21st Measles. 102.3 103 100.2 98. 98. 130 124 112 102 98 80 Scarlet Fever. 104.2 104. 103. 101.2 100.6 100. 100. 99.8 99. 98.6 144 148 134 122 108' 106! 110 108 100 104 84 Febricula. 103. 103.7 104 102.6 98.4 99 Kheumatic . Fever. (Pneumonia. 99 103 105 101.8 99 102. 102. 103. 100. 100. 99.4 101. 101. 102. 100.9 100. 98. 99. 102. 103. 101.6 101.7 105 114 102. 102. 103. 104. 103. 116 1102.8 120 90| 96 86 104 102 100 100 88 90 94 96 102 100 104 100. 99. 98. 8 123 3 120 6 122 126 122 122 114 94 78 The above table, prepared from a series of observations, by Dr. J. S. "Warter,* illustrates the normal and average contrasts of pulse and temperature in the course of the diseases specified, when their tendency is to recovery. * St. Bartliolomeio' s Hospital Reports, vol. ii, p. 78. 18 DIFFERENTIAL DIAGNOSIS. II. The pulse is increased in frequency, and may be either hard, full and bounding, or tense, small and contracted. The former condition is more common in active inflammation of the organs above the diaphragm ; the latter, in many inflammations below the diaphragm and in idiopathic fevers. In fevers of a typhoid form, an unusually slow pulse is some- times encountered, as also a pulse with apparently a double beat, the "dicrotic" pulse. In the later stages the pulse may be soft, gaseous or thready, indicating febrile changes in the walls of the vessels and the heart. III. The tongue in the beginning of the febrile state is usually whiter and dryer than usual, and more or less coated with a "fur" or viscid covering, from the more rapid evaporation of the watery secretions. Later on, in the progress of severe fever, the tongue becomes dry, and the exsiccated mucus and epithelium form a brownish or blackish crust, while the papilla? shrink, so that on this crust becoming detached, the surface of the organ looks glazed and smooth. The peculiar appearance of the tongue in certain diseases will be described in connection with these diseases. IV. The urine in fever is scanty and high colored. Its alteration from the healthy average is chiefly in the much larger quantity of urea and urates which it contains, and the diminution of its chlorides. According to the researches of Dr. J. Burdon Sanderson, in the early stage of fever a patient excretes about three times as much urea as he would do on the same diet if he were in health, the difference between the healthy and the fevered body consisting chiefly in this, that whereas the former discharges a quantity of nitrogen equal to that taken in, the latter wastes the store of nitrogen contained in its own tissues. That this disorder of nutrition is an essential constituent of the febrile process is indicated by the fact that it not only accompanies the other phenomena of fever during their whole course, but precedes the earliest symptoms and follows the latest. That it anticipates the beginning of fever was first demonstrated by Dr. Sidney Ringer in his investigation of the relation between temperature and the discharge of urea, in ague. That the same condition continues after the crisis has passed, i.e., the temperature has begun to sink, was shown by Dr. Squarey. There are various methods of determining the rate of secretion and FEVERS. 1 9 the amount of urea. Its relative excess may be inferred when the urine has a deep yellow color, a high specific gravity, and a strong urinous odor. If a small quantity of it be allowed to evaporate to a mucila- ginous consistence, and nitric acid be added, drop by drop, crystals of nitrate of urea are found after a few hours. They are of a pearly white lustre, and their proportion roughly indicates the quantity present. When the urea is in great excess, the crystals will form on the addition of nitric acid to the urine, without the preliminary evaporation, by merely allowing the test tube to stand for a short time. V. The skin, in common with the other emunctories, has its functions much influenced by the fever process. Apart from the changes in tem- perature, considered above, there are alterations in the appearance of the skin, and in the character of its secretions, which accompany fevers ; certain eruptions also appear, that are more or less characteristic ; such as the smallpox pustule, the chicken-pox vesicle, the urticarial wheal, and the scarlatinal acute desquamative dermatitis. The parasitic diseases of the skin, although they may accidentally be associated with pyrexia, exist entirely independently, and the fever bears no causal relationship to them. The skin during fever has for its typical appearance a color which if not decidedly dull and sallow, is at least less clear than in health ; in typhus it may be quite dusky ; in bilious remittent and yellow fever it becomes jaundiced. In typhoid the surface is more nearly that of health, but the cheeks are flushed and there are rose-spots on the chest and abdomen. In acute rheumatism and in the third stage of intermittent, the skin is covered by a profuse perspiration, which in the former case has a sour smell. Exhausting sweats also occur in pyaemia and phthisis. But the dull-colored, dry and harsh skin is the characteristic appearance, and is due to deficient action of the perspiratory and other glands. INFLAMMATORY (SYMPTOMATIC) AND ESSENTIAL FEVERS. The group of symptoms, collectively known as a fever, often accompa- nies strictly local maladies and injuries. In such cases it is distinguished as Inflammatory, or Symptomatic, Fever, and it is of the first importance to distinguish it from Essential, or Idiopathic, Fever, under which general 20 DIFFERENTIAL DIAGNOSIS. term all true fevers are included. The development of this distinction has been one of the most prominent achievements of the modern methods of diagnosis. " It is astonishing," remarks a recent writer, "with the progress of medicine, how many affections have been passed over from the domain of fevers to the narrower circle of inflammation of individual organs." Hence it is of prime importance to determine promptly in the beginning of a case whether the febrile symptoms are a feature of a local disease or the commencement of a general one. Inflammatory or Symptomatic Fever. Is usually preceded by some local lesions or symptoms. Pulse frequent, full and generally tense. Is accompanied by marked and definite local disturbance. Course is indefinite, dependent upon the progress of the local lesion. Anatomical lesions definite and invariable. Prognosis mainly depends upon the progress of local lesion. Essential or Idiopathic Fever. Has no definite antecedent local symptoms. Pulse frequent, full or small, but rarely tense. ( Da Costa. ) Local disturbances vary, and are not prominent, or but temporarily so. Runs a definite course, with a strong tendency to spontaneous ter- mination at a given time. Generally characterized by rela- tively unimportant, or entirely ab- sent anatomical lesions. Local manifestations of less im- portance in estimating the prognosis. Dr. William Stokes* divides the local symptoms of essential fever into three groups : (1) Functional or nervous; (2) those dependent on special anatomical changes; (3) those arising from re-active inflammation. Examples of functional symptoms are delirium, carphologia, cough, diarrhoea, epigastric tenderness, and the like ; of the second group, the alterations which occur in the brain, heart, lungs, spleen or intestinal glands; and of the third, the swelling and infiltration of organs. What he calls " the grand rule of diagnosis" in fever is not to apply to these local symptoms in essential fever the rules of diagnosis of local diseases, as this would lead to a false appreciation of the disease, and to erroneous treat- ment. For example, a typhus patient may exhibit the marked symptoms * "Lectures on Fever," London, 1874. FEVERS. 21 of inflammation of the brain; but if he is treated with active antiphlo- gistic treatment, and with ice to the head ; and leeches, he forthwith sinks and dies. Of hardly less importance is the distinction between organic and functional (or neurotic) changes in fevers. Delirium, pain, coma, convul- sions, cough, etc., may all appear as phenomena of the evolution of the poison which produces a general fever, without signifying any definite anatomical lesion. In other words, essential feveV produces local symp- toms without organic change. "It is/' remarks the author just quoted, " because this proposition has not been sufficiently accepted, sufficiently engraved upon the minds of medical men, that so much mischief has been done in the erroneous treatment of fever." THE DIAGNOSIS OF THE ESSENTIAL OR ERUPTIVE FEVERS (EXANTHEMATA). This group includes smallpox, varioloid, scarlet fever, measles, roseola, and also those more indefinite forms, varicella and rotheln. They have many points of similarity. " They are all characterized by a period of incubation, during which the poison lies dormant in the system ; by a fever of more or less intensity preceding the eruption ; by an eruption which presents a distinct aspect in each disease, and which pursues a definite, clearly defined course until it, and with it the febrile malady, disappears. Moreover, they are all very prone to occasion serious sequela? ; are all, in the main, disorders of childhood ; rarely attack the same person twice; are contagious, and have not as yet been brought under specific treatment." (Da Costa.) It is of great credit to the practitioner, and often of the utmost utility to others, for him to make an early diagnosis between these diseases. This is not always possible to accomplish. But a close observer will find several indications which will guide him to a correct opinion before the appearance of the rash. One of the principal of these is The condition of the throat. This region is affected at a very early stage in nearly all cases. In simple scarlatina the very earliest symptom is a more or less uniform redness of the middle of the soft palate, the uvula alone, or the uvula, anterior pillars of the fauces, and tonsils ; never the posterior wall of the pharynx alone. On the other hand, in 22 DIFFERENTIAL DIAGNOSIS. smallpox, the part first affected is the posterior wall of the pharynx ; while in measles the posterior walls of the fauces and neighboring parts of the pharynx are always redder than the anterior pillars and soft palate (Dr. Alois Monti). In rotheln and measles the tonsils are red and swollen early in the disease ; but in simple scarlet fever, for the first twelve hours there is generally very little swelling of the affected parts, and children seldom complain of pain in the neck or in swallowing. After twelve or twenty-four hours the swelling commences, and the redness becomes less uniform, and more punctiform. This peculiar punctiform appearance may be noted often ten or twelve hours before the rash on the skin is visible. If in malignant scarlatinal sore throat, however, there is, from the first, parenchymatous inflammation of the tonsils and the submucous con- nective tissue, and this condition is associated with well-marked nervous symptoms, a severe case with ulceration of the fauces may be confidently predicted. Iu general terms, it may be said that when the soft palate has a diffused red hue, "similar," as Trousseau remarks, "to, but deeper than, that of the skin," while the tonsils are not involved ; when with this is a very hot skin, a very quick pulse, vomiting, a tongue with thick, creamy fur, red borders, and prominent papula? ; and with these symptoms, exposure to the presence of a scarlatinal epidemic, the physician need not hesitate in pronouncing it scarlet fever. A very early symptom of scarlet fever has been insisted upon as strictly pathognomonic by an Irish physician, Dr. Joseph Duggan.* It is that the eye assumes a peculiar brilliant and glistening stare, very different from the liquid, tender, watery eye of measles, and which, once carefully noted, remains impressed on the observer's memory. The character of the preliminary fever often differs. In scarlatina it is marked and high, which distinguishes it broadly from diphtheria, which is not marked at the outset; in measles it is of a catarrhal form ; while in smallpox it is often associated with very severe pains in the back and loins, not observed in the other exanthemata. This spine-ache is central in its position, and is less affected by change of posture than is the pain of lumbago, and is not confined to one side nor to the erector * Medical Press and Circular, Feb., 18G9. FEVERS. 2.; spince muscles. It is stated by some authors that this pain is increased in proportion with the severity of the attack, and thus forms an important element in the prognosis ; but this statement should be confined in its application to adults, as in children the rachialgia is rarely intense. Dr. Wilks observes that the most virulent cases of variola are almost apyretic and devoid of feverish symptoms. In all the exanthemata the eruption makes its appearance in the throat or the mouth, from twelve to twenty-four hours (and, in many instances longer) before it appears on the cutaneous surface. In smallpox, in scarlet fever, in measles, in all their grades, the eruption may be looked for, with confidence, in this region long before it can be detected at any other point, and as the eruption is often the last link in the chain of evidence necessary to decide a question of diagnosis, the knowledge of this fact will often relieve both physician and patient. The eruption may, in smallpox, often he felt before it can be seen; the sensation imparted to the finger being like little shot underneath the skin. Its first appearance is as a simple red point or pimple, soon changing to a papule. The red blush of scarlatina disappears on pressure, but is immediately restored when the pressure is removed. It has no decided prominence to sight or feeling. Previous to the general boiled-lobster appearance of scarlatina, there is generally a punctate eruption and the skin appears to be rough, upon passing the hand over it, something like a nutmeg-grater. Dr. Osler, of Montreal, has called attention to and described a num- ber of initial rashes, which precede, by twelve to twenty-four hours, the appearance of the variolous eruption. They are principally noticeable on the upper part of the trunk, and generally have the similitude of a deep, suffused flush. The pulse in variola is asserted, by some, to be pathognomonic, and significant so early in the disease that the malady can be positively diag- nosed many hours before the eruption appears. But no definite descrip- tions nor tracings of this pulse have been given.* Having thus defined the special indications for a diagnosis of these diseases in their earliest stage, we give in the following table a synopsis of their comparative clinical history : — * See Dr. A. S. Payne, Ya. Med. Monthly, March, 1878 ; J. S. Conrad, Trans, of the Med. and Chirurg. Faculty of Md., 1874. 24 DIFFERENTIAL DIAGNOSIS. ROTHELN. SCARLET FEVER. INCUBATION. Period of incubation from one to two weeks. Very uncertain ; from a day to several weeks ; on an average about twelve days. INVASION. Languor; sbiverings j nausea and] Shiverings ; nausea; vomiting; vomiting; perhaps sore throat, but throat very much inflamed ; sneezing not severe. and discharge from the nose; con- vulsions occasionally in children. Premonitory fever of short dura- Great heat of skin and very fre- tion; relieved by the eruption. quent pulse; not relieved by the eruption. ERUPTION. Appears early and almost simul- taneously over the whole body — is sudden and general — is less marked on the limbs than on the trunk, and especially on the chest; may first appear upon the back, upon the chest or neck, upon the cheek or upon the forehead; travels down- ward. At first minute dots, which rap- idly assume the appearance of large, irregular-shaped patches, somewhat like measles, but less distinct in color and form, varying from three- cent piece to twenty-five-cent piece in size. These patches are raised above the surrounding skin, especially to- ward the middle, and are of a darker red color at the centres. Fades in about four days; des- quamation, when it occurs, is fine and bran-like. On second day; first on neck, and face, and body; spreads rapidly to limbs. The skin feels harsh and rough (like a nutmeg-grater), minute points of redness next appear, soon sur- rounded by deep rosy areola (like a boiled lobster). The eruption is uniform, or in very large patches, of a scarlet hue, with interspersed raised spots and perhaps a few vesicles; the rash is followed, after the seventh day of its appearance, by complete desqua- mation. The disease is communicated by these epithelial scales. FEVERS. 25 MEASLES. SMALLPOX. INCUBATION. Generally from seven to fourteen I Generally about ten days, but days. I varies from five to twenty days. INVASION. Lassitude, shivering, catarrh ; sneezing, discharge from nose ; harsh cough ; rarely vomiting. Fever, with hot skin and frequent pulse ; rather increased by the erup- tion. Shivering, severe pains in the back ; nausea. There may be a marked chill followed by vomiting. Fever often very violent, with bounding pulse and pain in the loins ; great relief from occurrence of the eruption. ERUPTION. Appears on fourth day, first on face, spreads gradually in forty-eight hours to the rest of body. Comes out in small circular dots, like flea-bites. These dots run to- gether and form blotches, of a rasp- berry color, and the latter are very prone to assume a crescentic or horse- shoe shape, being slightly elevated above surrounding skin. Eruption is sometimes diffused over the whole body in a confluent form, and is of a dull, deep red color, offering a contrast to the crim- son or scarlet redness of scarlet fever. Lasts five days; followed by in- complete desquamation. Eruption at end of third or on fourth day; first on lips, palate and forehead. Eruption is first papular; after about a day becomes vesicular, then pustular; on the eighth day of the eruption, the pustules maturate ; about the twelfth the scabs begin to fall. The danger of contagion does not cease until desquamation is com- pleted. 26 DIFFERENTIAL DIAGNOSIS. ROTHELN. SCARLET FEVER. ACCOMPANIMENTS. Only moderate sore throat, with hoarseness ; swelling of the neck ; and rarely eorv/.a. Cerebral symptoms absent. General systemicdisturbance mild. Sore throat; coryza or bronchitis rare. Tongue red ; raspberry character. Cerebral symptoms frequent and grave. Marked systemic disturbance. THERMOMETRY. " The temperature always highest I Temperature may reach 105.6 c on first day of attack, not exceeding 102°, next day falling to 100°, and getting normal on the fifth day." {Fox.) " The temperature nearly always sub-febrile (99.5° to 100.4°)— some- times febrile (101.3° to 102.2°)." ( Wunderlich.) No secondary fever. Minute particles of cuticle, like scales of fine bran. Always begins toward centre of the eruptive patch, and gradually extends to the circumference. or even a higher point. It usually remains continuously high during the eruption, and it is thus "well distinguished from those affections with which, on account of other symptoms, it is most easily con- founded, and more particularly measles and rotheln." ( Wunderlich.) It begins to subside about the tenth day. No secondary fever. DESQUAMATION. Comes off in branny scales and in large patches. Occasionally epi- dermis of the hands is detached en- tire, and may be slipped off like a glove. This is true also of the feet. Sometimes several successive des- quamations occur. Is frequently accompanied with itching, which in some cases is ex- cessive. COMPLICATIONS. Pneumonia rare; pleurisy more I frequent. Endocarditis exceptional. SEQUELS. Dropsy rarely; swelling and sup- Bright's disease, dropsy, conjunc- puration of the cervical glands not tivitis, deafness, phthisis, chronic uncommon. diarrhoea, glandular enlargement. Epidemic, moderately contagious. I Very contagious. . Pneumonia rare. FEVERS. 27 MEASLES. SMALLPOX. ACCOMPANIMENTS. Bronchitis, coryza and redness of the eyes, very constant ; sore throat rare. Tongue coated, or red at edges. Cerebral symptoms very rare and not severe. Sore throat and dry cough ; bron- chitis rare. Tongue coated and swollen, or red at edges. Cerebral symptoms, especially convulsions in children, frequent. THERMOMETRY. Temperature during the prelimi- nary fever may reach 105°-106°. Within twelve to twenty-four hours from appearance of rash it sinks speedily to the normal. Protracted defervescence indicates a complica- tion. No secondary fever, though the fever may increase slightly before eruption leaves. Temperature during the prelimi- nary fever high, often 106° ; falls rapidly to about 100° after eruption. Rises again during the secondary fever and falls slowly ; a slight rise during desiccation. Secondary fever well marked in all cases. DESQUAMATION. Always in branny scales, not in In scabs, crusts and thick scales, patches or flakes. COMPLICATIONS. Catarrhal pneumonia is very fre- I Pneumonia not very frequent, quent, especially in adults. SEQUELS. Chronic bronchitis, phthisis, con- junctivitis. Contagion almost exclusively lim- ited to children. Chronic diarrhoea, glandular en- largement, various diseases of the eyeballs and eyelids. Very communicable ; mild cases may cause severe or malignant ones. Chiefly adults. 28 DIFFERENTIAL DIAGNOSIS. TYPHOID AND TYPHUS FEVERS. Until within comparatively few years these two fevers were con- founded ; and although now, in this country at least, they are distinctly recognized as wholly different diseased conditions, yet there are numerous instances where the clinical features of cases assimilate them to one or the other of these conditions, and yet fail to answer satisfactorily their cur- rently received definitions. Such are the numerous gastric, nervous, simple continued, synochal, mixed, entero-miasmatic, typho-malarial, etc., types which are so often referred to in medical literature. There are, in fact, wide variations in the local features of this group of diseases, and it is the exception to find the classical portraits of one of the group, drawn in the hospital wards of great cities, correspond precisely with the case as seen, modified by the numerous special conditions of particular regions. We shall cite some of these modified types, after having considered the early symptoms and broad distinctions of typhoid and typhus. Typhoid fever is peculiarly a disease of slow and insidious approach. For days, and sometimes for weeks, the patient is ailing ; and as this gradual onset is known to the public, the physician is often called upon to pronounce an opinion as to the probability of the threatenings being of typhoid long before any positive sign is present. The general symptoms are a sense of weakness and fatigue, loss of appetite, muscular soreness, headache, generally dull, sometimes severe, disturbed sleep, poor appetite, low spirits. A characteristic and often early symptom is epistaxis. Frequently there is a bronchitis, with shallow and rather frequent breathing, with some sonorous rales over the chest. A skilled auscultator can often pronounce from the character of the rale as to the presence of typhoid, as they yield a peculiar, dry, ringing sound. In one of his clinical lectures, Dr. DaCosta remarks on this: "I should be loath to rest upon this symptom alone, but there is something about it that often makes the diagnosis of typhoid special and specific."* This point is worthy of further investigation. The pathognomonic symptoms of typhoid are those connected with the abdomen. The belly is swollen and tympanitic; there is diarrhoea with * Medical and Surgical Reporter, Vol. xxviii, p. 11. FEVERS. 29 perhaps abdominal pains ; rumbling and tenderness near the ilio-csecal valve and about the right iliac fossa. The tongue is tender, and some- times moved with pain; the teeth show accumulations of dried mucus (sordes); thirst is rarely excessive; vomiting is rare; the mind is dull, and the delirium is usually low and muttering. The peculiar eruption appears on the chest and belly, most frequent between the nipple and navel, about the sixth or eighth (never before the fifth) day of the fever. It is in scattered, small, reddish, delible spots, resembling flea-bites. Later they become rose-colored, and are surrounded by an area of erythema, shading off into the surrounding skin. They are not elevated, or very slightly so, and they disappear entirely on firm pressure, but promptly re-appear. They give no feeling of hardness to the finger passed over them. These spots are, however, often wholly absent ; and their presence, number and size do not seem to bear any relation to the severity of the attack. The prodromal symptoms above mentioned are, however, often varied. Dr. A. Labeabee, of Louisville, remarks that the characteristics of the prodromal stage, the lassitude, epistaxis, and even the susceptibility of the bowels to purgatives, which are valuable aids to early diagnosis in more northern latitudes, are not so important in the malarial regions of the southern and southwestern United States;* and Dr. Juegensex, of Kiel, Prussia, has given the history of a number of cases, with the ana- tomical characteristics of typhoid fever, when the attacks were sudden, with a well-marked chill, a high temperature (104° Fah.) and quick pulse, swelling of spleen and little or no diarrhoea, f Such a course is extremely rare in this country. In typhus the eruption usually appears as small, discrete spots, slightly elevated, of a dingy red color and not completely fading on pressure. In a short time the spots cease to be elevated, and fade less on pressure, and a purple mottling appears in the interjacent portions of skin. At a still later period — say on the eighth, ninth or tenth day — the spots become entirely petechial, not being at all affected by pressure. The eruption begins to fade about the ninth or tenth day, and disappears about the fourteenth, and, if there be no local complication and the patient has not * Trans. Kentucky State Med, Soc, 1876, p. 123. \ Med. Times and Gazette, 1874. 30 DIFFERENTIAL DIAGNOSIS. been very greatly prostrated, convalescence is established between that day and the twenty-first. In slighter cases, however, the serious illness may continue for only about a week, the eruption may never be very marked, and the patient may become convalescent from the tenth to the fourteenth day; while, in very severe cases the rash may become petechial at an early period, and may continue on the skin till near the end of the third week, and the convalescence may be very greatly protracted. Generally, in a simple uncomplicated case of typhus, the pulse and tem- perature fall below the normal standard at the earlier period of convales- cence, and again rise when the patient takes more food and is capable of some little muscular exertion. Usually the bowels are confined during the course of the disease, but such is not always the case ; sometimes towards the height of the fever and when there is great prostration of strength, the bowels are relaxed, apparently from want of power in the sphincter to retain the fecal matter; but in some cases there is profuse diarrhoea during the whole course of the disease, and this independently of any medicine. It is impossible to base the diagnosis between typhus and typhoid upon the confined state of the bowels in the former disease and the occurrence of relaxation in the latter, for it is not uncommon for the bowels to be confined in typhoid. So, also, though as a rule the cerebral disturbance is more marked in cases of typhus than in typhoid, it sometimes happens that a patient will pass through a marked or even severe attack of typhus without much delirium, and retaining his intelli- gence to such an extent as to be able to answer simple questions put to him, without any apparent difficulty. In such cases, however, the patient, on recovery, has no recollection of anything that has occurred from a very early period of his illness till convalescence is far advanced. In the following table, the leading jjhenomena of the two diseases, as given by the best authorities, are contrasted, for the purpose of estab- lishing their clinical distinction. The non-identity of the two affections is now everywhere acknowledged. (In Germany typhoid is often called abdominal typhus; an unfortunate title.) FEVERS. 31 TYPHOID. Age generally from eighteen to thirty-five. Not directly contagious; often sporadic. Attack generally insidious. Duration fully three weeks ; often much longer. Death hardly ever before end of second week; more generally in or after third week. Cerebral symptoms come on grad- ually; last longer. Great emaciation. Face pale, or flush confined to cheeks. Skin hot, sometimes covered with acid perspiration. Abdominal symptoms, such as diarrhoea, tympanites; intestinal hemorrhage not unusual. Epistaxis common. Bronchitis and sometimes pleu- risy. Eruption light red and not on extremities. Autopsy shows morbid state of Peyer's patches and solitary glands ; enlargement of mesenteric glands ; ulceration of mucous coats of intes- tines ; enlargement and softening of spleen ; ulceration of the pharynx. TYPHUS. At all ages, often in persons be- yond middle life. Highly contagious, generally epi- demic. Attack generally sudden ; no lengthened prodromata. Duration somewhat shorter; often not prolonged beyond second week. Death not unfrequently at end of first week, and often before conclu- sion of second. Delirium or decided stupor comes on soon, sometimes almost from the onset; headache has appeared and disappeared by about the tenth day. Less emaciation ; greater prostra- tion. Face deeply flushed, of dusky hue ; eye injected. Skin of pungent heat, sometimes emitting: an ammoniacal odor. No abdominal symptoms; bowels constipated ; meteorism rare ; no in- testinal hemorrhage ; sometimes acute dysentery during convalescence. No epistaxis. Pneumonia, or marked congestion of the lungs, and bronchitis of finer tubes. Eruption darker color and all over the body. No constant post-mortem appear- ances ; most common are dark-col- ored, liquid blood, and enlargement of the spleen; softening of heart more common than in typhoid ; no intestinal lesions. 32 DIFFERENTIAL DIAGNOSIS. COMPARATIVE THERMOMETRY (DR. J. W. MILLER). TYPHOID. TYPHUS. The duration of elevated tempera- ture is verv rarelv less than twentv- one days ; it is generally longer, and days ; it is generally shorter by sev eral days, and may be even so short as nine days. may be protracted to thirty-five days or even more. The evening temperature is al- most constantly higher than that of the morning. The difference between the morn- ing and evening temperature is gen- erally, throughout the case, greater than in typhus ; and toward the end of the fever there occurs the very characteristic oscillation of tempera- ture, during which the difference is frequently five, six, or even seven degrees, and which may continue from a few days to a week or more. A high temperature is frequently accompanied by a pulse but slightly accelerated, and occasionally by a pulse slower than normal, and not infrequently dicrotic, especially dur- ing convalescence. The duration of elevated tempera- ture is very rarely beyond eighteen The evening temperature is fre- quently lower than that of the morn- ing. The difference between the morn- ing and evening temperature, during the heiglit of the fever, or from about the third to the tenth or elev- enth day, is comparatively seldom above one degree, and although about the period of defervescence the dif- ference is sometimes much greater ; the oscillation is not continued over more than one or two days. A high temperature is, as a rule, accompanied by a high pulse. The varieties of fever called gastric and nervous have not been recog- nized as distinct types by the most recent writers. Yet there is no doubt that many cases of continuing fever present gastric rather than abdominal symptoms, and various other perceptible variants from the type of a mild typhoid. The following semeiological table, drawn from Dr. Copland's work, will illustrate this : — FEVERS. 33 FORMS OF TYPHOID. SIMPLE CONTINUED TYPE. 100-120, small, weak, irregular ; intermittent when a dangerous attack. Heat of surface generally rises over 100°. NERVOUS TYPE. Pulse. Soft, feeble, and quick : about eleventh day very quick and un- equal. Temperature. Heat of skinnotmueb <]<■• in< I: it may even seem natural or di- minished. Tongue. Loaded or covered with a dirty mucus, afterward brown or black, incrusted or fissured. Fetor of the breath and of the discharges, an irregular relaxed state of the bowels, pain at the epigastrium, nausea and vomiting. Countenance pallid or tran- siently flushed, head heavy, con- tinual restlessness, want of sleep, tremor, hearing dull, unconscious evacuations, low delirium, early stupor and coma. The bronchial surface is the part chiefly affected ; substance of the lungs sometimes complicated. Sore-throat, occasionally so se- vere as to resemble an attack of anginose maligna. Often announced by a crisis. Gastric Symptoms. Head Symptoms. Lung Symptoms. Affection of Throat. Recovery. true White, foul, loaded or furred ; again red at its sides, and point loaded with dirty yellow fur. Tenderness at epigastrium ; looseness or diarrhoea of an ochery hue ; vomiting early. Pain in head, throbbing of arteries, brilliant expression of eyes, marked acuteness of senses, watchfulness and restlessness, moaning and incoherent mutter- ing, dilated pupils, and coma. A common and early complica- tion, either to bronchial surface or congestion of substance. Sore-throat or inflammation of fauces sometimes accompany. By subsidence of the prominent morbid actions indicative of a gradual decline. Gastric fever, which is not to be confounded with gastritis (although this is more properly a fever of gastric origin), is recoguized by Niemeyer and other competent authorities as a separate type. It commences with loss of appetite, headache and languor, followed by a slight chill, with marked gastric irritability, great nausea, frequent vomiting, and consti- pation. There is considerable tenderness on pressure over the stomach, a low pulse (60 to 70 per minute), and a temperature at first risino- slightly to (100° Fahr.), then falling below the normal as the disease advances (to 95° and even lower). A grave symptom is double vision or total loss of sight. There are no tympanites, diarrhoea, delirium, sub- sultus tendinum, spots, iliac tenderness, nor sordes, as in typhoid. \Yomen are more liable to it than men, old persons than those of middle ao-e or youth. Its outbreaks indicate it to be a zymotic disease, and the mor- 34 DIFFERENTIAL DIAGNOSIS. tality is even higher than in typhoid. The pathognomonic symptom of the disease is the peculiar sweetish odor of the breath; it is likened by some to the odor arising from hot water poured on garlic, having a slightly alliaceous odor; or, according to others, it resembles a faint aroma of valerianic acid.* Typhlitis can readily be distinguished from typhoid fever by the path- ognomonic sign of a dense tumor in the iliac fossa, increasing, and exceedingly tender on pressure. TYPHOID AND MALARIAL FEVERS. TYPHO-MALARIAL (Woodward), ENTERO-MIASMATIC (Wood), OR REMITTO-TYPHUS (Drake). In order to bring into relief the broad distinctions between the typhoid and malarial fevers when in their typical forms, the following compara- tive table has been prepared, which is chiefly that of Dr. E. M. HuME.f TYPHOID. Cause. Decomposing animal and vege- table matter, especially human excrement. Old soil ; may be high and dry and long settled, especially where saturated with sewage. Epidemic of typhoid fever. Seldom after forty. Continued without intermission or decided remissions. Lasts three or four weeks ; can- not be cut short. Great nervous disturbance and prostration ; dull, heavy, throb- bing, persistent frontal headache ; twitching of muscles ; tickling of throat ; ringing in ears ; deafness ; mind stupid. Asthenic, not wild. Frequent. Catarrhal bronchitis with some- times tough, tenacious sputa. Locality. MALARIAL. Emanations from marshes, damp, low or new soil ; always vegetable, never animal. New land, moist, low and swampy. Circumstantial Evidence. Prevalence of malarial disease. Age. All ages. Periodicity. There is either intermission or remission. Duration. Can be interrupted and. cured in a few days. Nervous impli- cation. None, although there is some- times severe headache, simula- ting meningitis. Delirium. Sthenic. Epistaxis. None. Lungs. Congested, when affected at all. * Dr. G. B. Ballard, Trans, of the Vt. Med. Soc. 1877, pp. 52-56. f Peninsular Journal of Medicine, Feb., 1875. FEVERS. 3D TYPHOID. From 70 to 140 beats per rain- Pulse. ute, small, irregular or dicrotic. Hot, even when moist ; emits Skin, a peculiar, musty odor, pathog- nomonic of this fever. Indicates an increase of tem- Thermometer. perature from morning to even- ing of about 2 deg. , and a de- crease of 1 deg. from night to morning ; commences first day 98.5 deg., reaches its maximum of 104 deg. on the morning of the fourth day ; from this time the evening temperature ranges between 103 deg. and 104 deg., morning 1 deg. lower, until end of second week, when it gradually declines in the same regular man- ner, always lower in the morning than in the evening, except when there is a complication. Protrudes tremblingly ; is cov- Tongue, ered with a whitish yellow coat, which subsequently disappears and is replaced by a dry, pale brown one, with red, glazed tip and edges ; teeth covered with dark-brown sordes. Pale, livid, muddy, or may be Complexion clear, with cheeks flushed. Foaming, light color, free from Urine. sediment ; frequently contains albumen ; has typhoid odor like body. Diarrhoea, except in mildest Excretions cases ; stools offensive, pea soup, from Bowels. bright yellow or brown ; devoid of mucus, but sometimes contains whitish flocculi. Tympanites occurs, giving tub Abdomen, shape to abdomen ; pressure over shape, etc. cascum produces pain and gurg- ling sound ; tenderness over spleen. Stomach not involved ; no se- Pain. vere pain anywhere, except when peritonitis occurs. MALARIAL. More frequently high, full and bounding. Varies ; sometimes dry and hot ; odor acid and swampy ; at other times may be normal. Rises rapidly to 105 deg. or more first day or two, and falls suddenly ; is not so uniform ; may rise and fall seven degrees in one day. Coated all over with a heavy, dark yellow coat. No sordes. Sallow ; eyes yellow. Dark color, turbid, no albu- men, except in malarial hemor- rhagic fever. Bowels costive ; dark, hard, dry, bilious stools. No tympanites or tenderness of abdomen. Gastric disturbance and vomit- ing of bile ; pain in stomach and elsewhere very intense ; may be throughout the entire body. 36 DIFFERENTIAL DIAGNOSIS. MALARIAL. Eruptions of different kinds sometims occur, but are so dif- ferent in shape, feel, duration, number, extent and place, thai they need never be mistaken for the typhoid eruption. Very slight — not one fatal case in a hundred. Hemorrhage from congestion of bowels rare ; congestion of stomach, lungs, liver and spleen, the two latter sometimes become enlarged. TYPHOID. Occurs during second week ; Eruption. from one to twenty small rose- colored spots, size of pin bead, appear on abdomen, chest or back : do not extend to extremi- ties; present no distinct elevation to the touch, disappearing upon pressure, but reappearing upon its removal ; last about three days : fade away and a fresh crop appears. This eruption is claimed to be "peculiarly and absolutely diagnostic of typhoid fever." Later in the disease sudamina appear. Great — averages one in five. Mortality. Inflammation and ulceration of Lesions. Peyer's, solitary and Brunner's glands ; sometimes perforation of bowels with peritonitis, and fatal hemorrhage ; inflammation and enlargement of mesenteric glands and the spleen (which sometimes bursts) ; the brain, stomach, liver and lungs sometimes inflamed. We shall now consider the character of a disease presenting in its dif- ferent stages symptoms both of malarial and typhoid fever. The experience of numerous observers has proven that there is a com- plex form of fever prevalent in malarious districts, in which the typhoid and miasmatic elements are combined. It has been proposed by Dr. J. J. Woodward to call this " typho-malarial fever," a term which he explains to be applied " not to a specific or distinct type of disease, but to the compound forms of fever which result from the combined influence of the causes of the malarious fevers and of typhoid fever."* The name Remitto- Typhus was given to it by Dr. D. Drake, who also spoke of it as " the typhoid stage of remittent or autumnal fever." He does not consider it a distinct disease, but a genuine hybrid of typhoid and remittent fevers. He remarks that in many cases the stage of inva- sion is nearly the same length in both ; both attack males more than females ; and that when remittent terminates fatally ; subsultus tendinum, a dry tongue and intestinal hemorrhage are sometimes present. He has, * Transactions of the International Medical Congress, 1870, p. 340. FEVERS. 37 however, never seen a decided intermittent pass into typhoid ; nor well- marked typhoid terminate in an intermittent.* During and since the war, typho-malarial fever has attracted much attention, and its traits have been thus distinguished from simple typhoid : — TYPHO-MALARIAL. Only in miasmatic localities ; TYPHOID. Occurs in all localities, most com- mon in the north. Invasion gradual and without re- in ittence. Daily exacerbation and remission slight. Diarrhoea the rule. Tympanites common. Abdominal tenderness considerable ; epigastric and hepatic tenderness slight. Temperature comparatively low. Delirium low and muttering. Spleen not involved to the same extent. Sordes on the teeth the rule. Peyer's glands always involved. Rose-colored eruption present. Pigment deposits absent. most common in the south. Often begins as simple intermit- tent or remittent. Decidedly marked. Constipation the rule. Tympanites rare. Abdominal tenderness slight ; epigastric and hepatic tenderness considerable. Temperature high, especially at outset. Delirium active. Tumefaction of spleen very marked. Sordes rare. Rarely involved. Generally entirely absent. Pigment deposits in various tis- sues and organs very common. THE TYPHOID STATE. It is a common error to confound the typhoid condition which occurs in many diseases with typhoid fever, properly so-called. This typhoid state may be developed in typhus and other fevers, in acute pneumonia, rheumatism, tuberculosis, pysemia, and various renal diseases, especially the granular or gouty kidney, and Bright's disease. The exciting cause in all these cases, it is believed, is the accumulation in the blood of the nitrogenous products of disintegration of the tissues. The so-called " typhoid symptoms" are a quick, soft pulse ; a dry, * " Diseases of the Interior Valley of North America," p. 556. 38 DIFFERENTIAL DIAGNOSIS. browD tongue; the phenomena and physical signs of hypostatic congestion of the lungs ; impairment of the mental faculties ; stupor passing into coma; delirium, which is at one time acute and noisy, at another low and muttering, and not unfrequently associated with muscular tremor; invol- untary discharges. The skin is dusky, moist and often emitting a fetid odor. There is little thirst and often difficulty in swallowing. The temperature and urine vary considerably. The respirations are shallow and somewhat accelerated. The bowels are sometimes constipated, but often relaxed with offensive evacuations. The difference between this condition, as it supervenes in the above named diseases, and true typhoid, or continued fever, may be thus presented : — TYPHOID FEVER. Begins without any history of preceding disease. Can often be traced to an external zymotic or septic influence. Diarrhoea, tympanites, epistaxis, tenderness over intestinal glands, pain in iliac fossa. Eruption of rose-colored spots. THE TYPHOID STATE. Arises in the course of an ante- cedent local disease. Is always traceable to blood-poi- soning from deficient elimination. Abdominal symptoms generally absent. Occasionally there may be spots of diffused rosiness, from dilatation of superficial capillaries, but nothing like the tdches rouges. Intestinal hemorrhage not to be expected. Ague-cake not usual, except in malarious cachexia. Urine may show albumen or pus. Intestinal hemorrhage not infre- quent. Enlargement of spleen very con- stant. Albumen and pus not present. MALARIAL FEVERS. The characteristic symptom of all malarial diseases is 'periodicity. It is not, however, pathognomonic; for hectic and syphilitic fevers, neural- gia and many other diseases, simulate this trait very closely. The diag- nosis, however, in most instances is facile. Intermittent begins with a chill, cold extremities, pale face, chattering FEVERS. 39 teeth and pulse feeble ; followed by a decided fever, the face flushed, the skin hot, the pulse full and rapid; and ends with a profuse perspiration, soft, moderate pulse, and restoration of the secretions. This recurs at definite intervals, with complete intermissions between. In remittent fever we find the same development of the phenomena, the chill, the fever, the perspiration, but without complete abatement of the febrile symptoms in the interval. They continue, though lessened, and usually have daily exacerbations. It is generally preceded by inter- mittent. Between these two most common forms there are the differences that in intermittent the patient is well between the paroxysms ; in remittent he continues ailing; in intermittent a distinct chill precedes each attack ; in remittent the chill is slight or absent ; in intermittent the appetite is good between the invasions ; in remittent nausea and anorexia are present. Dr. Daxiel Drake says : " If we suppose an ague shake to be reduced to a mere chill, but the subsequent hot stage aggravated and prolonged, we shall form a just conception of the relations, in symptomatology, between intermittent and remittent fever."* The more intense cases of malarial poisoning develop algid pernicious or congestive chills, malignant remittent fever, and malarial hemorrhagic fever. In congestive chill the symptoms of an ordinary intermittent are present, but in an exaggerated form. The chill is intense, the skin and even the breath seem cold ; the face is cadaveric ; the respiration is sigh- ing ; the pulse scarcely distinguishable ; the shivering shakes the bed. When the stage of fever comes on the pulse is full and so quick that it can scarcely be counted ; the skin of the body is hot while the feet and hands are cold ; delirium is active ; thirst intense ; the stomach is irritable. The perspiration that follows brings no relief; the patient lies prostrate and sometimes unconscious. When the congestion affects the lung there is a sense of smothering, difficult breathing and bloody expectoration ; when it attacks the stomach and bowels there are violent spells of vomiting, foaming or soap-like white discharges, and great epigastric tenderness. In these cases the mind is usually clear ; but when it is the brain which is involved, there is intense headache, the *" Diseases of the Interior Valley of North America," p. 95. 40 DIFFERENTIAL DIAGNOSIS. mind is dull or delirious, and coma is apt to supervene. Patients rarely survive the third chill of this intensity. The diagnosis of malignant remittent has been carefully set forth by Dr. Daniel Drake as follows : — 1. The pulse does not rise in fullness and force during the exacerba- tion, as in other forms of remittent fever, but is generally small, frequent, weak and variable. When the remission begins it generally improves slightly, but to a much less extent than in mild remittents. 2. The feeling of abdominal oppression, and the anxiety, restlessness and gastric irritability are deeper in this than in other forms of remittent fever ; and these symptoms never entirely cease during the remission. 3. A coldness in the hands and feet, or of the ends of the toes and fingers only, continues through the hot stage, while the trunk of the body and the head are in high fever heat. With the arrival of the remission this coldness, in milder cases, is replaced by a natural temperature ; but in the more malignant it continues. Many experienced physicians regard this as the most characteristic sign of malignant remittent. 4. There is no time when the fever is absent ; and whatever irrita- tions or congestions are formed in the cold stage, and whatever inflamma- tions are set up in the hot stage, remain, though moderated in degree, throughout the remission.* Hemorrhagic malarial fever commences with a chill of the congestive type ; and during the first paroxysms the symptoms which distinguish this from all other fevers usually make their appearance. These are jaundiced skin, and vomiting, apparently without any effort, of a dark fluid ; the faeces dark, offensive, and tawny looking ; the color of the skin yellowish or bronzed, and the urine colored with blood. The last mentioned is pathognomonic. Sometimes the urine is profuse, though mixed with blood, which is a favorable symptom. Most of such cases recover ; but when the urine grows scanty, and suppression ensues, the result is said to be always fatal.f The remissions are irregular and often ill-defined; and after the hot stage there is no perspiration. J Pain in the back is severe and incessant ; the stomach is irritable, and the mental powers often obscured. * Loc. cit. f Dr. Greensville Dowell, "Yellow Fever and Malarial Fever," p. 213. % Dr. Thackeu, Cincinnati Medical News, 1872. FEVERS. 41 The tongue presents in malarious diseases some peculiar appearances. One of these has been described as follows by Dr. Wm. A. Love, of Atlanta :* — /'While the appearance of the tongue indicative of physiological and pathological conditions of the alimentary mucous membrane presents itself on the upper papilla ted surface, the border and outer edges present the peculiarity indicative of malarial toxsemia. It consists in a peculiar pectiniforme appearance of the edges of the tongue, as though these edges had been under the pressure of the sides of the teeth of a comb — just as, in certain " languid and flabby " states of the prima? vise, we find the edges presenting a crenated appearance, produced by the indenta- tions resulting from the pressure of the teeth in the oral cavity — -just within this pectiniforme edge, making the outer border of the upper surface of greater or less width, in different cases; or in different degrees of malarial toxaemia there appears a smooth margin, both the pectiniforme edge and the smooth margin presenting a cleaner appearance and a brighter hue than the other portions of the surface of the organ." A characteristic color of the tongue in malarial poisoning has been observed by Professor Charles O. Cijrtman, m.d., of St. Louis. He describes it as almost uniformly present. The color of the dorsum of the tongue as far back as the circum vallate papillae is of a bluish gray tinge, somewhat resembling that of old sheet zinc or lead. It occurs in various degrees of intensity, giving the impression of a coloring of greater or less thickness, superimposed upon the epithelial surface, some- times quite thin and transparent, at other times quite opaque. In some cases this hue is observed without any other pronounced symptoms of malaria ; but in all such the distinct malarial symptoms follow. The disappearance of this color serves as a valuable index of the perfect restoration to health. f The symptoms of malarial poisoning are multiform, and are frequently so masked and disguised that the closest observation fails to detect their origin. This is the condition of malarial toxaemia. It is broadly characterized by a tendency to cerebral, thoracic and abdominal con- gestion, obstinate to ordinary remedies, and often slightly periodic in * " Transactions of the Medical Association of Georgia, 1878." f St. Louis Medical and Surgical Journal, 1869. 42 DIFFERENTIAL DIAGNOSIS. exacerbations. Bronchitis, diarrhoea, simple fever, toothache, neuralgia, ophthalmia, urticaria and other skin diseases, even haemoptysis, hysteria and rheumatism, may all be caused, instituted, or simulated by this subtle poison. Careful examination will sometimes disclose evidence of periodicity in an increase of suffering at regular periods; sometimes at intervals of several days, or even weeks, apart; or they may be regularly aggravated at morning, noon or night. Sometimes subordinated to the prominent symptoms, and apt to be overlooked by the patient unless particular inquiry is made, are slight recurrent headaches, intolerance of light, shiverings, or a sense of cold, or alternating heat and cold, or perspira- tions. A trace of blood in the urine, especially in the tropics, is a common indication of malaria. Nausea or vomiting, or a copious watery discharge from the bowels at periodic intervals, are often observed, especially in children.* The skin is harsh, dry, and presents a muddy or else a greenish-yellow hue, which is most noticeable on the face, neck and arms. The appetite is capricious, the strength easily exhausted, the temper irritable, the mind readily depressed, and the energies diminished. On careful percussion the spleen is nearly always found to be decidedly, and the liver slightly, larger than in health. The condition of the blood in malarial poisoning has been studied with definite results. Dr. A. Kelsch has found that the white cor- puscles diminish during an attack to one-half or one-third of their normal number, and continue less than usual so long as there is splenic enlargement. f Dr. E. L. Moss, staff-surgeon in the British Navy, has constantly found, after the lapse of forty-eight or more hours, organisms in the blood of intermittent fever which he was unable to find in fresh blood. The organisms consist of bacteria, singly or in pairs, in active move- ment, sometimes stationary in zooglea groups, occasionally in chains of four or more. Dr. Moss's method would appear to exclude every possibility of infection. His apparatus consists of a series of small glass bulbs connected by capillary tubes, so that one bulb and its contents *See an article on "Infantile Malarial Toxaemia," by Dr. Joel C. Hall, in the Medical and Surgical Reporter, Vol. xxxi, p. 147. f Archives de Physiologic, October, 1876. FEVERS. 43 can be separated from the balance by the blowpipe. The tubes and bulbs are so arranged that the entire apparatus can be heated in a water or paraffin bath. One end of the series is left open, packed with baked wool and connected with an aspirator; the other end is drawn to a fine point and sealed. The sealed point is connected with a fine hypodermic needle by a piece of rubber tubing ; the needle is protected by a glass sheath. The apparatus is repeatedly heated in a water bath before using. To use the apparatus the sheath is removed from the needle and the latter is plunged into aoy suitable vein, the sealed point inside the rubber connection is broken and the blood flows gently through the bulbs, drawn on by the aspirator. When sufficient blood has entered, the tube next to the needle is instantly closed by the blowpipe, and then the end near the wool plug. CEREBROSPINAL FEVER (EPIDEMIC MENINGITIS, OR SPOTTED FEVER). The onset of this disease is usually sudden, often beginning with a chill, vomiting and intense headache, and an elevation of pulse and temperature. The pathognomonic symptom is that the head is drawn backward and downward, and the muscles at the bach of the neck are rigidly contracted, and very painful on motion. The pupils are also contracted. At an early period herpes may appear on the face or limbs, the skin is hypersesthetic, and the patient cannot bear handling. After about four days convulsions may set in, or tetanic contractions make their appearance, and stupor follows, passing into a coma, preceding dissolu- tion. The bowels are persistently constipated, and the urine passes involuntarily. In cases tending toward recovery the acute symptoms gradually subside, and, after a week or two, convalescence takes place, attended by more or less headache and muscular contraction. In regard to differential diagnosis, it may be simulated by typhus or masked variola. The absence of tetanic spasms of the post-cervical muscles in these diseases will aid in recognizing them. The protracted cases, where this symptom is not prominent, may resemble typhoid fever. In both there is an eruption, some similar cerebral symptoms, 44 DIFFERENTIAL DIAGNOSIS. and occasionally intercurrent diarrhoea. But the invasion of cerebro- spinal meningitis is more sudden, the headache more violent, and there is vomiting - and constipation ; while later the spinal pain, the herpes, the tetanic spasms and the continued headache, are broad distinctions. True tetanus is distinguished by the absence of epidemic prevalence, by the clearness of the mental powers, and by the history of the case pointing to some injury. Certain forms of malignant malarial fever counterfeit cerebro-spinal meningitis, especially during convalescence, when the affection presents periodical intermissions of the febrile state. The points of difference may be summed up as follows (Hamilton) : — CEREBRO-SPINAL MENINGITIS. Inceptive chill not marked. Disease epidemic, and chiefly among children. Muscular spasms the rule. Bowels constipated. Pulse and temperature do not suffer rapid variations. Temperature does not undergo periodical changes. Face flushed; eruption before fourth day. Delirium and coma not affected by large doses of quinine. Increase of fibrin and rapid coagulation of blood when drawn. CONGESTIVE PERNICIOUS MA- LARIAL FEVER. Chill quite marked. Epidemic and common to all ages. Muscular spasms very rare. Not usually so. Both subject to great variations, feeble and irregular. Undergoes decided periodical changes. Complexion sallow; no eruption. All symptoms modified usually by large doses of quinine. In distinguishing it from other head affections it should be observed that, while pain in the head, vomiting, epileptiform attacks, disease of the optic discs, emaciation, eruptions, involuntary micturition, are symptoms found in many of them, the sudden onset of symptoms, pain in the back of the neck, the stiffness of the muscles of the neck, and retraction of the head, are sufficient to separate cerebro-spinal FEVERS. 45 meningitis from hydrocephalus acquisitus, basilar meningitis, and tumor of the brain, diseases to which, in its symptoms, it is nearly allied. It may also be noted that Dr. Hayden, of Dublin, a competent au- thority, states that he never saw a case of cerebro-spinal meningitis unattended by pains in the calves of the legs, and he should make a pre- sumptive diagnosis from the presence of that symptom alone. Dr. Dowse, of London, has insisted on the importance of distinguish- ing sporadic from epidemic cerebro-spinal meningitis. He maintains that in its epidemic form the sensorium is more or less affected from the first, and that the membranes over the superior cerebral convolutions, cerebel- lum, and posterior columns of the cord, including the nerve substance, are primarily, if not wholly, the seats of lesion. In the sporadic form, on the contrary, the sensorium and special senses are only slightly influ- enced, and the inflammation centres itself upon the meninges at the base of the brain and the anterior columns of the cord. He therefore gives to the latter affection the name of occipito, or basic cerebro-spinal menin- gitis, in contradistinction to the former well-known disease. He draws his conclusions and diagnosis from signs and symptoms, as evidenced in the following; table : — EPIDEMIC CEREBRO-SPINAL MENINGITIS. Attack sudden, without any spe- cial predisposing cause. Apparently of a contagious or in- fectious origin. Sensorium affected from the first. Excito-motor spasms of a tonic character in groups or groupings of muscles, with marked loss of cutane- ous and muscular sense. Reflex movements common. Vomiting urgent and uncontrol- lable. Temperature rarely exceeds 100°. SPORADIC OR BASIC CEREBRO- SPINAL MENINGITIS. Attack commences gradually and resembles an onset of acute rheuma- tism. Usually arises from exposure to cold, exhaustion, and privation. Sensorium never affected until the last stage. Incoordination of movement with cutaneous formication, partial anaes- thesia, muscular hyperalgia, but no tetanic spasms. Reflex movements rare. Vomiting not so severe. Temperature often rises to 105°. 46 DIFFERENTIAL DIAGNOSIS. EPIDEMIC CEREBROSPINAL MENINGITIS. Purpuric maculae diffuse and gen- eral. Death usually takes place from coma. Prognosis grave. Post-mortem appearances reveal the membranes over the superior cerebral convolutions and posterior columns of the cord as the seat of lesion. SPORADIC OR BASIC CEREBRO- SPINAL MENINGITIS. Maculae never seen in the desu- date form. Death usually takes place from apneea. Prognosis hopeful. Post-mortem appearances reveal the membranes over the base of the brain and over the anterior columns of the cord as the prime seat of lesion. This distinction has, however, not been wholly accepted by American authorities. Dr. Da Costa questions the main point of difference — the temperature; and Dr. Alfred Stille 1 writes: "The whole medical literature does not contain a single case of sporadic idiopathic cerebro- spinal meningitis with the characteristic sudden onset of the epidemic disease." From that writer's admirable monograph* we extract the fol- lowing exhaustive comparison of meningitis and typhus, with which latter it has often been confounded : EPIDEMIC CEREBRO-SPINAL MENINGITIS. A pandemic disease; occurs in places remote from one another and without intercommunication. Attacks all classes of society. Is never primarily developed by squa- lor and deficient ventilation. Is not contagious. More males than females attacked. More young persons than adults attacked. Generally occurs in winter. TYPHUS FEVER. Essentially an endemic disease. Always due to local causes. Spreads by intercommunication only. Attacks primarily the poor, filthy and crowded alone. Contagious in a high degree. The two sexes equally affected. More adults than young persons. Epidemics irrespective of season. * "Epidemic Meningitis," pp. 107, 117. FEVERS. 47 MENINGITIS. Eruptions are wanting in at least half the cases ; they occur within the first day or two. The eruptions are very various, including erythema, roseola, urti- caria, herpes, etc. Ecchymoses are common. Headache acute, agonizing, ten- sive. Delirium often absent ; often hys- terical, sometimes vivacious, some- times maniacal. Generally begins on the first or second day. Pulse very often not above the natural standard ; often preternatu- rally frequent or unfrequent. Is subject to sudden and great varia- tions. The temperature is lower than that recorded in any other typhoid or inflammatory disease. It is also very fluctuating. The body emits no peculiar smell. The tongue is generally moist and soft ; sordes of the teeth, etc., is rare. Vomiting, generally of bilious matter, is an almost constant and urgent symptom, especially in the first stage. Pains in the spine and limbs of a sharp and lancinating character are usual, and evidently neuralgic. Tetanic spasms in a very large proportion of cases, and within the first two or three days. TYPHUS. The eruption is rarely absent, and appears between the fourth and the seventh day. The eruption is uniformly roseo- lous, and then petechial. Ecchy- moses are rare. Headache dull and heavy. Rarely absent; usually mutter- ing. Rarely begins before the end of the first week. A slow pulse exceedingly rare ; its rate pretty constantly between 90° and 120°. The temperature is always more or less elevated, and it does not fall until the close of the disease. The skin is hot, burning, and pungent to the touch. The mouse-like odor of typhus is characteristic. The tongue is generally dry, hard and brown, and the teeth and gums fuliginous. Vomiting is rare and not urgent. Pains are dull, heavy, and appar- ently muscular. Tetanic spasms are unknown in typhus. Convulsions sometimes oc- cur, due to pyaemia. 48 DIFFERENTIAL DIAGNOSIS. MENINGITIS. Cutaneous hypersesthesia a promi- nent symptom. Strabismus common. The eye, if injected, has a light red or pink- ish color. The pupils are often unequal. Deafness is often complete and permanent. Duration very indefinite ; but generally from four to seven days. The blood is often highly fibrin- ous. The lesions, unless in the most rapid cases, consist of a fibrinous or purulent exudation in the meshes of the cerebro-spinal pia mater. Mortality from 20 to 75 per cent. TYPHUS. The sensibility of the skin is generally blunted. Strabismus rare. The blood in the conjunctival vessels has a dark hue ; the pupils are always equal. Deafness is hardly ever perma- nent, or attended with signs of dis- organization of the ear. Duration from twelve to fourteen days. Blood never fibrinous. There are no inflammatory lesions whatever. Mortality from 8 to 40 per cent. ACUTE TUBERCULAR (GRANULAR) MENINGITIS. This serious disease is apt to be confounded, especially in the adult, with typhoid or typhus fever, the exanthemata and pneumonia. The following characteristics of the disease, as given by Drs. Reginald South ey and Hamilton, will serve to distinguish it : — 1. The prodromal symptoms of this form of meningitis are well marked. The history of the case usually records an illness that has endured some two or four weeks, but one which has not attracted much attention until distracting headache, with some delirium at night, has supervened. 2. Vomiting is generally the first and most important symptom. Headache is invariably present. ?>. After two or three days there is a marked rise of temperature, say from 101° to 105°, with greatly increased pulse. 4. The bowels are constipated and not tender to firm pressure. Very little nourishment is voluntarily taken. The abdomen becomes retracted, and the aspect of the patient, with half-open eyelids, or some slight paralysis of these, becomes highly diagnostic. FEVERS. 49 5. There is no characteristic rash. The so-called tdche cerebrate of this form of meningitis is not a true eruption, but is produced by pres- sure or contact. When the finger is drawn across the skin of the fore- head it leaves a vivid red mark, which has been considered a pathogno- monic sign of the disease. 6. The skin is hypersesthetic, the delirium slight and transitory, the temper irritable, obstinate and unaccommodating. 7. There are general muscular pains, followed first by stiffness, and then by slight paralysis, as shown in the imperfect coordination of the muscular movements, in tremblings and in twitchings. The muscular pain and stiffness are often first complained of in the nape of the neck, and then in the muscles of the back. 8. Slight epileptiform convulsions are observed, followed by paralysis of motion in the limbs or parts convulsed ; this paralysis being most usually of a transitory or temporary kind. Among the paralyses most characteristic are those affecting the optic commissure and oculo-motor tracts, causing a slight internal squint, with dilated inactive pupil of one eye, with drooping of the same eyelid, and paralysis of the facial nerve upon one side. The paralysis of the limbs, although usually hemiplegic, is seldom one that invades the body upon one side in its entirety. Further, its mode of attack is gradual ; usually, the arm and leg are affected upon the same side, even when the facial muscles are not involved. YELLOW FEVER. The name Yellow Fever is misleading, as the coloration of the skin to which it refers is not an invariable nor even a common sign of the dis- ease. According to Dr. Greensville Dowell,* the skin does not turn yellow in more than one case in six, and many die before there is the least appearance of yellowness even in the eyes. Of those who die after the black vomit has set in, not more than one in three presents the yellowness. The pathognomonic sign of the disease is the black vomit. It is brownish black, semi-fluid, with a glistening reflection and acid reaction, and varies in quantity from a mere stain on a handkerchief to many pints in the twenty-four hours. It, however, is not thrown up in more than one in three fatal cases. * "Yellow Fever and Malarial Diseases." 50 DIFFERENTIAL DIAGNOSIS. The usual course of the disease as witnessed in the southern and south- western States is as follows: — 1. Onset with a chilly feeling along the spine, passing into actual rigor. 2. Pain in the head, severe in proportion to the malignancy of the disease. 3. Fever slight, tending to perspiration. 4. Remission after a period varying from twenty-four hours to five days. 5. The secondary fever, commencing usually without a chill ; it runs an indefinite course. The discoloration begins at the white of the eye, and extends over the skin of the forehead, chest, abdomen, and extremities. The urine is high- colored and stains linen, and in some cases the perspiration gives the same yellowish stain. The shades which separate the symptoms of one fever from those of another, in warm climates, are sometimes of such gentle gradation that prime! facie they may seem to belong to one and the same disease; this more especially refers to the yellow and remittent type of fevers, between which so slight is sometimes the distinction, that bilious remittent has frequently been considered and classified as true yellow fever; for in the prominent symptoms which appear in both yellow and remittent fever a great similarity obtains; both take their origin in paludal soils; both in their course offer symptoms of so seemingly similar a nature that the shades of difference are so slight as to frequently escape even a good observer and cause him to fall into error. But this apparent similarity vanishes on close and continuous inspection, for then essential and dis- tinctive marks are observed, which stamp each with an individuality, and which characterize each as a separate disease, distinct in its essence and differing signally the one from the other. These differences may be summarized as follows (J. J. L. Donnet, DaCosta, Dowell, and others) : YELLOW FEVER. BILIOUS REMITTENT. Is essentially of an infectious na- ture, and found in cities. Chiefly vigorous and young con- stitutions fall victims to it. Colored Is not of an infectious nature, and usually found in the country. All ages and constitutions are liable, and the weakest most so. population less liable than white. | Colored population liable. FEVERS. 51 YELLOW FEVER. Restricted chiefly to the yellow fever zone. Is of a continued type; remis- sions not marked. Temperature in bad cases very high. Usually attacks at night. Severe nausea and vomiting throughout. Epigastric tenderness early and decided black vomit. Headache occipital. Hemorrhages from the gums and various parts of the body. Tongue clean or but slightly coated; pulse variable, becoming slow in the last stages. Eye highly injected and humid ; expression often fierce or anxious. Pain in the back very severe ; also pain in the calves and over the eyes. Delirium rare; mind generally clear and cheerful. Urine generally albuminous; sup- pression common. Muscular prostration slight ; con- valescence rapid ; no sequelae. Liver aifected and slightly en- larged. Spleen not aifected. One attack affords an almost cer- tain immunity. Mortality very high. Peculiar smell often perceptible. BILIOUS REMITTENT. Is to be found in all parts of the world where marshy soils prevail. Remissions observed in the morn- ing. Temperature not extraordinarily high. Usually attacks in daytime. Nausea and vomiting moderate. Epigastric tenderness slight. Head- ache frontal. No hemorrhagic tendency. Tongue heavily coated ; pulse varies little, remaining quick until convalescence sets in. Eye and physiognomy not pe- culiar. Rachialgia slight or absent ; head- ache moderate. Delirium frequent; mind always dull. sup- Albuminous urine rare pression also rare. Much muscular prostration ; con- valescence slow; sequela? various and tedious. Liver not affected. Spleen invariably affected. One attack seems rather to pre- dispose to others. Mortality slight. No peculiar smell observed. O'J DIFFERENTIAL DIAGNOSIS. YELLOW FEVER. Never merges into intermittent. Treatment unsatisfactory ; qui- nine useless. Autopsies show great congestion, inflammation, ulceration and soften- ing of the stomach. Liver en- larged, fatty, yellowish in color, its secreting cells filled with oil glob- ules. Heart often exhibits disinte- gration of the muscular fibres. BILIOUS REMITTENT. Often merges into intermittent. Quite amenable to treatment ; an- tagonistic power of quinine beyond question. Autopsies show congestion of the stomach, but rarely inflammation. Liver of an olive or bronze hue, not fatty. Spleen enlarged. RELAPSING FEVER. Of late years epidemics of this disease have appeared at various points in this country. It is eminently contagious in character, and a physician should be prepared to recognize it early. The invasion is sudden, the fever soon developed and high, the pulse very rapid, the skin often jaundiced, and the temperature elevated (106°-107°). Toward the close of the first week the symptoms rapidly subside, and convalescence seems at hand ; but after about another week the symptoms all return with as much violence as ever, to again disappear, as a rule, after four or five days. The epidemic prevalence of the disease, its sudden invasion, the per- sistence without remission of the high febrile symptoms, and the a-febrile interval, give it a peculiar physiognomy. The characteristic feature of the disease, asserted by some to be truly pathognomonic, is the presence of spirillium in the blood. The following method of demonstrating them is that recommended by Dr. R. Albrecht, of St. Petersburg :* — Spread out a drop of blood on a slide, not too thin ; let it dry; treat it with a drop of acetic acid, and repeat it in a few seconds. By this means all the fibrin and blood-corpuscles will be destroyed and dissolved, and after careful washing away of the acid with distilled water, and final drying, the preparation is ready for use. With a little care in washing, which must not be in a stream, the spirilla are not lost, especially if the preparation has been dried for six to twelve hours before being treated * St. Petersburg Med. Wochenschrift, June, 1878. FEVERS. 53 with acetic acid. The glass slide then looks quite transparent, and, at the place where the drop of blood was, it looks a little dusty. Under the microscope the nuclei and nucleoli of the white blood corpuscles are visible, and between these the spirilla lie in great numbers and in the most distinct arrangement and position, showing up very beautifully and distinctly. They give the impression of being thicker than they gener- ally are, probably because they are no longer imbedded in a highly re- fracting substance — plasma. Relapsing fever is liable to be mistaken for one of the forms of con- tinued fever. Its epidemic prevalence will naturally put the physician on his guard. It is, moreover, especially a disease of the lower classes, who suffer from insufficient food and filthy surroundings. In most cases it is associated with jaundice, which is a rare complication in typhoid. When the disease rapidly abates, and this cessation is followed by the characteristic relapse, no reasonable doubt as to its nature can be enter- tained. The main distinctions between relapsing and typhoid may be thrown into a comparative view as follows : — RELAPSING FEVER. Invasion sudden. Bowels generally constipated Conjunctivitis. Liver engorged, skin yellow, ten- derness over epigastrium. Temperature high, 105°-107°. Fever abates in three or four days, with critical sweats ; diminution or cessation of the febrile symptoms, with subsequent relapse. Spirilla in the blood. Splenic enlargement. No characteristic eruption. TYPHOID FEVER. Invasion gradual, with epistaxis ; no chill. Generally diarrhoea. No conjunctivitis; eyes bright and clear. No yellowness; tenderness over right iliac region. Temperature during first week rarely above 104°. These phenomena absent ; symp- toms continuous for three or four weeks. No spirilla. Spleen not materially enlarged. " Hose spots," inflammation of Peyer's glands. 54 DIFFERENTIAL DIAGNOSIS. CHAPTER II. DISEASES OF THE BLOOD. Contents. — The Dyscrasia — The Arthritic, Dartrous, or Rheumic Dys- crasia — The Scrofulous or Strumous Dyscrasia — The Syphilitic Dys- crasia — The Tuberculous Dyscrasia — Rheumatism — Chronic Rheuma- tism — Gout — Rheumatic Arthritis — Pernicious Anosmia and Leukemia. THE DYSCRASIA. As is justly remarked by Professor Theodor Billroth, in his Sur- gical Pathology, while it is true that there are some objections to the employment of the term dyscrasia, as committing one to a humoral pathology, these are overbalanced by the fact that there are certain well- defined, long-recognized, inherited physical peculiarities, which render the person possessing them unusually prone to certain diseases and complications, and which lend a complexion of their own to very many affections seemingly remote in form and pathology. These constitutional tendencies may as well be known by the term Dyscrasice as by any other, since their existence cannot well be denied. The principal dyscrasise are : 1. The arthritic, sometimes called dar- trous or rheumic, believed to be pathologically akin to gout and rheuma- tism ; 2. The strumous, or scrofulous ; 3. The syphilitic ; and 4. The tuberculous, or phthisical ; the last three mentioned, in the opinion of some, being derived from a common ancestral taint. I. THE ARTHRITIC, DARTROUS, OR RHEUMIC DYSCRASIA. This form of blood poisoning has been aptly termed, by Mr. Jonathan Hutchinson, " the basis-diathesis on which both gout and rheumatic arthritis are built, and which to a large extent is indifferent and common to both." When a man with such a diathesis becomes affected with a renal disease, gout develops itself; otherwise he will probably have DISEASES OF THE BLOOD. 55 rheumatism. In many families it is observed that the males have gout, the females rheumatism. The explanation is not far to seek.* In another lecture Mr. Hutchinson describes gout as "chronic rheumatism plus a dietetic derangement." Many skin diseases, nervous affections (so-called), "cramp colic," head- aches, sciatica, vertigoes, palpitation, and obstinate dyspepsia are really latent gout. In such cases there is usually a history of antecedent or hereditary rheumic diathesis, frequent acid eructations, the emission of pale, limpid, acid urine, of low specific gravity, and with traces of sugar or albumen or both; some varicosity of the veins; the nails are brittle; and there is slight redness around the eye, indicative of mild chronic con- junctivitis (Dr. J. Russell Reynolds). The following are the signs as stated by Professor Hardy, of Paris : Persons who have this diathesis appear to enjoy good health, but their skin is habitually dry and their perspiration scanty. They often expe- rience a lively itching without eruption. The appetite is generally well developed, and they are apt to eat a much greater quantity of food (especially animal food) than others in analogous conditions. Another important peculiarity is the extreme sensibility of the skin and the facility with which it is influenced by the lightest and most fugitive impressions. Sometimes general excitement, alcoholic excess, watching, use of coffee, of certain kinds of food; sometimes a local excitement, irritating frictions, or the application of a plaster, will give rise to an eruption, often ephemeral, which reveals a peculiar predisposition of the economy, and the existence of a latent vice which needs but a favorable occasion to manifest itself. To this diathesis Hardy ascribes eczema, lichen, psoriasis and pityri- asis, among diseases of the skin.f Mr. Prescott Hewett adds that when a patient complains of dys- pepsia, more or less troublesome, frequent deposits of lithates in the urine, slight eczematous eruptions on the skin from time to time, anoma- lous wandering pains in various muscles, sharp, deep-seated pains in the tongue, continuing for two or three days, and then disappearing alto- gether for a while, crackling about the cervical spine on slight niove- * Medical Times and Gazette, June, 1876. f Maladies de la Peau, Paris, 1860. 56 DIFFERENTIAL DIAGNOSIS. ments, some, it may be very slight, knottiness about the smaller joints of the fingers — we mavbe very certain that he has the arthritic diathesis. Sir James Paget adds to the above: Small (chalky) nodules in the cartilages of the ears (tophi); nodular enlargement of the knuckles; thickening of the cutis, with subcutaneous bursee over the knuckles, chiefly between the first and second phalanges of the fingers ; thickening of the palmar fascia, adhering to the cutis, and producing contraction of the fingers ; spontaneous pain in the tendo-Achillis ; pain in the heel ; frequent and persistent erections at night, not connected with any sexual feelings; "burning soles" and "burning palms;" sensations of heat; ting- ling and burning patches of the skin of the thighs, without external ap- pearances of redness or eruption; patches of "dry eczema." In such patients, an injury may be followed by a well-marked attack of gout ; or the trouble may linger, with pain and occasional swelling, and with constantly increasing distrust of surgery and the surgeon, till some one suspects the existing taint of the arthritic diathesis, and acting on the suspicion, addresses his remedies to . it, and promptly cures the local trouble. (The points of diagnosis between the gouty diathesis and chronic rheumatism, as summed up by Fothergill, are given on page 64, in the section devoted to " Diseases Likely to be Confounded with Rheuma- tism.") II. THE SCROFULOUS OR STRUMOUS DYSCRASIA. Sir James Paget defines the principal signs of scrofulous constitution to be slowly progressive and long abiding inflammation, provoked by less causes than would excite inflammation in healthy persons, the inflam- matory process tending to the production of " cheesy " matter ; the middle permanent incisors, with their borders barred, crenated, thin and brittle; the mucous membrane of the lower turbinated bone swollen, puffed and congested ; a long abiding ozsena in early life, with frequent or daily discharge of scabs ; general swelling, with glandular enlargement of the whole naso-palatine mucous membrane; a granular pharynx, with its lining membrane more or less thickly scattered with prominent glands ; the perforating ulcer of the nasal septum — these are some of the minor signs. Still more positive are enlarged and suppurating lymph glands DISEASES OF THE BLOOD. 57 discharging curdy pus, and slowly healing with red-banded and barred scars; pustules by the edge of the cornea; frequent impetigo with swollen glands; periosteal swellings of the phalanges; chronic thickenings of synovial membranes ; obstinate otorrhoea. If a patient is found to have or to have had any few of these, he may justly be pronounced scrofulous, and scrofula may be suspected in any localized morbid process in hirn. Or, if these diseases are known to have occurred singly or together in many members of a family, we should look out for scrofula as an element of whatever disease may appear in any member of that family. Dr. Francis Delafield, of New York city, observes* that practi- tioners in this country see comparatively so little of scrofula that it is difficult for them to appreciate the prominent place it holds in the minds of physicians in European countries. It is a condition which is hardly susceptible of a definition, and yet it is not hard to understand what is meant by the term. It means this: When an individual acquires an inflammation of a mucous membrane, of the skin, of the joints, of the bones, of the genito- urinary apparatus, or of almost any part of the body, such an inflam- mation usually runs an acute course and terminates in resolution, or in suppuration, or in the formation of organized new tissue. But, if the inflammation, instead of doing this, simply reaches a certain point and stays there, and then, instead of resolving or suppurating merely, goes through a succession of degenerative changes, such an inflammation is said to be scrofulous. The scrofulous inflammations have several well-marked characteristics. They are very slow in their progress ; they are very rebellious to treat- ment ; they are accompanied by an extensive cellular infiltration of the inflamed parts, so that when the degenerative changes ensue there is large destruction of tissue. The degeneration which occurs in the products of such a scrofulous inflammation is peculiar in its nature ; it is commonly called cheesy degeneration, and consists in the transformation of the pro- ducts of inflammation into a dry, yellow mass, composed of amorphous granular matter. Examples of this form of inflammation will at once suggest themselves. Caries of the vertebra, hip-joint disease, white swelling of the knee-joint, scrofulous orchitis, and enlarged lymphatic glands, are all of frequent occurrence. * N. T. Medical Record, Vol. x, p. 338. 58 DIFFERENTIAL DIAGNOSIS. III. THE SYPHILITIC DYSCRASIA. Apart from the special recognition of constitutional syphilis, it is of the utmost importance for the physician to be on the alert to recognize and meet the syphilitic dyscrasia as it exists, (1) in the infantile period of life by inheritance, and (2) in advanced years developed, or in the condition of latency. Mr. Jonathan Hutchinson (loc. cit.), states that in the infantile period we recognize syphilis by the peculiarity of certain single symp- toms, or else by the peculiar grouping of several different symptoms. The rash on the skin is one of the commonest evidences. It is usually erythematous or papular, of a peculiar red or coppery tint, in abruptly- margined patches. Pustular, vesicular and bullous rashes and condylo- mata about the anal orifice are also frequent. The snuffles, a peculiar, obstinate coryza, is almost always present. Iritis and a tendency to deep-seated inflammation of the eyes are often met with. At or about the age of one year, if the child survives, these symptoms usually all disappear, and the disease enters upon its stage of latency. To detect its presence in the system at this period, we must first look to the evidences of past disease. A sunken bridge of nose, caused by the long continued swelling of the nasal mucous membrane when the bones are soft; a skin marked by little pits and linear scars, especially near the angles of the mouth ; the relics of an ulcerating eruption in early life; a protuberant forehead consequent upon infantile arachnitis ; clouds in the cornea from past iritis — are all signs pointing to the constitutional taint. The teeth furnish valuable aid in diagnosis. The upper central incisors are narrow and short, and notched in the centre in a half-moon shape, a shallow furrow running from this notch to the gum; the canines are narrow, rounded and peg-like ; there are usually interspaces between the teeth. This may be considered an almost absolute sign of the taint. The general growth is not often retarded, but the complexion is an important indication. It is exceedingly rare to meet a florid, good com- plexion in a young adult who is the subject of this taint. It is almost always pale. Such persons, seemingly in full youth and vigor, generally have little DISEASES OF THE BLOOD. 59 spontaneous physical energy ; they do not seek athletic exercise nor the trials of strength ; and are languid in motion. Other signs which may be mentioned are: a patch upon the choroid, an optic irregular neuritis; a faint interstitial keratitis; an unequal thicken- ing of the vocal cords, with cicatrices of old ulceration ; and last, but not least — and especially where syphilis is associated with a gouty habit of body — psoriasis upon the sides of the tongue, as well as an indurated irregular thickening of the lower bowel. IV. THE TUBERCULOUS DYSCRASIA. There are families in which the children, while apparently healthy during their development, perish early in adult life with tubercular manifestations, especially in the lungs. This indicates a peculiar inherit- ance, which may be called the tubercular dyscrasia. More frequently the children of decidedly strumous parents die in infancy, with tubercular meningitis, which furnishes ground for the belief that in many instances tubercular disease is brought about by the strumous dyscrasia; and, indeed, it is by many identified with it. The physical characteristics of scrofu- lous subjects belong also to the majority of consumptives, in a greater or less degree. Others are predisposed to the disease through defective oxygenation caused by unfavorable form of the thoracic walls. But the researches on this subject are still incomplete, and it is well to bear in mind the words of Dr. A. T. H. Waters : — "There is no temperament which does not furnish victims to consump- tion ; nor can we say that there is any conformation of the body which is characteristic of the phthisical. I have seen men and women with the best developed frames and the most ample chests attacked with phthisis. You must not, therefore, be misled, by the existence of these conditions, by the appearance of robustness in your patients, into imagining that they cannot possibly become the subjects of this disease." The diagnosis of these different conditions is made less difficult by bearing in mind their peculiar tendencies and characteristic manifesta- tions, as set forth in the table upon the next page. 60 DIFFERENTIAL DIAGNOSIS. SCROFULOSIS. More particularly limited to childhood. Affects especially t h e lymphatic glands (causing abscess), the mucous membranes (ophthalmia), the skin (obstinate cutane- ous diseases, especially the pustular) and bones (caries and necrosis, abscesses in- dolent (cold abscess). Fre- quently resulting in phthisis and hydrocephalus. Generally afebrile. Temperament phlegma- tic ; mind and body back- ward : skin muddy ; upper lip thick ; nostrils wide and alas thickened. Abdomen tumid; ends of bones large; shafts thick. Otorrhcea, ozaena, ophthalmia com- mon. Mercury prohibited. TUBERCULOSIS. Not specially limited. Affects internal organs (phthisis, hydrocephalus, peritonitis, tabes of mesen- teric, or bronchial, glands). Pyrexia marked in acute cases, irregular in chronic. Nervous system highly developed ; mind and body active ; organization deli- cate and refined. '' Thin skin, clear complexion, the surface veins distinct, eyes bright, pupils large, eye- lashes long, hair silken, face oval, ends of bones small, shafts thin, limbs straight" (Jexner). Mercury only for tempo- rary indigestions, etc., used carefully. INHERITED SYPHILIS. Manifests itself early, generallybefore third month (from fourteen days to six weeks). Prominent symptoms : — Cachectic appearance, snuf- fles, condylomata around the anus. Child thin, poorly nourished, muscles flabby. Skin brownish, cracked, thick and rough. Fonta- nelle open; ossification slow. Posterior cervical glands en- larged. Second set of incis- ors characteristic ( Hutchin- son teeth). The central inci- sors short, narrow and thin, chisel-shaped ; edges soon become notched and bro- ken ; also striped or ribbed horizontally. Hair thin, and may have alopecia. Eruptions copper - colored and chronic ; generally dry, but may be pustular (eryr thema, lichen, psoriasis and eczema, or impetigo, ecthy- ma and pemphigus), often seen on palms of hands or soles of feet. Liver en- larged (albuminoid). As- cites common, with tympa- nites. Pyrexia only in compli- cations. Physically and mentally inferior in structure, and slow in movement; inactive, dull and often cachectic looking. choi Mercury the sheet-an- They resemble each other in hereditary character, their familiar mani- festations being readily induced by defective hygienic conditions. DISEASES OF THE BLOOD. 63 DISEASES LIKELY TO BE CONFOUNDED WITH RHEU- MATISM. Ordinarily an attack of acute rheumatism is recognized without diffi- culty by the pains in the joints, their swelling and tenderness, the shift- ing character of the disorder from joint to joint, and the absence of the symptoms so common in continued fevers, of disturbance of the stomach and brain (if we except the so-called cerebral rheumatism which appears to be associated with a ursemic condition, if its symptoms are not in reality occasioned in this way), as well as of the intermissions or remis- sions of periodic fevers. Nevertheless it is true, as remarked by Dr. S. O. Habershox,* that while there are many characteristics of true rheumatic disease, few maladies are more easily mistaken, and there is no sign which is uni- formly present. Pain is, perhaps, the most constant indication, with stiffness of one or more joints; but rheumatic pericarditis may, and often does, exist without any pain whatever. The same may be said in refer- ence to febrile symptoms, to increase of temperature, and to changes in the urine ; none of these signs is pathognomonic. Many maladies are designated rheumatic which have no connection with that disease. 1. Diseases of the spine are often said to commence with an attack of rheumatism ; but it will generally be found that the pain in the course of the nerves or in the fibrous tissues arises from direct implication of the nerves or their centres. 2. The same remark applies to pain produced by the pressure of can- cerous, aneurismal, or other tumors. Thus cancerous disease of the lum- bar glands is often mistaken for lumbago ; so also the pain from aneurismal disease of the thoracic and abdominal aorta, when no pulsating tumor can be detected, is referred to rheumatism. 3. During the course of renal disease, abnormal irritation arises not only in the serous membranes, producing pericarditis, pleurisy, perito- nitis, etc., but a similar change happens with the synovial membranes, and a form of disease is induced which simulates rheumatism. 4. In chronic poisoning by lead, vague pains in the fasciae, as well as in the joints, have been designated "saturnine arthralgia." * Half- Yearly Compendium of Medical Science. III. 62 DIFFERENTIAL DIAGNOSIS. 5. Periosteal disease is occasionally a source of fallacy in the diagnosis of rheumatism. 6. Shingles or herpes zoster may be found in the course both of the cerebral and spinal nerves; and the severe pain which precedes the erup- tion of the vesicles, and which also follows their disappearance, closely simulates local rheumatism. 7. A more important disease, and one which is attended with fatal issue, is pycemia. It closely resembles rheumatism ; for, with rigor and febrile symptoms, there is fixed pain and swelling in the joints — first one and then another being affected, though without subsidence of those parts first attacked. But while there may be some similarity in the symp- toms, the prognosis is widely different. The one is generally a curable disease ; the other a fatal one. 8. Acute synovitis closely resembles rheumatism, having pain and heat in the joint, with distention. But as a rule it affects only one joint; it is never subject to metastasis; and there is little or no effusion into the sur- rounding tissue. The accumulation of fluid in the joint is greater, but the constitutional symptoms are less prominent. 9. Milk leg occurs after fevers, or, in women after confinement. The limb swells throughout, becoming white, firm, hot and shining, and pits but little on pressure. The history of the case and appearance of the limb are usually sufficient to form the diagnosis. CHRONIC RHEUMATISM. The most common form of chronic rheumatism is that which affects the muscles, and it is frequently by no means easy to distinguish the pains due to the rheumatic diathesis from those of a wholly diverse etiology. The principal distinctions are — 1. From neuralgia. Neuralgic pains are usually confined to the dis- tribution of one nerve; they are not increased by motion or pressure; they are not attended with diffused soreness ; and they are variable in intensity, and are not attended with acid secretion. The tender spots of Valleix may be detected along the trunk of the nerve or in its distribu- tion. 2. From the pains of organic lesions. These are usually so clearly DISEASES OF THE BLOOD. 63 localized as to point to their origin. Nevertheless the pain in the right shoulder, symptomatic of hepatic disease, and especially of an abscess approaching the serous surface of the liver, and the sympathetic pain down the left arm in some cases of heart disease, are often carelessly looked over, and their significance unheeded, by classing them as rheu- matic. Intercostal rheumatism has included pleurisy, pleurodynia, broken ribs, herpes, neuralgia, the peculiar pain, generally of the left side, found in women and connected with menorrhagia and leucorrhcea; the pain on either side, which is intimately connected with debility and anaemia; and again is confounded with that condition of pain and sore- ness of the muscle developed by overwork, and attended with both muscular and cutaneous hyperesthesia, designated by Inman "myalgia." 3. From the osteocopic pains of syphilis. The history of the case throws some light ; but as this often cannot be had, it should be remem- bered that syphilitic periostitis evinces a decided partiality for the perios- teum and shafts of the long bones, and is very generally accompanied by nodes, especially in the anterior surface of the tibia, which are almost pathognomonic. There is often, too, a more marked cachexia than is found along with non-specific rheumatism. The clavicle, humerus, and forearms, are frequent locations of this form of rheumatism. As well as its favorite seats and accompanying nodes, there are evidences of skin and throat affections, a mutilated iris, etc., which will assist in formino- a correct diagnosis. Furthermore, the ready response to a specific treat- ment aids in distinguishing syphilitic pains. 4. From progressive locomotor ataxia. Ataxic patients often bitterlv complain of supposed rheumatic pains. These pains, in locomotor ataxy, come on in severe pangs — "stabbing, boring, shooting like lightning flitting from one place to another in a very erratic manner, and recurring in paroxysms lasting from a few minutes to many hours." Their sudden- ness is their especial characteristic, and should always put the medical observer on his guard to look out for the other indications, as loss of tactile sensibility, etc. These pains may be accompanied by a feeling of coldness, thus closely simulating some forms of rheumatism. The im- portance of them lies in the prognosis, as the causes of locomotor ataxv are not to be relieved by art, although the pains may be mitigated by anodynes and frictions. 64 DIFFERENTIAL, DIAGNOSIS. 5. The pains of chronic renal disease often closely simulate lumbago, or muscular rheumatism of the loins. No clinical distinction can be positively drawn, except from examination of the urine; but, in some forms of renal disease albumen is often absent for long periods together. Moreover, the amount of the urine varies, and when great in quantity is usually of low specific gravity, and contains granular casts, which, however, are often few T in number and not easily found. An absolute diagnosis is not always attainable. In gouty kidney we may fall back upon the rational symptoms, and the distinguishing characteristics may be found to run in the following directions : Rheumatism is asso- ciated with the fibro-serous texture; in lithiasis the poison has more affinity for the true serous surfaces, and is often the cause of pleurisy and peritonitis. Lithiasis more affects the muscles, and rheumatism rather the large joints. Diarrhoea, vomiting and other affections of the mucous membrane, as bronchitis, accompany lithiasis; and in these it differs from rheumatism. Lithiasis is accompanied by headache, especi- ally of the vertex (persistent and recurring vertical headache is almost pathognomonic of lithiasis), or the pain may be frontal. (Fothergill.) 6. A dislocation of the shoulder has been prescribed for as " rheuma- tism," which shows the necessity of inspection of affected joints. A typical effect of the acid diathesis of chronic rheumatism is the rheumatic markings of the teeth, to which attention has been directed by Dr. L. G. Noel.* These markings seldom appear until after middle life is past. They are most frequent upon the crowns of the teeth, though they are some- times seen upon their buccal and labial surfaces. It is that condition of the teeth treated of in dental works as "spontaneous abrasion." The abrasion often begins as decay in the fissures on the grinding sur- face of the molars and bicuspids, but instead of following the tubuli, and dipping deep into the interior of the teeth, these become closed by a calcareous deposit, as fast as laid open, and the decay spreads out into a wide saucer-shape. This cupping out of the teeth is not, however, confined to the molars and bicuspids, but commencing upon the cusps of the canines, and cutting edges of the incisors, as mere mechanical abrasion, asperities disappear, the teeth become square and polished on * Nashville Journal of Medicine and Surgery, Feb., 1875. DISEASES OF THE BLOOD. 65 the ends, and presently the surfaces begin to assume a concave, in of their original convex, appearance. This cupping out may go on until the pulp is so nearly reached as to become irritated to the point of inflammation and death; but usually its irritation is only sufficient to cause a deposition of secondary dentine on the interior of its chamber, a part of its substance forming a matrix in which lime- salts are deposited. GOUT. The signs of gout have already been in part referred to (page 55). It is not nearly so frequent in the United States as in England, and is apt, therefore, to be mistaken for rheumatism, which it closely resembles. The following table of differences will facilitate the diagnosis : — GOUT. Generally a hereditary history. Occurs usually in males, beyond middle age. Attacks generally periodic, and last about a week. The small joints chiefly affected, especially that of the great toe, or lower extremity. Much local pain, redness, oedema, and enlargement of veins. Kidneys generally affected; little fever; no sweating; heart not im- plicated. Chalk stones in the joints and ears. Uric acid always present in the blood in large excess (Gaerod). RHEUMATISM. Rarely hereditary. Occurs oftener in females, and before middle age. Attacks dependent on exposure, and last several weeks. The large joints are those generally attacked. All these symptoms less marked. Kidneys not involved ; fever often high ; sweating profuse ; heart often implicated. Chalk stones never present. Uric acid never found in excess. Dr. Garrod says that the presence of uric acid in the blood can readily be demonstrated by taking a fluidrachm of the serum from a blister, adding to it six minims of acetic acid, and placing a thread in the mixture. The uric acid, if present, will be deposited in fine crystals along; the thread. G6 DIFFERENTIAL DIAGNOSIS. RHEUMATOID ARTHRITIS (RHEUMATIC GOUT, ARTHRITIS RHEIMATTCA DEFORMANS). This is by no means an infrequent disease in this country, and is a very serious one. It is now acknowledged by the best authorities to be a distinct malady, different in origin, history and treatment from both rheumatism and gout. It is common in women and young persons, and is not produced by alcoholic or other excesses. It implicates joints of all sizes, and in all the extremities. They become permanently affected, stiffened and enlarged, but no deposits of urate of soda are found in them. The disease frequently shows itself without fever; the joints swell by serous effusions into the capsules, and along with this the ends of the bones enlarge. The integument is not inflamed, or but moderately so, and the muscles do not appear to suffer. The result on the joint may be subluxation, relaxation, or anchylosis. The concretions attendant on the disease prove, on analysis, to be of the same composition as bone, with a slight preponderance of lime (Drachmann). Phosphoric acid is diminished in the urine and in- creased in the blood (Bocher). Neither the treatment of gout nor that for acute rheumatism yields its usual results in this disease. PERNICIOUS ANAEMIA AND LEUKiEMIA. The positive diagnosis of these conditions can only be secured by a microscopic examination of the blood. In pernicious anaemia, according to Dr. Eichhorst, the characteristic appearances are : A portion of the red corpuscles are seen to retain their normal size, but are marked by an extreme paleness, with a tendency to crenation and the formation of rouleaux, while others among them attract attention by their small size, which is reduced often to one-fourth the diameter of the well formed corpuscles. These small ones are more deeply colored, and if allowed to roll over under the thin cover-glass, their appearance in profile shows them to have lost to a greater or less extent their bi-concave outline. For the examination of the blood in such investigations, Dr. Gowers, of London, recommends the use of the hcBmacytometer, by which he DISEASES OF THE BLOOD. 07 measures for the. purpose of ascertaining the number of red and vrhite cells in a given volume of blood. The essential part of the apparatus consists of a glass slip, on which is a cell one-fifth of a millimetre (.008 inch) deep. The bottom of this cell is divided into one-tenth millimetre squares. Upon the top of the cell rests the glass cover, which is kept in its place by the pressure of two springs. In estimating the number of corpuscles, the patient's finger is pricked; then by means of a capillary pipette, five cubic millimetres of blood are taken up and well mixed up with 995 cubic millimetres of saline solution; a drop of the dilution is then placed in the glass cell, the cover is adjusted, and -the slide is placed in the field of a microscope. In a few minutes all the cor- puscles have sunk to the bottom of the cell, and are seen lying on the squares ; the number of corpuscles in ten squares is then counted, and this, multiplied by 10,000, gives the number in a cubic millimetre of blood. The degree of dilution and size of the squares are so proportioned that, with normal blood, two squares contain about 100 corpuscles, and the number in two squares thus expresses the percentage proportion of corpuscles to that of health. The proportion of white corpuscles to red, or their absolute number, may be easily determined during the same observation. A simpler method is used by Dr. J. G. Richardson, of Philadelphia. He spreads a drop of fresh blood thinly on a glass slide, letting it dry, and then counting the number of white corpuscles. The specimens when thus prepared can be kept dry for any length of time, if preserved from dust and moisture, and by comparing specimens of different persons' blood, prepared similarly, the variations in the number of white corpuscles can be readily observed. By this means he claims to detect leukaemia in its early stages. Profound anaemia is met with in the following conditions : (1) After great loss of blood or exhausting discharges ; (2) where there is inanition (insufficient nourishment) ; (3) in chlorosis ; (4) in cases of malignant disease ; (5) in Bright's and Addison's disease, (6) leucocythemia, and (7) chronic metallic poisoning. The symptoms of the idiopathic or " progressive pernicious " form of anaemia are described by Dr. Byron Bramwell as follows : A profound anaemia, which is associated with marked changes in the microscopical 68 DIFFERENTIAL DIAGNOSIS. characters of the blood, and (in most cases) with the presence of retinal hemorrhages. The patient is generally well covered with fat, the skin is smooth and soft, the face looks slightly swollen, and is of a pale yellow or yellowish-green color. All the symptoms of profound anaemia arc present, viz., extreme pallor of the mucous membrane, great debility, tendency to fainting, dyspnoea and palpitation on exertion, buzzing in the cars, headache, subcutaneous oedema, etc.; loud blowing murmurs are heard over the heart and great vessels ; there is a venous hum in the neck ; the pulse is very soft and compressible. Attacks of vomiting and diarrhoea are frequent; irregular elevations in temperature, transient paralyses, hemorrhages from the mucous membranes occasionally occur. The causes of the disease are at present unknown. The disease is said to occur more frequently in women than in men. In the majority of cases the termination is in death, the end being ushered in by profuse diarrhoea, coma, or delirium. THE ORIGIN OF ZYMOTIC DISEASE, AND THE SO-CALLED GERM THEORY. The following is an abstract of an instructive and elaborate paper by Dr. D. D. Cunningham, on the " Development of Certain Microscopic- Organisms occurring in the Intestinal Canal,"* which is introduced here because it has a direct bearing upon the so-called germ theory of disease that is now exciting much discussion : — " At a time when the association of special parasites with morbid states of their host is readily interpreted as evidence in favor of current theories regarding the parasitic origin of disease, any exact information regarding the true significance of the phenomenon in particular cases may serve a useful purpose." Monads and amoeba? in excessive numbers are met with in the intes- tinal canal in cholera and certain other conditions characterized by special characters of intestinal contents. Davaine appears to have been the first to observe them, during the cholera epidemic of 1853-54. Similar bodies have been described by others in diarrhoea, typhoid fever, and dysentery. Drs. Cunningham and Lewis recorded the occurrence of amoebal orgau- * Fifteenth Annual Report of the Sanitary Commissioner with the Government of India, 1878. Calcutta, 1880. Notice of, in Medical Herald, Louisville, July, 1880. DISEASES OF THE BLOOD. 69 isms in choleraic and other excreta in 1870-71, and Losch, in 1875, as- sumed that amoebae eoli was the specific cause of a dysenteric condition of the large intestine. The monads present in the digestive canal of man in India present characters entitling them equally to a place in two genera — cercomonas and trichomonas. These monads, or zoospores, exhibit no constancy of form, but are continually varying, in consequence of both intrinsic and extrinsic influences. The body in most cases is a mere fragment of naked protoplasm, with no differentiated covering, and with hardly, if any, in- dications of a differentiation of ectosarc and endosarc. Owing to this and to their minute size it is almost impossible to determine with any certainty many points regarding it when in a state of full activity. Nearly all reagents almost immediately produce destructive changes, leading on rapidly to disintegration and disappearance, and even slight changes in the medium, such as depression of temperature or dilution with water, are sufficient to arrest activity and induce disintegration. The presence of zoospores is by no means confined to choleraic excreta. The two media best adapted to secure the demonstration of their presence are, first, the alkaline fluid of choleraic excreta ; and second, a solution of cow-dung. The zoospores are not peculiar to any diseased condition. Indeed, certain diseases associated with an acid reaction of intestinal secretions are incompatible with their presence. That they have been rarely de- tected in Europe is probably due to their ready destruction by very slight reduction of temperature. Other infusorial organisms are prejudicially affected by the initial fermentative changes occurring in the excreta. Monads and amoebae abound in the excreta of horses and cows. There are less bacterial elements in vaccine than human discharges. As bearing, perhaps remotely, on the phenomena of periodicity of dis- ease, there is a very interesting observation by Dr. Ctjxxixgham relating to the periodicity of sporangial development. In cultivation experi- ments, while at dawn there would be no trace of sporangia, an abundant crop of such bodies appeared within the course of a few hours. The development is regularly limited to the period between dawn and noon, or at least, 1 p.m. If sporangia have not appeared by the latter hour they will not appear until the following morning. At first sight it appeared 70 DIFFERENTIAL DIAGNOSIS. not improbable that light conditions were the determinant of this phe- nomenon, but experiments proved that this was not so, for the develop- ment followed the same course, even where all light was carefully and absolutely excluded. Dr. Cunningham asserts that the characteristic parasitic zoospores and amoeba? of human and vaccine excreta are identical, and this affords a ready explanation of the extreme frequency of the parasite in the human subject, owing to the presence of a constant source of readily transferred reproductive elements. This transfer is principally effected through the air. The sporangia when thoroughly dried are detached, by the slightest contact, from their points of attachment, and having been so are so light as readily to be carried about by breezes. Desiccated, these sporangia probably resist fairly the action of the gastric juice; active or softened, they might fail, more easily than if dried, to reach unhurt the lower por- tions of the digestive canal. Dr. Cunningham's conclusions are as follows : — " 1 . Special parasitic forms may be specially associated with particular forms of disease without holding any causal relation to them. " 2. The monadic, amcebal, and sporoid bodies, so abundant in many choleraic excreta, are all developmental forms of one species of parasite, which I propose to call Protomyxomyces coprinarius. " 3. This parasite appears to be closely related to the organisms in- cluded within the Protist groups of Protomonadina? and Myxomycetes, and in certain respects seems to represent a connecting link between them. " 4. It is not confined to choleraic or even to human excreta as a basis, and only attains its full development external to the bodies of the animals within which it occurs. " 5. Its immature forms occur parasitically, as normal inmates of the digestive canal in certain of the lower animals. "6. In the human subject, both in health and disease, they are very frequently present in varying numbers. " 7. During health their number and activity are limited, due to re- pressive influences exerted by the normal intestinal contents as a medium. " 8. Their excessive abundance in certain forms of disease is due to abnormal conditions of the intestinal contents, permitting of processes of rapid multiplication. DISEASES OF THE BLOOD. 71 "9. Normal human excreta do not form a medium in which any further development of the parasitic elements outside the host-body can occur. "10. On the contrary, the normal series of fermentative changes through which the excreta pass after exit from the body, insures the complete destruction of the parasitic elements. "11. No such destructive effect, however, is exerted by the changes occurring during the decomposition of the excreta in certain lower ani- mals, especially cows and horses; and here the parasitic elements, on their escape from the body, undergo further processes of development, resulting in the production of reproductive bodies, securing the continuance and diffusion of the species. " 12. Such excretal matters, therefore, serve as a constant source whence parasitic elements may be transformed in the bodies of other animals. " 13. Human excreta which have passed through the initial processes of decomposition, and which have thus become alkaline, allow of the con- tinued existence and multiplication of elements of the parasite which may then obtain access to them, and may thus serve as a second centre of re- production. " 14. The introduction of the reproductive elements of the parasite into the human body is mainly effected through the medium of the air. "15. The introduction of the reproductive elements 'per se seems to be quite innocuous. "16. The special association of the parasite with intestinal disorders appears to be dependent on the abnormal condition of the intestinal con- tents, allowing of the rapid multiplication of reproductive elements which may obtain access to them. PART II LOCAL DISEASES. CHAPTER I. DISEASES OF THE NERVOUS SYSTEM. Contents. — Cerebral Disorders — Congestion — Anosmia — Apoplexy — Thrombosis — Embolism — Meningitis — Tubercular Meningitis — Rheu- matic Meningitis — Acute Cerebritis — The Ophthalmoscope in Nervous Disorders — Headache — Chronic Cerebral Disoixlers — Hypertrophy — Hydrocephalus — Brain Tumor — White Softening — Abscess — Chronic Meningitis — Thrombosis — Sclerosis — Localization of Brain Disease — Lesions of Cerebral Cortex — Brain Lesions other than Cortical — Tab- ular View of Paralysis with Seat of Lesion — Spinal Disease — Organic and Functional Paraplegia — Diagram of Spinal, Lnflammatory and Degenerative Diseases — Tabular View of Spinal Paralysis, Congestion, Meningeal Apoplexy, Spinal Apoplexy, Acute Primary Myelitis — Comparison of Acute Spinal Disorders — Tumors — Tremors — Chronic Degenerative Diseases of the Cord — Prof. Charcot's Diagnostic Chart of Cerebro-Spinal Affections — Patellar- Tendon Reflex of Westphal — Analysis of Symptoms of Focal Lesions of the Cord (Gowers, Charcot, and Frb) — Comparative Semeiology of Cerebro-Spinal Sclerosis, Paraly- sis Agitans, and Locomotor Ataxia — Paraplegia from Reflex Irrita- tion and Myelitis Compared — Gowers' Classification of Spinal Lesions — Pseudo-Hypertrophic Pairdysis — Lead Palsy — Hysterical Paralysis — General Paralysis of the Insane — Sjnnal Irritation, and Spinal Weakness — Hysteria and Hystero- Epilepsy — Neuralgia — Insanity, Its Different Forms; their Pathology and Etiology. Recent advances in the physiology of the nervous system have thrown much light upon mental and nervous manifestations ; and many con- 73 74 , DIFFERENTIAL DIAGNOSIS. ditions which had been hitherto regarded as primary have been shown to be in reality symptomatic and secondary to definite morbid changes occurring either in the central nervous system, the trunks of the nerves, or in their peripheral terminations. It is evident that diseases having their origin or seat of lesion in the nervous system will vary in their symptoms with the locality of the morbid process and the function of the part affected. Disorders of intellection and insanity result from involvement of the cerebral hemispheres, with impairment of special senses, and paralysis of parts supplied by cranial nerves, and occur- ring with or without loss of power in the extremities. Diseases of the spinal cord give rise to paralysis of organs having direct connection with the seat of lesion, and also to disorders of sensation and nutrition. Hemiplegia may be of cerebral origin ; paraplegia is generally spinal. Pressure or irritation of nerve trunks may cause local palsy, spasmodic affection, or neuralgia, while myopathic paralysis (such as encountered in lead palsy, pseudo-hypertrophic paralysis, and progressive muscular atrophy) may be due to a peripheral nervous affection. Hysteria, vertigo, neurasthenia and some mental disorders, being of uncertain seat and unknown relations, may be provisionally considered as functional disorders of the nervous system. The principal symptoms referable to the brain may be considered as being caused by congestion, anseinia, apoplexy, thrombosis, embolism, brain tumor, cerebritis and abscess; by influence upon the brain disease of neighboring structures, such as meningeal inflammation, hemorrhage, effusion or neoplasm, necrosis, disease of the middle ear ; and by poisoned conditions of the blood, as in ursemia, alcoholism, and the delirium of fevers. An irregular and abnormal distribution of the blood supply may give rise to night terrors, epilepsy, syncope, temporary (functional ?) paralysis, cerebral exhaustion, aphasia, aphemia and agraphia ; and irregular motor discharges from the cerebral centres are directly associated with chorea, tremor, and epileptiform convulsions; the higher mental jjowers being apparently merely held in abeyance in catalepsy, trance and hysterical coma. Passing to the diagnosis of the principal cerebral disorders, the follow- ing points are of importance in distinguishing cerebral congestion and cerebral anaemia, which sometimes are difficult of clinical separation and diagnosis : — DISEASES OF THE NERVOUS SYSTEM. 75 CEREBRAL CONGESTION. Severe, throbbing and diffused. Headache. May be absent. Vertigo. Full, throbbing, tortuous and Temporal distinct. Vessels. Full, tense ; often signs of pie- General thora. Circulation. May be rumbling or singing. Tinnitus aurium. Hallucinations ; may have ac- tive delirium. Surface temperature of scalp may be increased. Contracted. Not increased ; may contain urates and phosphates (Ham- mond). Mental Phenomena. Temperature. Pupils. Urine. CEREBRAL ANEMIA. Less sharp, generally vertical. Usually a marked symptom. Not prominent. Pulse irritable, often ana;mic murmur of pulmonary artery. Noises may be short and high- pitched. Below normal ; incapacity for mental application. Surface temperature, if at all affected, is diminished. Dilated. Limpid, and may be passed in excess : decrease of salts. Cerebral exhaustion is sometimes so marked as to produce coma, and thus form a variety of apoplexy, and its diagnosis is made by excluding hyperemia, hemorrhage, embolism and thrombosis of basilar artery. Where the latter condition terminates in recovery, it is almost identical in its manifestations; indeed, "it would be difficult to disprove the asser- tion that cases of cerebral exhaustion belong in this category" (Flest). A sudden attack of coma iu a case of albuminuria may be set down as due to urcemia, if embolism and apoplexy are excluded (by noting the absence of hemiplegia). Should the coma be associated with epilepti- form convulsions this diagnosis is likely to be correct, even if no albumen can be detected in the urine; since the form of renal disease most likely to give rise to ursemic poisoning is the cirrhotic form (con- tracted kidney), in which the albumen may be absent from the urine for considerable periods of time. The early diagnosis of diseases attended by coma is of great import- ance, with the view of promptly instituting proper treatment. CEREBEAL APOPLEXY. Apoplexy is to be distinguished from drunkenness, narcotic poisoning, uraemic poisoning, epilepsy, concussion of the brain, cerebral thrombosis, embolism, and insolation or sunstroke. 7G DIFFERENTIAL DIAGNOSIS. Drunkenness. The odor of liquor may excite suspicion. If the patient vomit, the ejecta may be tested for alcohol. Or the urine may be examined by Anstie's test, as follows : — R. Bichromate of potash, 1 part Strong sulphuric acid, 300 parts. Mix. To fifteen minims of this add a few drops of the urine, and if the patient has taken a toxic dose of alcohol, the mixture will turn an emerald green. In drunkenness the pulse is generally rapid, the pupils not dilated, the eye injected. The patient can be roused and hiccoughs. Dr. MacEwen, of Glasgow, gives the following method of distin- guishing alcoholic coma from that of apoplexy, fracture of the skull, and other causes. In alcoholic coma, as long as the patient is undis- turbed the pupil is contracted ; but if any stimulus not sufficient to arouse the patient be applied to him, such as a shake or a pull of the beard, the pupil dilates, only, however, to become contracted again as soon as the person is left at rest. * Narcotic poisoning. In this condition the outset is gradual; there are often convulsions, but the patient may be roused. In opium poisoning the pupil is contracted ; so it is in hemorrhage in the pons. The vomiting, the acrid odor of opium, and the gradual intensification of the coma are diagnostic. There is no hemiplegia. Urcemic poisoning. Here the coma nearly always comes on gradually and is preceded by convulsions. It is not deep, and at first the patient may be aroused. The stertor of the breathing is more superficial, while there is also frothing at the mouth. Nearly always, distinctive modifications of the heart sounds will be heard, as reduplication of one or both, intensity of second sound, etc.; while there are elevation of the arterial tension and increased cardiac impulse. Of these cardiac physical signs none seem so constant or remarkable as muffling of the first sound. (Mr. "W. Whittle.) There are, moreover, in many cases marked prodromata. The skin has been waxy and oedematous, the eyelids puffed and the legs and feet swollen. The urine may or may not be albuminous (but this may also be present in apoplexy). Epileptic coma presents a history of convulsions ; lasts but for an hour * British Medical Journal, November 16, 1878. DISEASES OF THE NERVOUS SYSTEM. 77 or two; there is frothing at the mouth; and the temperature is ele- vated. In hysteria and catalepsy there is no elevation of temperature and no frothing at the mouth. In concussion or compression from injuries to the head the skin is pale, the pupil dilated, and vomiting occurs. The symptoms are usually of short duration and there is a history of injury. Meningeal hemorrhage from injury presents no points of difference from true apoplexy, except that hemiplegia is generally wanting (Flint). Syncope is readily distinguished by the feeble pulse, the pale face, the quiet respiration and the brief duration of the unconsciousness ; while in asphyxia the livid face, distressed breathing and blue lip which precede the coma indicate its distinction. In regard to thrombosis and embolism of the larger cerebral vessels the diagnosis is often extremely difficult. The following table of the com- parative symptoms is drawn up from the works of Buduy, Gelpke, Flint and Hamilton : — CEREBRAL HEMORRHAGE. Occurs in advanced age, with atheromatous arteries. Onset generally sudden. Hypertrophy of left ven- tricle. Alcoholism or other debilitating habits. Pain in the head. Aphasia ataxic, second- ary to a loss of conscious- ness. Intelligence much involved. Often coma. Paralysis very marked ; occurs on either side. CEREBRAL THROMBOSIS. In advanced age. May occur in children during scarlet fever and renal dis- Development of symp- toms gradual. No rheumatic history. Endarteritis deformans of peripheral arteries some- times present. No headache. Aphasia incomplete and primary, occasionally ab- sent. Intelligence less in- volved. Earely loss of conscious- ness. Paralysis less marked. CEREBRAL EMBOLISM. Almost always in early or middle life (Flixt). Prodromata absent. Previous articular rheum- atism or other disease lead- ing to formation of clots. Often cardiac valvular in- sufficiency. Coincident em- bolisms are sometimes pre- sent. No headache. Aphasia amnesic. Reten- tion of mental power. No coma. Muscular paralysis exten- sive ; nearly always on the right side (Flint). 78 DIFFERENTIAL DIAGNOSIS. CEREBBAL THBOMBOSIS. No apoplectic phenomena at onset. llceovery slow : more or less hemiplegia may re- main. May have oedema more marked on affected side. CEREBBAL EMBOLISM. Early apoplectic pheno- mena, bul without loss of consciousness. Very rapid, or else quite imperceptible disappear- ance of the residual disor- der. May be followed by softening. One-sided oedema, often in the arm alone. CEREBRAL HEMORRHAGE. Apoplectic phenomena from the outset. Symptoms of cerebral pressure. 1 disappearance of the res- idual disorder after a mod- erate time. May terminate in chronic abscess. After a few days pain in the head and inei perature of the body on the unaffected side (Flint). The high temperature (108° to 113° F.) of cases of sunstroke serves to distinguish such from the coma of apoplexy ; although iu some cases of insolation the coma is probably due to cerebral exhaustion, the distinguish- ing features of which have been previously considered. The subjects attacked are generally laboring men, who have been exposed, while at their work, to a continuous high temperature. ACUTE CEREBRAL INFLAMMATIONS. Considering the acute inflammatory state of the brain and its cover- ings, we tabulate their comparative semeiology as follows : — SIMPLE MENINGITIS. (Lcplo-meniwjitie.) Due to disease of the cranial bones, traumatism, expo- sure to sun. (Very frequently the me- ningitis o f young adults has a syphi- litic source.) Maybe epidemic. A disease of both infants and adults, though usually in the latter. Previously healthy; no prodromata. No chest symp- toms. TUBERCULAR MENINGITIS. Scrofulous inherit- ance. Often children un- der five years of age. I [istory of persist- ent headache and obstinate constipa- tion; wasting. Previous pulmo- nary trouble. RHEUMATIC MENINGITIS. Rheumatic diathesis. Adults. Often during an attack of joint in- flammation. None. ACUTE CEREBRITIS AND CEREBRAL ABSCESS. May be due to general causes, such as pyasmia, etc., or to local causes, as traumatism, bone disease, local irrita- tion, extension from meninges, etc. Often in elderly subjects. Rarely occurs in previously healthy persons. None. DISEASES OF THE NERVOUS SYSTEM. 79 SIMPLE MENINGITIS. (Lepto-meningilis.) Onset sudden. Headache intense on both sides o f head. Pupils contracted. Intelligence clear at first, but may be- come furiously deli- rious. Vomiting early, frequent. Pulse f u 1 1 and rapid. High fever. Convulsions early, contracted pupils, with contractions of flexor muscles o f arm or leg. In fatal cases death generally oc- curs in a week ; re- covery is slow. Prognosis favor- able under prompt treatment. TUBEBOULAR MENINGITIS. Takes four or five days to develop; ap- proach insidious. Persistent a n d marked headache, which exacerbates. Pupils irregularly dilated. Delirium of low grade at night (stu- por in second stage); strabismus, and os- cillation of eyeballs. Vomiting occa- sionally. Irregular and slow pulse. Fever not intense. Convulsions late, with dilated pupils and hemiplegia. Lasts from one to three weeks. Prognosis unfav- orable. RHEUMATIC MENINGITIS. Rapidly developed. Intense pain. Leads to active delirium. Not marked. Pulse full and rapid. Temperature may be very high. No convulsions. Lasts a few days; death often occurs from continued high temperature. Prognosis fair. ACUTE CEREBRITIS AM) CEREBRAL ABSCESS. Slow, and may simulate typhoid. Dull , per and localized; less than in meningitis. Mental confusion and impairment of intelligence. Vomiting not in- frequent. Less fever. No convulsions ; but sudden hemi- plegia may occur. Course is often chronic. Prognosis not en- couraging. Dr. Gee notes that meningitis of the base of the brain is generally tubercular ; and when tubercular meningitis attacks the convexity, there is a constant convulsive condition, moderate force and very variable pulse. (See page 48 for a more detailed account of tubercular menin- gitis.) These cerebral diseases may be distinguished from typhoid fever by the history and course of the affection. Typhoid occurs in the spring and fall, and is often endemic; it never appears in children under five, and generally attacks young adults. It is a continued fever, coming on in a hitherto healthy person with malaise, epistaxis and diarrhoea. Chills and vomiting are rare. Convulsions and paralysis are late manifestations, 80 DIFFERENTIAL DIAGNOSIS. and duo to complications. Delirium of low type, headache dull, moderate deafness, pulse rapid but regular. Abdominal symptoms generally pro- minent, tympanites, diarrhoea, tenderness and gurgling on pressure in the right iliac fossa, and a discrete rose-eolored eruption upon the chest and belly. Convalescence at the beginning of the third week ; disease generally continues about four weeks. THE OPHTHALMOSCOPE IN NERVOUS DISORDERS. In the diagnosis of intracranial disorders the ophthalmoscope is often of great service, though, perhaps, scarcely to the extent advocated by Bouchut. The discrete tubercles of the choroid accompanying meningeal deposit, the choked disc in cerebral tumors and inflammations, and the reti- nitis and retinal hemorrhages of Bright's disease, are of great importance. Bouchut declares* that the ophthalmoscope is as indispensable to the physician as to the oculist, and he was among the first to point out the great importance of this aid to practical medicine. We quote his opinions and conclusions: — " All diseases of the brain and spinal cord, and all the nervous affec- tions termed neuroses, because they are regarded rather as functional than organic, ought to be investigated by its aid. When' by its assistance the physician discovers a lesion of the optic nerve, of the retina, or of the choroid, in a case presenting convulsive, choreic, paralytic, or spasmodic nervous phenomena, he may be certain that a cerebro-spinal lesion is the starting-point of these symptoms. Every symptom regarded as nervous, which is accompanied by a lesion of the fundus of the eye, is caused by an organic alteration of the brain, the cord, or the membranes. Thus is it with chorea, considered by many physicians as a simple neurosis ; and yet this should, in consequence of the congestive optic neuritis found in its subjects, be regarded as a congestive affection of the anterior spinal columns. So also epilepsy, in a certain number of cases, is the result of cerebro-spinal lesions which at the same time induce changes in the optic nerve or retina. Hysterical paraplegia and paralysis produce no neuro- retinian changes, while symptomatic paraplegia and spinal ataxia pro- duce either simple hyperemia of the optic nerve or hyperemia and atrophy. So leucaemic, tubercular, glycosuric, or albuminuric diatheses * "Revue Cerebroscopique," in Gazette des Hupitaux, for January, 1874. DISEASES OF THE NERVOUS SYSTEM. 81 are often revealed by optic neuritis, the ophthalmoscopic diagnosis in some of these cases being most striking. It is especially in patients attack'' I by general acute tuberculosis, accompanied by typhoid symptoms, and which are mistaken for typhoid fever, that cerebroscopy becomes truly remarkable. In an infant in whom the disease had all the appearance of typhus, the ophthalmoscope, by revealing tubercles of the choroid with neuro-retinitis, determined that there were tubercles in the brain, and consequently productions of the same character all over the body — which the autopsy demonstrated to be the fact. "Can any diagnosis be more exact than this? You see, in the living man, tubercles of an organ which permit you to conclude that they will also be found elsewhere. You see a nerve either healthy or diseased, and this indicates whether its roots are sound or diseased; and you have almost laid bare arteries and nerves which are so afferent to the brain that changes in them, studied with care, represent similar changes in a portion of the nervous centres. It seems almost marvelous; and I do not think that since auscultation there has been anything discovered so useful to semeiology. Henceforth, the physician may divine and often affirm lesions of the brain, cord, or meninges, the diagnosis of which before was impossible or only probable. Thus: 1. From hypersemia and hyper- aemic tumefaction of the optic nerve there results the diagnosis of me- chanical or inflammatory hypersemia of the brain in meningitis, in cere- bral hemorrhage, effusions into the brain, and in some cases the diagnosis of ataxic or other spinal diseases. 2. By papillary oedema joined to hyperaemia I recognize oedema of the meninges ; or an obstructed cerebral circulation through meningitis, cerebral tumors, ventricular hydroceph- alus, cerebral hemorrhage, meningeal effusions, thrombosis of the sinus, etc. 3. By neuro-retinian and choroidean anaemia, I recognize cerebral hemorrhage of ramollissement, and if the anaemia be absolute it is fatal. Empty arteries and veins of the eye, and an exsanguineous condition of the choroidean network, indicate arrest of cerebral and cardiac circulation. 4. By exudative and fatty optic neuro-retinitis, I recognize chronic rne- ningo-cephalitis ; the encephalitis of cerebral tumors, and the changes in the nervous substance which accompany these tumors. 5. By retinian varices and thromboses, I distinguish meningeal thromboses, or those of the sinuses. 6. By the aneurisms of the retinian arteries we may recog- 82 DIFFERENTIAL DIAGNOSIS. ni/.c the miliary aneurism.- of the brain. 7. By simple retinian hemor- rhages we recognize a compression of the brain by hemorrhagic or other effusions; but if those retinian hemorrhages are accompanied Iry retinian steatosis, there is also cerebral steatosis, and this is the ease in chronic albuminuria, leucocythsemia, and glycosuria. 8. By atrophy of the opt ie nerve, tumors of the brain and cerebral or spinal sclerosis are discovered. 9. Finally, we never meet with tubercular granulations in the choroid without the existence of similar ones in the lungs or other organs.* The ophthalmoscope is now frequently employed for diagnostic pur- poses in ordinary medical practice where there is imperfection of vision, to determine whether it is due to other than nervous lesions, to discrimi- nate between affections of different portions of the eye, and, sometimes, to measure the amount of refraction in cases of hypermetropia and myopia. Even where there is no impairment of sight, there still may occur very decided and characteristic retinal changes and alterations in the optic disc, which are readily detected by ophthalmoscopic examination, as already indicated; so that in obscure cases the routine examination of the eyes has become nearly as imperative as the chemical and microscopical exam- ination of the urine. HEADACHE. Some of the most trying cases to treat are those of headache, because this symptom may appear in many and even diverse morbid states, and often indicates serious cerebral disorder. Mr. Wm. Henry Day, of London,t has made a study of these conditions, and thus summarizes his conclusions : — Headache usually denotes some functional disturbance of the brain or its membranes, induced (1) by excess of local blood pressure, (2) by absorption into the blood of poisonous matters, (3) or by such a diminution of healthy blood as provokes irritation and suffering. It may be a svmptom of organic disease, either of the brain or its membranes, or of the kidneys or stomach, and uterus. Cerebral anosmia. — A striking symptom is pain at the top of the head, which often feels hot and burning, sometimes gnawing and scraping.. * Medical Times and Gazette, January 23, 187-5. f British Medical Journal, Nov. 16th, 1878. DISEASES OF THE NERVOUS SYSTEM. 83 Irritability of temper. Face livid and cold. Patient easily exhausted. Eyes dull. Plypercemia, Active or Passive — Active. — Arterial fullness. Head hot, pain frontal, throbbing and bursting, pulse tense, full. Conjunctiva; red- dened. Eyes bright. Photophobia. Mentality dull. Apoplexy may ensue. Passive. — Venous fullness from obstruction caused by heart disease, bronchocele, etc., pleuritic effusion, defective ventricular action. Sympathetic headache. — Faulty digestion or ovarian excitement. Stomach sometimes weak and over-sensitive. Catamenial headache. Dyspeptic and bilious headache. Irritation of the sympathetic reduces the amount of blood in (he brain. Nervous headache. — Disturbance of brain from overwork, worry and anxiety. Aggravated by some of the circumstances favoring sympathetic headache. In women there is a passage of a large quantity of limpid urine ; feet and hands cold. Confusion of ideas. Nausea and sickness, not attributable to errors in diet, may precede the attack. In nervous people constipation may cause headache. Poor seamstress headache. — Spansemia. Headache of excessive men- struation, or menorrhagia. Hereditary influence strong. Neuralgic headache. — From decayed teeth, peripheral irritation, ma- larial poison. Pain and tenderness along the fifth nerve. Pain intense ; not relieved by vomiting. Toxcemic headache. — Poisoned blood acting on nerve centres, from particular articles of food or drink, and drugs. Or certain specific diseases — gout, rheumatism and syphilis. Headache of vitiated atmos- phere. Organic headache. — Morbid growths ; meningitis. When slowlv progressing pain is limited to smaller area, and is intense. Periosteal in- flammation is accompanied by tenderness upon pressure. Headache in children, due to accidental injuries, to derangement of alimentary canal, anaemia, exhausting influences, such as bad food and impure air, immoderate intellectual efforts, and sometimes to organic diseases (often tuberculosis). In strumous and weakly children headache must be carefully watched. A headache of long standing in a child is significant, and requires more serious attention than in the adult. -I DIFFKRKXTIAT. 1 'I A< JNOSIS. CHRONIC CEREBRAL DISORDERS. In children the diagnosis may be required to he made between hyper- trophy of the braiD and hydrocephalus, which have enlargement of the head as a common sign. HYPERTROPHY. Increase in size most marked above the superciliary ridges. Head square in shape. No yielding of fontanelle on pressure. Eyes at normal distance. Excessive amount of brain, es- pecially white matter. Patient dull, liable to epileptic fits, and suffers from headache. HYDROCEPHALUS. Increase in size most marked at the temples. Head more rounded. Fontanelle elastic. Distance between the eyes in- creased. Excessive amount of fluid in ventricles, or sub-arachnoid space. Mentality feeble; generally can be traced to congenital source ; death may occur from convulsions. No marked headache. The diagnosis of hydrocephalus may be confirmed by tapping the fontanelle with the aspirator, or a hypodermic syringe. In adults brain tumor and sclerosis are among the prominent disorders of slow progress, the symptoms varying in a very marked manner with the location of the lesion. Chronic inflammation of the brain may terminate in insanity or in abscess. In its course it has been mistaken for dyspepsia, but a proper inquiry into the mental condition of the patient will reveal the cerebral mischief, which continues to progress even after any coexisting indigestion has been corrected. There is, moreover, sluggish intelligence, and partial paralysis or rigidity of certain muscles of the extremities. Attacks of delirium or mania finally confirm the diagnosis, and the patient dies in a state of coma. Intra-cranial disease of a chronic character is often so obscure as to leave even the most experienced in doubt, and the post-mortem examina- tion sometimes produces revelations that disconcert the medical attendant, Due regard to some of the characteristic phenomena in the accompanying table will often serve to clear up the doubts surrounding a difficult case. DISEASES OF THE NERVOUS SYSTEM. 85 BRAIN TUMOR. SOFTENING (WHITE). Of slow develop-i Approach and pro- ment. gress Blow. Follows embolism or apo- plexy. Non-inflam- matory. Intellect not dis- ordered at first. Headache violent, paroxysmal and often localized. Paralysis slow in appearing, and often limited to the mus- cles of eye or of the face ; more rarely hemiplegia. Convulsions a com- mon symptom, epi- leptiform in charac- ter. Not followed by palsy or hebetude. Vertigo and tinni- tus auriuni. Early affection of intelligence. Marked impairment of mem- ory. Dull and constant. Motor and senBor phenomena more frequent and promi- nent. Partial palsies and disturbances of sensibility subse- quently. Begins often with apoplectiform at- ABSCESS. Follows injury to the skull or chronic disease of the head. Varies with seat. Sudden in its de- velopment, and gen- eral. Course is much more rapid : con- vulsions, drowsi- ness, paralysis and coma quickly de- veloped. Con vulsio ns early; paralysisbe- Vomiting. tacks, which seldom .longs to developed occur afterward. stage. Vertigo. Not unfrequently. Rare, CHBONIC THROMBOSIS OF MENINGITIS. SINUSES OT BBA I NT. Caused by syphilis, S u <1 d e n develop- rheumatism, disease mentof symptoms, of bones, blows upon the head, etc. Intelligence not af- fected, except during attacks of delirium. Subj ect to exacerba- tions, but generally chronic. In consequence of meningeal exudation may present the clini- cal signs of a brain tumor. More vertigo. Frequentvomiting. No vomiting May be uncon- sciousness or not. In- telligence subse- quently good. No headache ; oede- ma of forehead and eyelids. May be coma ; va- ries greatly, accord- ing to part of brain whose vascular snp- ply is disturbed. Very rare. SCLEROSIS. Sclerosis is a disease of the nerve centres, in which there is increase of connective tissue elements, without primary involvement of the nerve cells. It may exist as diffused cerebral sclerosis, spinal sclerosis (several forms), cerebro-spinal sclerosis (sclerose en plaque), and glosso-labio- laryngeal paralysis. Cerebral sclerosis occurring in children can be distinguished from deficient development by the following character- istics : — DEFECTIVE DEVELOPMENT OF INTELLIGENCE. Intelligence stationary, instead of progressing with age. Not connected with disease. DIFFUSED CEREBRAL SCLEROSIS. Speech restricted to few words, imperfectly pronounced. retrogressive and Often terminates in Intelligence more affected, idiocy. May follow injury to head, zy- motic fevers, severe application of body or mind. Never learns to talk, or speech becomes imperfect or lost after it has been acquired. $6 DIFFERENTIAL DIAGNOSIS. DEFECTIVE DEVELOPMENT OF INTELLIGENCE. No paralyses. Muscular system in good condi- tion. No convulsions. Improved by training and educa- tion. DIFFUSED CEREBRAL SCLEROSIS. Usually more or less hemiplegia. Arrest of growth of certain parts of body, with contraction and dis- tortion of affected limbs. Frequent convulsions. Progress very chronic, and may live to advanced age. LOCALIZATION OF BRAIN DISEASE. The localization of diseases of the brain is a subject of great interest. In order that a correct diagnosis should be made the important anatomical and physiological data must ever be borne in mind. We proceed first to the consideration of LESIONS OF THE CEREBRAL CORTEX. [The accompanying excellent diagram, or physiological map of the principal cerebral cortical centres, modified from Ferrier and Ecker, CORTICAL CENTRES OF THE IIVMAN J1RAIN. A, Ascending frontal gyrus; lesions which S, Fissure of Silvius; c, Fissure of Rolando; po, Paricto-occipital fissure. A, Ascending B, Ascending parietal gyrus; F 3 , Third frontal gyrus; P./, Gyrus angularis. Circle I, Seat of (on the left aide) cause aphasia. Circle II, Seat of lesions which convulse or paralyze the upper extremity of the opposite side. Dotted Circle III, Seat of lesions which probably convulse or paralyze the face on tho opposite side. Dotted Oval IV, Seat of lesions which probably convulse or paralyze the lower extremity of tho opposite side. These districts receive their blood supply chiefly from the middle cerebral artery. The re- maining letters refer to anatomical points which explain themselves. DISEASES OF THE NERVOUS SYSTEM. 87 by Seguin, will be found very useful, as it embodies the results of the recent researches of Fritsch and Hitsig, Ferrier, Daltox and Seguin;* particularly as this subject is now attracting much attention.] The following is the summary given by Seguin (Joe. cit.) : — PHYSIOLOGICAL. " In the first place, it appears al- most absolutely certain that in man a lesion involving the posterior part of the third frontal convolution (on the left side usually) causes aphasia; i.e. impairment or loss of articulate speech, or even of language in gene- ral. It would seem, besides, that (1) lesions of the same part on either side of the brain produce paresis of many muscles concerned in lingual and pharyngeal movements; (2) that lesions of the anterior folds of the island of Reil (convolutions which are continuous with the third frontal), may also produce aphasia ; and that (3) loss of speech may re- sult from injury to the white sub- stance lying between the third front- al gyrus and the basis cerebri. I believe in a not too limited localiza- tion of the motor functions exerted in language, and would graphically represent this by the circle marked I. " In the second place, lesions limited to the inferior portions of the ascending frontal and parietal gyri have produced spasmodic and paralytic phenomena limited to the upper extremity of the opposite side. I am disposed to admit as highly probable that these parts are con- nected in the healthy living man * See Lectures in New York Medical Record, delivered at the College of Physicians and Surgeons, New York, in January, 1878. PATHOLOGICAL. " 1. The symptoms of an irritative lesion of these parts consist in con- vulsions, with or without subsequent transient paralysis ; e. g., such a lesion in circle III would give rise to spasmodic movements in the su- perficial muscles of the face on the opposite side, with slight paralysis. Irritative lesions of the regions in- closed in circles II and IV will cause convulsions limited to, or first appearing in the hand and arm, or foot and leg, of the opposite sides. As regards circle I (Broca's speech centre), we know little of the effects of its pathological irritation. In one case which I have placed on record, a thickening of the meninges involving the third frontal convolu- tion of the left side produced inter- mittent and incomplete aphasia. " It was by the close study of the clinical and pathological aspects of cases of localized epilepsy (fingers and hands), that Dr. J. Hughlings Jackson was enabled to form his theory of motorial discharges from irritation of the cortex cerebri, and thus pave the way for Ferrier's admirable researches. Dr. Jackson must, I think, be considered, after Prof. Broca, as the founder of our present growing doctrine of cortical localizations. 88 DIFFERENTIAL DIAGNOSIS. PHYSIOLOGICAL. PATHOLOGICAL. with the various voluntary move- 1 " 2. Destructive lesions of portions incuts of the arm and hand. This of the excitable district produce zone is represented by circle II. j paralysis in peripheral parte across " I am not prepared to go further the median line. The symptoms in admitting- pathologically proved | will, to a certain extent, correspond cortical centres, but would add that with the precise location of the le- t lure are some reasons for believing! sions, very much as in irritative that future autopsies will locate one lesions; e.g., embolism of the first centre for the external facial muscles just forward of the two centres named above, viz., the region in- cluded in the dotted circle III ; and another for movements of the legs upon the upper parts of the as- cending frontal and parietal, as indicated by dotted oval roughly IV." branch of the middle cerebral artery on the left side will cause softening of the posterior part of the third frontal gyrus, with the symptom aphasia. A destructive lesion of the principal part of the motor zone on the right side will produce left hemiplegia without aphasia; but if this lesion occupy the left hemi- sphere, loss of speech will co-exist with the paralysis." It must be added that secondary descending degeneration ensues after destructive lesions of the motor regions of the cortex, and that we have late contracture or rigidity of the paralyzed limbs as part of the symptom group. Negative characters of these cortical lesions are preservation of sensi- bility in the paralyzed parts, and (except with epileptic attacks) preser- vation of consciousness, and incompleteness of paralysis. In diffused lesions of the cortex the chief symptoms are delirium, convulsions and pain ; evidences of intense irritation. The coma and paralysis which follow may in some degree be caused by impaired nutri- tion of the cortex, but more probably by circulatory and tension changes in the whole encephalic mass. As regards sensory cortical centres, Dr. Seguin believes that we have as yet no pathological data for their study. DISEASE OF BRAIN CENTRES OTHER THAN CORTICAL. The following tabular view of the paralyses, with the localization of the lesion, is mainly that of Professor DaCosta.* * " Medical Diagnosis," 4th Edition, Philadelphia, 1876. DISEASES OF THE NERVOUS SYSTEM. 89 SYMPTOMS. Hemiplegia, without disturbance of sensation. Incomplete paralysis of face. Electro-muscular contract- ility normal or increased. Gener- ally accompanied by apoplectic symptoms. Crossed paralysis (i.e. face of right and hemiplegia of left, or vice versa). Paralysis of face marked, both of motion and sensation. General symptoms giddiness, nausea. Same as above, except complete facial paralysis (both sides of face). Paralysis of arm and leg, slight paralysis of face, dilatation of pupil of opposite side, with external squint (3d nerve paralysis). General paralysis, more or less complete; sensation diminished upon one side, increased upon the other. Local temperature varia- tions. As regards the side of the brain aifected, certain peculiarities have been noted by able observers. SEAT OF LESION. In corpus striatum, near the in- ternal capsule ; on side opposite to hemiplegia. Pons Varolii upon opposite side to palsy of limbs (below decussation of facial nerve). Pons at level of decussation of facial nerve. Crus cerebri on side correspond- ing with affected eye. Medulla oblongata on side of in- creased sensibility and temperature, at the level of decussation of ante- rior pyramids. LESIONS OF THE RIGHT HEMISPHERE. Anaesthesia more complete. Paralysis more complete. Paralysis of sphincters. Alterations of nutrition (oedema, eschars, fevers, pulmonary conges- tion). Disorders of special senses. Hysterical symptoms. LESIONS OF THE LEFT HEMISPHERE. Loss of speech (aphasia). Paralysis of muscles of articula- tion. Less marked. Less marked. Less marked. Hysteria seldom. The observations of Brown Sequard have demonstrated that in excep- tional cases the symptoms do not correspond as accurately with the 90 IM FFEKEXTIAL DIAGNOSIS. anatomical position of the lesion as is above indicated. At the present time these cases must be looked upon as really exceptional, and as not affecting the rules which have just been cited. More particularly are these aberrant symptoms likely to appear in tubercular disease of the brain. Indeed, Prof. Henoch (in CharitP Annalen, fourth year), reports nine cases of tuberculosis of the brain that show how risky it is to localize, basing this upon recent physiological investigations. The results are as follows: — SYMPTOMS. Case I. — Left hemiplegia. Case II. — Tremor and paresis of the right side, finally, contraction of all extremities. Case III. — Hemiplegia and con- tracture of the left side, as well as of the facial nerve. Case IV. — Contracture and in- voluntary motion on right half of face and body. Case V. — Complete absence of symptoms uutil meningitis set in. Case VI.— Paralysis of the left abducens, the left iris and right arm. Case VII. — Absence until men- ingitis set in. Case VIII. — Complete absence. Case IX. — Paralysis of the right abducens. LESION. Multiple tubercles of the cortical layer of both hemispheres, the frontal lobes and tubercle of the left half of the cerebellum. Tubercle of the left frontal lobe, the left corpus striatum, both tha- lami and right half of the cerebel- lum. Tuberculosis of the right frontal lobe. Tuberculosis of the left frontal lobe. Tuberculosis of the commissure of the cerebellum and of both hem- ispheres. Tuberculosis of the commissure of the cerebellum. Tubercle in the pons. Tubercle of the left posterior lobe. Tuberculosis of both posterior lobes, the posterior corpora quadri- gemina, the pons and left crus cere- belli. Of all these cases only II and III show the possibility that lesions of the motoric centre of the frontal convolutions produce motoric lesions DISEASES OF THE NERVOUS SYSTEM. 91 of the opposite side. This chance of diagnosis, however, is very limited, as is shown by the other cases where these locations were free from dis- ease, and yet the same symptoms produced with lesions in other parts of the brain, even cerebellum (Case VI). Sometimes the intensity of the symptoms does not seem to correspond with the intensity of the lesion (V and VI). Henoch believes that a close study of the fibres leading from and to these physiological centres will do much to reconcile the apparent contradictions between pathological and symptomatological differences.* The subject of insanity will be separately considered at the end of this section. SPINAL DISEASES. A leading symptom of many diseases of the spinal cord, whether functional or organic, is paraplegia. It is so rarely of cerebral origin that ordinarily the brain may be omitted from the discussion, unless there is the co-existence of distinct evidences of brain disease, as headache, impaired cerebration, and paralysis of parts supplied by nerves arising above the spinal cord. The following classification of diseases giving rise to paraplegia, with their characters, has been proposed by Prof. H. C. WooD.f Disease of the cord. FUNCTIONAL. HYSTERICAL. Anaemic. Hysteria. Reflex (from peripheral irritation, renal, preputial, etc.). Dyscrasic (diphtheritic, etc.). The last mentioned, hysterical, is also functional, but simulates the organic more closely than does the second group. (For further consider- ation of Hysterical Paralysis, see Hysteria.) It must be admitted, how- ever, that so-called functional disorder cannot long exist without being followed by change in structure. The general distinctions between the organic and functional paraplegias may be presented as follows : — * Cincinnati Lancet and Clinic, May 31, 1878. f " On the Diagnosis of Diseases accompanied by Paraplegia." 1875. 92 DIFFERENTIAL DIAGNOSIS. ORGANIC. Onset may be almost instanta- neous or very rapid, though some- times gradual. Usually at some period spasm or pain in the affected limbs. Often a sensation of a band or stricture around the waist, girdle- pain (pathognomonic). Anaesthesia frequent and often complete. Retardation of sensation (a per- ceptible time elapses between the patient's seeing his feet touched and feeling that they are) (pathogno- monic). Symptoms of paralysis of the bladder. FUNCTIONAL. The onset always more or less gradual, except the hysterical form, where the paralysis is generally abrupt. Spasms or pain rarely or never present. Not found. Anaesthesia absent or but partial. Sensation, if present at all, is not retarded. No symptoms whatever of vesical paralysis, except in the hysterical form. Where the bony canal is involved and caries is present, this condition may generally be discovered by Rosenthal's test. This consists in passing down the back a pair of electrodes attached to a faradaic battery of some power, one pole being placed upon each side of the spine. Under these circumstances if there be any caries or inflammation of the verte- bra?, the moment its locality is reached the patient starts or screams, from the burning, sticking pain caused by the passage of the galvanic current through the inflamed tissue. Dr. Wood states he has not found this test as trustworthy as its originator claimed it to be, and as, apparently, it ought to be. In cases simulating caries, however, the pain is probably not so severe as where the vertebrae are really affected. Moreover, absence of the pain in any case seems to be conclusive evidence of the non-existence of bone disease. The following study of the principal organic spinal diseases, from the writings of Seguin, Charcot and other authorities, when taken in conjunction with the tabular view of paralysis, will often enable the diagnostician to determine both the nature and location of a spinal lesion : — DISEASES OF THE NERVOUS SYSTEM. 93 DISEASES OP SPINAL CORD. m „„„„„„ j-«-,„„j „ . «•*•„ , t„ „„j „u„ i„\ f occupying the entire section of a limited portion of the Transverse diffused myelitis (acute and chronic) j ^ ^ or legg coml ,, etely- {(■Patches of disease situated primarily in the connective I Disseminated sclerosis (sclerose en pldques).< and scattered without regard to the "systematic" grouping (^ of the nervous elements. Its distribution is " sys- tematic," and, probably, it is essentially a primary disease of the nerve ele- ments lather i han of the connective tissue. ("Ditto, though its pathology is as yet almost -< purely a matter of inference. Its characteristic (. symptom is muscular rigidity, Degenerative disorders, mainly affecting ihe columns of the cord. Symmetrical lateral sclerosis. (Paralysis spinalis spastica.) f Poliomyeltis anterior. Myelitis of the gray matter of the anter-< ior cornua. Antero-lateral sclerosis (amyotrophic). 1 Acute. Subacute. Chronic. /Infantile paralysis. ^ Acute spinal paralysis of the adult. f Often classified as a special form of po- liomyelitis chronica, but characterized by the absence of paralysis, except such as is directly due to the muscular atrophy. Not yet thoroughly studied, but believed by Charcot and others to involve at once the lateral columns and the anterior cornua ; the characteristic symptoms being atrophy with contracture, beginning in the upper extremities. Progressive muscular atrophy and pro gressive bulbar paralysis (" labio glossopharyngeal paralysis"). TABULAR VIEW OF SPINAL PARALYSIS. SYMPTOMS. Paralysis of compressor urethrse, accelerator urinse and sphincter ani. No paralysis of muscles of the legs. Paralysis of muscles of bladder, rectum and anus. Loss of sensation and motion in muscles of legs, ex- cept those supplied by anterior cru- ral and obturator (viz., psoas iliacus, sartorius pectineus, three adduc- tors, obturator externus, two vasti, rectus femoris, etc.). Both legs paralyzed as to sensa- tion and motion. Loss of power over bladder and rectum. Lateral muscular walls of abdomen para- lyzed, thus interfering with expira- tory movements of respiration. Electro-muscular contractility dim- inished or lost. Paralysis of legs, etc., as above. Paralysis of all the intercostal mus- SEAT OF LESION. In the terminatiou of the cord, low down in the sacral canal. In the cord at the upper limit of the sacral region. In the cord, at the upper limit of the lumbar region. In the cord, low down in the cer- vical region. 94 DIFFERENTIAL 1>IA< i N'< >SIS. TABULAE YIIAV OF SPINAL PARALYSIS. SYMPTOMS. cles, and consequent interference with inspiration. Paralysis of muscles of upper extremities, except those of the shoulders, which re- ceive their nerves from the higher portions of the cervical region. In addition to the preceding, dif- ficulty of swallowing and vocaliza- tion, contraction of pupils, palpita- tion of heart and priapism. In addition to above, paralysis of the phrenic nerve and diaphragm, of the scaleni, intercostals, serrati magni, and many of the accessory respiratory muscles which act upon and from the shoulder. Death re- sulting at once from suspension of all respiratory movements. Paraplegia developing itself sym- metrically. Paraplegia of the legs. Paraplegia of the arms. Cerebral paraplegia, so-called, are very rare, and are in reality two distinct hemiplegia?. Paraplegia from disease of the vertebral column. Characteristic symptoms of tabes dorsal is or locomotor ataxia. Progressive muscular atrophy. Hemiplegia with crossed hemi- amesthesia. SEAT OF EESION. In the cord below the middle cervical region. In the cord, at or above the mid- dle of the cervical region, or the level of the fourth cervical pair of spinal nerves. Anterior half of the medulla spinalis or its sheaths. Dorso-lumbar enlargement of cord. Cervical enlargement of cord. In both sides of the brain. Ex- ceptions in cases of disease of the medulla oblongata (very rare). Roots of spinal nerves at point of injury, especially posterior roots, which long remain in a state of painful excitation. Posterior half of med. spinalis. Gray substance of spinal cord in vicinity of the central canal or dif- fused through anterior roots. In one lateral half of spinal cord. The hyperesthesia of the paralyzed DISEASES OF THE NERVOUS SYSTEM. 95 TABULAR VIEW OF SPINAL PARALYSIS. SYMPTOMS. Bilateral neuralgia of the legs and arras accompanying symptoms of tabes dorsalis. Bilateral contractions affecting the extensor muscles. Unilateral contractions affecting the flexor muscles. SEAT OF LESION. side is probably due to paralysis of the vaso-motor nerves of that side. In posterior roots of spinal nerves and their prolongation into the gray substance of the cord. In the spinal cord. In the brain. The diseases of the spinal marrow are classified by Dr. Wood accord- ing to the rapidity of their onset, as follows, the attack being considered rapid when decided paralysis has developed within forty-eight hours : — RAPID ONSET. Congestion. Meningeal apoplexy. Spinal apoplexy. Acute myelitis. SLOW ONSET. Sexual exhaustion. White softening. Chronic myelitis. Tumors. In congestion of the cord the diagnosis rests upon : Suddenness of onset; uniform, bilateral loss of voluntary motion, reflex activity and sensation ; absence of all symptoms of irritation, such as spasms or violent pains ; absence of constitutional disturbance. It must also be remembered that the palsy affects first and most severely the lower limbs, but may rise to the arms, and, finally, to the muscles of respiration, and thus prove fatal ; that so far as the paralysis extends, all the muscles are involved; that motion is affected more than sensation; and that very rarely, if ever, does ulceration or other indications of trophic changes occur. In meningeal apoplexy the symptoms are also due to pressure, but the effused blood not only disturbs the cord by pressing upon it, but also irritates the membranes and the nerve-roots, especially when first thrown out. Consequently, in the first few hours or days of a meningeal hemorrhage, there are violent spasms and pains, due either to an incipient * From Prof. J. Aitkeu Meigs' Lectures (not published). 96 DIFFERENTIAL DIAGNOSIS. meningitis, or more probably to a direct irritation of the nerve-roots. The extent and amount of the symptoms vary, of course, with the position and amount of the hemorrhage. Later there are symptoms of pressure, varying in intensity with the amount of the effusion ; and absence of febrile symptoms, unless decided meningitis be produced by the clot. In true spinal apoplexy the symptoms come on with absolute abrupt- ness. The cord is so small a body that a clot in its substance interrupts at once its function. The paralyses of motion and sensation are complete, and reflex movements are greatly exaggerated. As there is no correlation of the spinal nerve-roots, the spasms and pains of meningeal hemorrhage are wanting. Acute primary myelitis is a very rare affection. The diagnosis should present no difficulty. The distinct febrile reaction, which is stated to be always present, separates it at once from all other acute affections of the cord proper, so that it can be confounded only with acute meningitis. Probably, in the majority of cases, it exists coincidently with this disorder ; but even when it is isolated, the symptoms at first closely simulate those of meningitis. COMPARISON OF ACUTE SPINAL DISEASES. Constant pain in the spine at a point corresponding with the upper limit of in- flammation, rendered more acute by pressure on verte- bral spine. The alternate application of ice and hot sponge to spine causes the same burn- ing sensation at seat of lesion, but above the sensa- tion is normal. Sensation as of a cord or ligature around the body at the limit of paralysis always present when dorsal region is affected ; when higher up spasm of the sphincters and priapism often occur. MENINGITIS. Pain usually rheumatic in character, diffused along the spine, not increased by pressure ; but augmented by flexions of trunk. Nerves, coming out through the inflamed part of the meninges, the seat of acute pain, much increased by movements of limb. Frequent spasms of mus- cles of the back. Spasm of sphincter vesicae may occur, followed by retention of urine and paralysis. Convulsive movements of paralyzed parts. CONGESTION. Formication alternating with numbness in the be- ginning of the attack, es- pecially in fingers and toes. Only slight pain in spine, scarcely increased by pres- sure. Frequently hyperesthe- sia ; sphincters more para- lyzed than in other forms of paralysis(BR0WN S^quard). DISEASES OF THE NERVOUS SYSTEM. 07 COMPARISON OF ACUTE SPINAL DISEASES. MYELITIS. Paraplegia complete. MENINGITIS. Anaesthesia or pares- thesia (except when gray matter is not involved, which is rare), muscular sensibil- ity much impaired, early. When disease is high up in dorsal region energetic reflex movements may be produced. Marked tendency to bed sores; sloughs form early on sacrum and nates. Paraplegia varies in de- gree, sometimes increasing and subsequently rapidly diminishing. Anaesthesia very rare generally hyperesthesia. Increased reflex move- ments, which cause pain, may be excited. Less marked in uncom- plicated cases of meningitis. CONGESTION. Paralysis generally not limited to lower limbs, but involves upper extremitie and respiratory muscles. In some cases power of mov- ing paralyzed legs is better after resting ; ordinarily, however, the paralysis is worse on first rising in the morning. Frequently morbid in- crease of sensibility. Slight spasmodic move- ments sometimes observed in paralyzed parts. Ulceration occasionally happens. CHRONIC SPINAL DISORDERS. In the slow or chronic forms of spinal disease, spinal tumors may be considered first. There are three classes of phenomena to be looked for in this disease : local symptoms of diseased structures ; atrocious pains at a distance from the seat of the disease, due to the involvement of nerve-roots and nerves, where they pass through the inflamed tissues ; and paralytic symptoms, the results of pressure, and to some extent of a local myelitis. In cases of suspected tumors of the spine all these symptoms are to be sought after. In cancer they are often all present, and the distant pains are especially remarkable for their atrocity. The other chronic spinal diseases may be classified with reference to the characteristic of tremors as follows : — WITHOUT TREMORS. Sexual exhaustion. White softening. Chronic myelitis. ( s ° ft emng. J I sclerotic. Local myelitis. WITH TREMORS. Paralysis agitans. Multiple sclerosis. The difference between sexual exhaustion and myelitis is probably one of degree only ; but the former is curable ; the latter is not. '.IS DIFFERENTIAL DIAGNOSIS. CHRONIC DEGENERATIVE DISEASES OF THE CORD. In distinguishing the various forms of disseminated or muUilocular cerebrospinal affections, the following table, given by Professor Chai:< < 1 1 . will render valuable assistance. The symptoms of greatest importance are set up in italics. CEREBROSPINAL AFFECTIONS. LOCOMOTOR ATAXIA. MULTILOCULAR SCLEROSIS. f Epileptiform Apo- Epileptiform Apo- plectic Attacks. plectic Attacks. DISSEMINATED STPHILOSIS. GENERAL PARALYSIS. Vertigo. Diplopia, mas. Amaurosis. Strabis- Inequality of Pupils Facial Anaisthesia. Deafness. Me'nie're's Vertigo. Embarrassment of Speech. Laryngismus. Vertigo. Diplopia. Nystagmus. Amblyopia, Atrophy. White Embarrassment of Speech. Difficult Degluti- tion. Pneumoga stri c Palsy. Epileptiform At- Epileptiform Apo- tacks. plectic Attacks. Paraplegic Hemi- plegic Epilepsy. Vertigo. Vertigo. Diplopia. (Diplopia. Amblyopia, Optic Amblyopia. Neuritis. ! Inequality of Pupils Headache, Fixed Headache. Pain. Embarrassment of Speech. Total Facial Palsy. Gastric Crises. Nephritic Crises. Vesical Crises. Paresis of Bladder. Cystitis. Gastric Crises. I Non-nervous Crises Paresis of Bladder. f Girdle-pain. Lightning pains. / 'sen do neural Pains Lightning Pains. .; 1 Hyperesthesia, An- Plaques. Spinal, Hemiances- Tingling. agsthesia. thesia. o Incoordina ted Incoordination. Incoordination. 5 Movement. > . Contractures and Special Trembling. Special Trembling A Trepidations. of Hand. Spasmodic Para- SpasmodicParaple- Paresis. Trepida- pu plegia. gia under form of tion. to 1 Hemiparaplegia. r . CO Eschars. Eschars. Eschars. = g Arthropathies. Arthropathies. c g Fractures. .Muscular Atrophy. Muscular Atrophy. Muscular Atrophy. DISEASES OF THE NERVOUS SYSTEM. 99 In applying these symptoms in practice, we should, of course, give first attention to those which are most characteristic. Thus, if we observe, in a patient, ataxy with nystagmus, we think at once of multilocular sclerosis and not of locomotor ataxy (tabetic series), because nystagmus is a valu- able symptom of multilocular sclerosis. In the same way spasmodic paraplegia (recognized by the continual trembling movements which are produced when a single blow is struck upon the muscle) we find is pro- duced by a localized lesion in the cord, more particularly involving the lateral columns. In order that these forms shall be better understood, it may not be out of place to review some of the chief points in the clinical history of the chief focal lesions caused by sclerosis of the cord. In sclerosis of the antero-lateral white columns Dr. Gowers* states that there is loss of voluntary power below the lesion, descending degeneration in the anterior and lateral columns (direct and crossed pyramidal tracts, especially the latter), and over-action of the lower centres. This over- action may be manifested only as excessive knee-reflexf and developed ankle-clonus (tendon-reflex), or it may increase from this to spasm and rigidity — spastic paraplegia. There is no wasting unless the degeneration extends from the lateral columns to the anterior cornua. Then we have a combination of spasm and wasting, in which, if the cornual degeneration proceeds, the spasm and rigidity may lessen as the degeneration advances. In disease limited to the lateral columns (at any rate, when the disease is limited to the pyramidal tracts) there is no loss of sensation or incoordina- tion, and no interference of the nutrition of the skin. These symptoms of "spastic paraplegia" [lateral sclerosis) may arise from a primary de- generation in the lateral columns, limited thereto. Such cases are extremely rare, and in the majority the disease is a focal lesion more or less extensive at some level in the dorsal or cervical cord, and the degeneration in the lateral columns is secondary. The evidence of the latter form is afforded by the frequently sudden or rapid onset of the symptoms in the first instance (primary sclerosis being always gradual in onset), and the evidence which may generally be discovered that there has been at some time, or is in some region, damage which extends * Address delivered before the Medical Society of Wolverhampton, Oct. 7th, 1879. f See page 102, note on Patellar-Tendon Reflex. 100 DIFFERENTIAL DIAGNOSIS. beyond the lateral columns. Descending lateral sclerosis, with secondary spasmodic phenomena in the limbs, may even result from damage to the motor tracts above their decussation — in the medulla, the puns, or the motor parts of the cerebral hemispheres. It occasionally results from bilateral injury to the surface of the brain during difficult birth, but such cases are very rare. 2. In disease of the posterior columns there is interference with coordination without loss of power ; eccentric pains, impaired sensation and diminution of reflex action, in consequence of the implication of the sensory roots. All these symptoms depend on disease of the root-zone of the posterior columns. Disease of the posterior median column gives rise to no known symptoms. The posterior columns may be damaged by any pathological process, and they are frequent seats of primary degeneration. The symptoms of locomotor ataxy usually present the following order : loss of the deep reflexes, pains, incoordination, diminution of sensation ; loss of the superficial reflexes, occasionally interference with the nutrition of bones and joints. There is no loss of motor power or wasting as long as the disease remains limited to the posterior columns. It may, however, extend forward into the anterior cornua, causing muscular atrophy and weakness to be conjoined with the ataxy. Or the lateral columns may be affected at the same time as the posterior ; we then have weakness as well as ataxy, but no wasting. The disease of the lateral columns causes increase of the deep reflexes, and this increase may thus coexist with incoordina- tion, the increased action of the reflex centres being so great that they are not arrested by the damage to the posterior root (which is often, in these cases, slight). Thus we have the anomaly of ataxy with excess of the tendon reflex instead of its loss. An important fact to remember regarding the posterior columns is their proneness to degenerate ; they recover less readily than any other part ot the cord. A lesion in one spot may set up a degeneration which ultimately involves them in their whole extent. Damage affecting the whole thickness of the cord may pass away from the rest and persist in the posterior columns, and even spread there. In such a case we have ataxy succeeding loss of power. Strength returns, incoordination remains. DISEASES OF THE NERVOUS SYSTEM. 101 3. The anterior cornua contain the motor nerve-cells, which, (1) influence the nutrition of the motor nerve fibres proceeding from them, and consequently that of the muscles; (2) constitute the terminal link in the path of the voluntary impulse from the brain to the muscles ; (3) form part of the reflex loop, probably also of the reflex centre, to which those muscles are connected. Hence we have as the result of disease of the anterior cornua, (1) degeneration of the motor nerves and wasting of the muscles ; (2) loss of voluntary power, i. e., paralysis of those muscles ; (3) interference with or arrest of the reflex actions in which these muscles take part. The extent of these symptoms, whether they are unilateral or bilateral, affect many muscles or few, will depend strictly on the extent of the disease in the spinal cord. Of the three symptoms the muscular wasting is incomparably the most important. Paralysis may result from disease elsewhere in the motor tract, i.e., disease of the lateral column higher up. Loss of reflex action may depend on disease elsewhere in the reflex loop, i. e., disease of the sensory fibres in or outside the cord. But muscular wasting is due only to a lesion of the motor cells, or to a lesion of the nerves cutting the muscles off from the influence of these cells. In most cases we are able to exclude the latter without difficulty ; the state of muscular nutrition comes thus to be of the highest importance as indicative of the state of the anterior cornua of the cord. Disease of the anterior cornua is often combined w T ith disease of the lateral (pyramidal) columns similar to the descending degeneration. Charcot believes that in these cases the degeneration in the lateral column is primary, its symptom, muscular rigidity, preceding the symptom of the cornual disease, muscular wasting, and he terms the affection "lateral amyotrophic sclerosis." I believe, however, that this position will need reconsideration, and that the degeneration in the lateral columns is, sometimes at least, secondary to, or simultaneous with, the disease in the cornua. It often spreads, however, beyond the fibres related to the degenerated cornua, and so may cause weakness and spasm in the limbs below the seat of the muscular atrophy. Thus we have wasting in the arms, and weakness with spasm in the legs, and even, as I have 102 DIFFERENTIAL DIAGNOSIS. seen, wasting in the should er-muscles, and weakness without wasting in the hands. ( Vrtain lesions may damage the motor tracts slightly and impair con- duction in a peculiar way, rendering it apparently unequal in different fibres. As a consequence the muscular action is unequal in different muscles, and instead of a balanced coordinated movement we have an unbalanced jerky movement. This is seen especially when irregular islets of sclerosis affect the cord — disseminated or insular sclerosis — and, according to the researches of Charcot, it appears that this irregular conduction is the result of the unequal wasting of the medullary sheaths, the axis-cylinders remaining. A precisely similar symptom may result from pressure on the motor tract — as by a growth. Not rarely this "disseminated" or "insular" sclerosis in one region is combined with a system-degeneration in another. An occasional combination, for in- stance, is the jerking movement (from cervical insular sclerosis) in the arms, and weakness with spasm (from lumbar lateral sclerosis) in the legs. 4. A total transverse lesion of the cord at any level, however limited in vertical extent, separates all parts below the lesion from the brain, and hence, so far as will and perception are concerned, produces the same effect as if the whole of the cord below the lesion were destroyed. A section across the cord in the middle of the cervical enlargement, for instance, paralyzes all parts below the neck. Hence the extent of the paralysis indicates only the upward extent of the lesion. This is also indicated by the position of the girdle pain, or zone of hyperesthesia, which is due to the irritation of the sensory roots in the lowest part of the upper segment — an important indication when the lesion is in the dorsal region, where the precise limitation of motor weakness may be recognized with difficulty. Patellar- Tendon Reflex. — For the diagnosis of posterior sclerosis, West- phal has noted the following symptom: " If a healthy man sits with one knee-joint resting upon the other (a very common attitude), and the liga- mentum patella? of the supported leg be smartly struck just below the knee- cap with the side of the hand, a sudden contraction takes place in the qua- driceps femoris muscle (of which the ligamentum patella? represents the tendon), and the foot is consequently jerked upward to a degree which DISEASES OF THE NERVOUS SYSTEM. 103 varies in different individuals. Now, in eonfirmed examples of locomotor ataxia this reaction does not take place. No matter on what part of the ligament below the knee-cap, or with what force the blow is struck, the foot hangs motionless. In order to establish with accuracy the absence of the phenomenon, certain precautions ought to be taken. The leg should be bare; the patient must not offer voluntary resistance to the movement of his leg, and the ligament should be struck with some hard implement which can be swung like a hammer. An ordinary wooden stethoscope answers very well if it is held loosely by the small end, and the blow given with the edge of the ear-piece. But, however adminis- tered, several blows should be struck on the ligament, slightly changing the position each time, as there is generally one spot from which the reaction is peculiarly energetic. This is usually a little below but very near to the patella. Ankle-clonus may be similarly developed by tapping the tendo-Achillis. The following are the conclusions given by Erb* in regard to the interpretation of symptoms : — In diseases of the spinal cord, paralysis rapidly followed by a marked degree of atrophy and by the reaction characteristic of degeneration, points to disease of the anterior roots (rarely), or of the gray anterior cornua (more frequently). In this case all reflex actions are absent. Paralysis with tension and contraction of muscles, without atrophy, is very probably due to some affection of the lateral columns. Paralysis without loss of reflex function and without atrophy, points to an affection of the parts which ascend to the brain, outside of the gray substance, or, at least, outside of the ganglia of the anterior cornua. Such are mostly cases of circumscribed disturbances of conduction, the end of the cord below the lesion remaining intact. Paralysis, with trophic disturbances, gives room for suspecting an affec- tion of the gray substance, since primary affections of the roots are rare. Very extensive palsy, with much atrophy, the reaction of degeneration, absence of reflex acts, points to a widely diffused lesion of the anterior gray substance. Paralysis in the districts supplied by certain pairs of roots (both arms alone, or both crural nerves) points to a strictly localized affection of roots, or *Erb. — Review in Journal of Nervous and Mental Diseases, Chicago, Oct., 1878. 104 DIFFERENTIAL DIAGNOSIS. lesion of the gray anterior eornna. The conclusions in regard to the nature of the lesion in the cord are far less certain than those relating to its place. Cases of spinal paralysis, accompanied by atrophy of the muscles, whether in children or adults, acute or chronic, are described under the head of poliomy el it is anterior, acuta and chronica. Destruction of the central trophic apparatus, or its separation from the peripheral parts, produces the symptoms of degenerative atrophy. " Upon the whole, we arc justified in assuming a disease of the anterior cornua when the electrical examination shows the existence of the reaction of degeneration, and consequently of degenerative atrophy of nerves and muscles, provided the disease is clearly of spinal origin" (Erb). In infantile palsy (lesion in the anterior cornua), observers are not agreed as to whether the change in the ganglion cell is primary or whether it is the consequence of an interstitial myelitis. The following table will be found valuable in diagnosticating certain chronic disorders (chiefly after Prof. Meigs). PARALYSIS AGITANS. CEREBRO-SPINAL SCLEROSIS. Disease of adult life. Tingling and numbness ; diminished muscular power, chiefly in the legs. Eye symptoms absent in spinal form ; when they oc- cur in cerebro-spinal form they are persistent and pro- gressive. Tremor or trembling fol- lows the paralysis. One or both limbs paretic, ultimately becoming com- pletely powerless. In the paretic stage the gait is distinctive ; the foot is swung around, describing an arc of a circle, and brought flatly upon the ground. With this eccen- tric curvilinear projection of the foot there is an exag- gerated alternate semi-ro- tation of both halves of the pelvis. In old persons chiefly. Felt mainly in the arms. No proper eye symptoms. Precedes paralysis. Muscular weakness in one or both arms, and then ex- tends into lower extremities. Only rarely passing into true paralysis. In attempting to walk first balances on his feet, and starts with head and trunk bent forward on the toes or fore part of feet, and with short steps goes hop- ping and trotting along at almost running speed (fus- tination). LOCOMOTOR ATAXIA. In adults. Tingling and numbness of legs without loss of pow- er (want of coordination exists). Ocular troubles, defect- ive vision and accommoda- tion, strabismus, ptsosis or double vision. These symp- toms temporary. Absent. No paralysis. A stumbling, staggering gait, without true paralysis. DISEASES OF THE NERVOUS SYSTEM. 105 CEREBROSPINAL SCLEROSIS. No spontaneous tremor ; always caused by motion or excitement. Nystagmus, usually bin- ocular. Articulation slow and scanning. Intellect early impaired. Boring, gnawing and lan- cinating pains rarely com- plained of. Earlyparesis, passing into paralysis, is characteristic. PARALYSIS AGITANS. Trembling early, inces- sant, even when at rest ; scarcely interrupted by sleep. Never met with. Articulation indistinct ; embarrassed. Unaffected until late. LOCOMOTOR ATAXIA. No tremor. Not present. Not affected. Not marked. Such pains frequently precede the loss of motion. Paraplegia always a late phenomenon. (For diagnosis of Locomotor Ataxia from General Paralysis of the Insane, see page 111, under this head.) Paralysis may also be caused by reflex irritation, and closely simulate organic disease of the cord. Brown-Sequard * gives the following points of distinction (with unimportant additions) : — PARAPLEGIA. FROM REFLEX IRRITATION. 1. Is preceded by an affection of uterus, bladder, kidneys, or pros- tate gland. May be caused by phimosis. 2., Usually lower limbs alone par- alyzed. 3. No gradual extension of the paralysis upward. 4. The paralysis is usually incom- plete, an extreme debility or weak- ness of the limbs rather than par- alysis. 5. Some muscles more paralyzed than others. 6. Reflex power neither much increased nor completely lost. * " Lectures on the Diagnosis and Treatment of Paraplegia," p. 33 FROM MYELITIS. 1. Usually no disease of the genito-urinary organs except as con- sequent on the paralysis. 2. Usually other parts paralyzed besides the lower limbs. 3. Most frequently a gradual ex- tension of the paralysis upward. 4. Very frequently the paralysis is complete. 5. The degree of paralysis the same in the various muscles of the lower limbs. 6. Reflex power often lost; or sometimes much increased. 106 DIFFERENTIAL DIAGNOSIS. PARAPLEGIA {Continued). FROM REFLEX IRRITATION. 7. Bladder and rectum rarely paralyzed ; or at least only slightly so ; sphincter ani weak. 8. Spasms in paralyzed muscles extremely rare. 9. Very rarely pains in the spine, either spontaneously or on applica- tion of pressure, percussion, or a hot, moist sponge, or ice. 10. No feeling of pain or con- striction around the abdomen or chest. 11. No formication, pricking, or disagreeable sensations of cold or heat. 12. Anaesthesia rare, the tactile sensibility being but slightly, if at all, impaired; but the muscular sense is almost lost. 13. Usually obstinate gastric de- rangement. 14. Variations in the degree of the paralysis corresponding with changes in the primary disease. 15. Usually the urine is acid, un- less the urinary organs are diseased. 16. Cure of the paralysis fre- quently and rapidly obtained, or taking place spontaneously after a notable amelioration or cure of the genito-urinary affection. 17. Usually muscles do not be- come atrophied, and temperature is little lowered. 18. Therapeutic results good. FROM MYELITIS. 7. Bladder and rectum usually completely paralyzed, or nearly so. 8. Always spasms, or, at least, twitchings. 9. Always some degree of pain existing spontaneously, or caused by external excitations. 10. Usually a feeling as if a cord were tied tightly around the body at the upper limit of the paralysis. 11. Always formications, or prick- ing, or both, and very often sensa- tions of pricking or heat or cold. 12. Anaesthesia very frequent and always at least numbness. 13. Gastric digestion good, unless the myelitis has extended high up in cord. 14. Ameliorations very rare, # and not following changes in the condi- tion of the urinary organs. 1 5. Urine almost always alkaline. 16. Frequently a slow and grad- ual progress towards a fatal issue, and rarely a complete cure. 17. Atrophy of muscles of the paralyzed parts. 18. Treatment of little benefit. DISEASES OF THE NERVOUS SYSTEM. 107 Mr. Gowers divides spinal lesions, according to the time required in their development, into six classes, whose comparative features are shown- in the following table : — Sudden [few minutes). \ Vascular lesions. Acute {few hours or days). j* ^1 Pressure f Sub-acute (one to four weeks) I l nflamm ation (myelitis). J Sub-chrome (one to two months). J r, ,1 } Chronic (two to six months). J ) -r^ ,• Growths. Kr i • / • 4.u i a\ r Degeneration. ^ V ery chronic (six months and upward). J & » He recommends, in examining a case of disease of the spinal cord, to follow a definite plan. " First endeavor to ascertain the exact seat of the lesion ; note how far the several conducting functions of the cord are impaired ; and the highest level of their impairment ; then ascertain the condition of the central functions, and especially muscular nutrition, and irritability and reflex action (first in the part below the level at which conduction is impaired ; and secondly, at the supposed level of the lesion, and in this way you may infer, without much difficulty, what is the extent of the lesion transversely and vertically). In the next place, endeavor to ascertain its nature by considering, first, how the symptoms came on and developed ; secondly, which of the lesions having this mode of onset and development are common in the region affected ; and thirdly, which of them are produced by the cause or causes to which the disease is apparently due." Some special forms of paralysis require separate discussion. PSEUDOHYPERTROPHIC PARALYSIS. This is a disease of children, usually attacking them in the second year of life. At that period it is found that when they are placed upon their feet they fall down, or clutch at the nearest object, to support them- selves; or in other cases it may be that the child has commenced to walk, when, without pain or fever, or sometimes after convulsions, it is found to be soon fatigued, either by walking or standing, and at length it can no longer walk or hold itself upright; or, again, it may be that the child does not walk until very late, 2 J or 3 years, and then very feebly and imperfectly. Symptoms. — The principal morbid phenomena are (Duchexxe) — 108 DIFFERENTIAL DIAGNOSIS. 1st. In the beginning, feebleness of the lower limbs. 2J. Lateral balancings of the trunk and widening of the legs during walking. 3d. A peculiar curvature of the spine (ensellure), or saddle-back (lordosis), both in walking and standing. 4th. Equinism (talipes equinus), with a peculiar over-extension of the first phalanges of the toes, which Duchenne calls "griffe des orteils." 5th. Apparent muscular hypertrophy. 6th. Stationary condition. 7th. Generalization and aggravation of the paralysis. "When the disease has arrived at the stage of apparent hypertrophy, the appearance of the patient is very characteristic, and its true nature would be at once obvious to any one who had any knowledge of its symptoms ; but in the earlier stages there is but little to guide us to a diagnosis unless we have some hereditary history. Of the hereditary nature of this affection the published cases give ample proof. There are apparently two forms of this disease, one of spinal the other of muscular origin. PARALYSIS, FROM LEAD POISONING AND HYSTERIA. In this form of paralysis the usual diagnostic symptoms, to wit, a history of exposure to lead, the blue line on the gums, constipation and colic, may all be absent ; hence the diagnosis must rest upon the peculiar characters of the palsy — especially the effects of electric currents upon the muscles. These are the only reliable evidences of the nature of the disease. These characteristic reactions, first described by Duchenne, are as follows : — Excitability to Faradaism absent or sensibly diminished in all the muscles of the forearm except the supinators longus and brevis. In health the supinator brevis cannot be directly Faradized, on account of its deep position. But in lead palsy it very often happens that the wasting of the extensor communis digitorum has proceeded far enough to uncover the supinator brevis sufficiently to allow a small rheophore to be applied to it in the space of about a square inch at the upper and back part of the forearm. If it be found (both arms being affected) that the common extensor fails to respond to Faradaism while the short supinator close by, DISEASES OF THE NERVOUS SYSTEM. 109 on a lower plane, is readily excited by it, the case may be positively set down as one of lead palsy. Hysterical Paralysis, in spite of its frequent close imitation of the organic forms, is readily diagnosed by attention to the following points : — 1. In hysterical hemiparesis the face is rarely, and the tongue never, affected. 2. In hysterical paraplegia incontinence of urine is never present (Hamilton). 3. No amount of help can keep the patient from staggering or falling when she attempts to walk (Reynolds). 4. The foot in walking is simply dragged along and not swung as in organic hemiplegia (Todd). 5. In all sudden cerebral palsies, the nails of the affected extremities cease to grow. In hysterical palsies, of one limb or both, whether para- plegic or hemiplegic, the rate of nail-growth is unaltered (Weir Mitchell). GENERAL PARALYSIS OF THE INSANE. This curious disease, long unknown in the United States, has of recent years been frequently observed in the Northern and Eastern States, but so far, rarely or not at all in the South and West. It is a disease of ad- vanced life, whose pathognomonic characteristics are constant troubles of motility, a progressive loss of mental power, and a constant belief on the part of the patient that he is perfectly well, and in the enjoyment of magnificent fortune and gigantic powers (delires des grandeurs). The following are the progressive traits of the disease as generally ob- served : — Psychical Symptoms. — 1. General restlessness and unsteadiness of mind, with impairment of attention ; alternating with apathy and drowsi- ness. 2. A change in disposition and temper, and a general loss of self- restraint; at first as regards trivial social observances, and then as re- gards general conduct. 3. Impairment of the reflective powers, so that there is no logical and systematic development of thought. 110 DIFFERENTIAL DIAGNOSIS. 4. General exaltation of thought, with a profusion of remembered images and ideas, and numerous extravagant desires. 5. Failure of memory and forgetfulness; at first of words, and then of events. 6. Delirious conceptions, and the transformation of desires into beliefs, these being generally connected with personal greatness and power. 7. Hallucinations of the senses, in which remembered sense impres- sions are so vivid and intense as to spread to the periphery. 8. Maniacal restlessness and excitement, in which present impulses and feelings instantly pass over into action. 9. Increased mental weakness, with the incoherent and fragmentary repetition of the false ideas previously entertained. 10. Failure of the senses, with more marked impairment of memory. 11. Complete fatuity, passage into coma and death. Motor Symptoms. — 1. Persistent contraction of the occipito-frontalis muscle, and some dilatation of pupils, causing the eyes to be widely opened and the forehead wrinkled, and giving an expression of sur- prised attention to the face. 2. Persistent contraction and frequent tremors of the zygomatic muscles, giving a pleased and benevolent expression of countenance. 3. Slight muscular restlessness and unsteadiness. 4. Impairment of the power of executing fine and detailed movements, so that manipulative skill is lost while movements en masse are still well performed. 5. Fibrillar tremors of the tongue, and some loss of control over its movements, so that it is protruded with difficulty ; is rolled about when protruded, and is suddenly withdrawn. 6. Twitchings of the nostrils and upper lip, with frequent tremors of the latter. 7. Impairment of articulation, which is thick and wanting in distinctness. 8. An alteration in the voice, as well as thickness and hesitancy in speech. 9. Loss of control over the combined movements of the hand and wrist, so that the handwriting generally deteriorates. 10. Changes in the pupils, which are at first irregularly contracted, and then become irregularly dilated. DISEASES OF THE NERVOUS SYSTEM. Ill 11. An alteration in gait, which becomes unsteady; the more complex movements of the thighs, leg, and foot, and the balancing of the pelvis on the hip joints, being performed with difficulty. 12. General muscular agitation and restlessness. 13. Gradual loss of power in the muscles of the face, tongue, neck, and limbs. 14. Spasmodic contraction of the masseter muscles, causing grinding of the teeth. 15. Convulsive seizures — most marked on one side of the body, and followed by transitory hemiplegia. 16. Loss of control over the sphincters. 17. Complete prostration of muscular strength and helplessness, and difficult deglutition. 18. Contractions of the muscles of the limbs, and paralysis of the muscles of respiration. The main diagnostic difficulty is to distinguish this from some phases of locomotor ataxy. The differences are that in general paralysis the mental symptoms are always present, and always precede the motor phenomena. The first symptoms in general paralysis are chiefly cere- bral ; viz., mental excitement, great garrulity, noisy hilarity, bragging, early violence of behavior, and very usually some exhibition of libidinous conduct; on the subsidence of excitement, the mind is found to be weak, and the motor phenomena gradually make their appearance. In ataxia, the commencement is in the spinal functions. There is first an attack of pain of some remote part, occurring most frequently in the lower extremities, and dating several years back, considered at the time perhaps to be rheumatic; this pain is worse toward evening, or when the patient is not mentally occupied ; it may improve or disappear for a time and return. Then follows a slight degree of numbness of the part; the patient feels as if he trod on wool ; occasionally "pins and needles" attack the part; in fact, those phenomena which we have all experienced after sitting in an awkward position, when one's own leg has "gone to sleep." There is, as most of us know, want of feeling, want of recognition of the member, especially as to its size, and even its ownership, then atrocious pain, and pins and needles. In the disease, on the subsidence of the pain, the patients exhibit some awkwardness in gait; the ataxy or want 112 DIFFERENTIAL DIAGNOSIS. of order on the movement is evident. These symptoms may extend over teo or twelve years with very little change, except, perhaps, increas- ing awkwardness in gait; there is doubtless some numbness of the cutane- ous surface in the course of the disease; the phenomena appear to spread upward by involving the functions of the nerves higher up; the erection of the penis, and soon afterward the sexual appetite, are lost, and, as the disease ascends, the expulsory power of the bladder and rectum become impaired. All this occurs while little change takes place in the mental functions; but in other cases the mind appears imbecile, the memory is affected, and there is distinct alteration in behavior and conduct; but there are no lofty ideas, no excessive excitement and garrulity, and in no case paroxysms of violence, or libidinous ideas. The differences may be better seen in a tabulated form : — GENERAL PARALYSIS. Runs its course in a few years. Commences with mental symp- toms. Is attended with libidinous ideas. The motor symptoms are second- ary in the order of time. Is only rarely complicated with pelvic difficulties. There often is great violence. LOCOMOTOR ATAXY. Is much slower usually, and may last ten or even twenty years. Commences with pains in distal nerves. Is attended with absence of sexual feeling. The motor symptoms are the pri- mary phenomena. Pelvic symptoms are a prominent feature. The mental phenomena are imbe- cility and impaired memory. There is also a form of general paralysis due to syphilis. The differ- ential features of this variety have been clearly defined by Dr. E. C. Seguin.* We do not obtain the regular gradations and stages of the true disease. The moral perversion which is peculiar to general paralysis is absent, neither do we see the pure, exalted notions. The fibrillary tremors that are so well marked in general paralysis are not present here. The articulation is more mumbling in character. ~\Vc, likewise, are apt to have a great deal of actual paralysis of cranial nerves or body in these * Hospital Gazette, September, 1878. DISEASES OF THE NERVOUS SYSTEM. L13 cases. In true general paralysis, after attacks of hemiplegia, the patient regains his full strength, whereas this is not apt to occur in the syphilitic variety. The following table will perhaps show clearly the main differ- ences : — TRUE GENERAL PARALYSIS. Prodromic stage. Exalted notions, numerous and varied, and relatively exalted ac- cording to the position in life. Speech is tremulous and jerky. Tremor of hands and lips. Preservation of strength. Pupils are apt to be contracted. None. None. Transient aphasic attacks. Spontaneous remissions. SYPHILITIC GENERAL PARALYSIS. Absent. Rare or absent. Speech is thick. Absent as a rule. Paresis or actual paralysis. Apt to be open or wide. Palsy of third or of other cranial nerves. Headache nocturnal. More serious aphasic attacks. Progressive except under treat- ment. Some other differences between the two conditions are as follows : The patient with syphilis has none of the cravings or abnormal appetites of the other ; the latter feels an impulse to get drunk or to have an excess of coition. The tendency to excessive coition is absent in syphilitic paralysis, and, indeed, there is a marked loss of the virile power. The temperature changes are also absent in syphilis of the brain. The rise in temperature in general paralysis of the insane is*very great, often reaching 103° in exacerbations. There is no rise of temperature in syphilis of the brain, except, perhaps, when the patient has hemiplegia from a large lesion. The most important point is, that in syphilis there is a paralysis ; in general paralysis there is irritation and incoordination without true pa- ralysis. 11-1 DIFFERENTIAL DIAGNOSIS. SPINAL IRRITATION (so-called) AND SPINAL WEAKNESS. This affection has been described by some writers as spinal hyperemia, by others as spinal anannia ; again as spasms of the spinal muscles, and lastly as abnormality of the spinal cells. Some have denied its exist- ence altogether; but in fact it is a distinctly defined and not unusual dis- order. About live-sixths of the cases are females, and it is often associ- ciated with uterine or ovarian disease ; and as often has some antecedent history of a blow upon or other slight injury to the spine. Its symptoms are of the most varied kind, so much so that it may simu- late almost every known ailment; but a careful examination of the spine will reveal its true character. The diagnostic rules laid down by Drs. William and David Griffin, in 1834, who first described the disease, have never been improved upon. They are as follows : — 1. The pain or disorder of any particular organ complained of is altogether out of proportion to the constitutional disturbance. 2. The complaints, whatever they may be, are usually relieved by the recumbent position, are always increased by lifting weights, bending, stooping, or twisting the spine ; and, among the poorer classes are often consequent to the labor of carrying heavy loads, drawing water, etc. 3. The existence of tenderness at that point of the spine which corres- ponds to the disordered organ, and the increase of pain in that organ by pressure on the corresponding region of the spine. 4. The disposition to a sudden transference of the diseased action from one organ or part to another, or the occurrence of hysterical symptoms in affections apparently acute. 5. The occurrence of continued fits of yawning or sneezing. These are not very common in the disease; but when they do occur, they may generally be considered as characteristic of nervous irritation. To this it may be added that the tenderness may extend along the spine generally; but is always greater in one or two spots. Gastric symptoms, headache and languor are usually well marked in spinal irri- tation; but there is neither atrophy, paralysis (except hysterical) nor waist constriction, which serve to distinguish it from a large class of spinal diseases. DISEASES OF THE NERVOUS SYSTEM. 1 1 5 In regard to the nature of spinal irritation, we know nothing definite at present (Erb). Neurasthenia spinalis, spinal nervous weakness, is defined as a diseased condition in which marked and unquestionable disturbances of the func- tions of the cord exist, for which no considerable anatomical basis can be found or assumed ; a disease, therefore, which must at present be classed among the functional disorders. It is most common among men, is caused by successive mental efforts, sexual excesses, bodily over-exertion. Weakness and inability from prolonged over-exertion, dysesthesia, pares- thesia, cold hands and feet, sleeplessness and general malaise are the prominent symptoms. " We do not at all know what may be the nature of the processes of nutrition which cause these symptoms. We, however, believe, that we are certainly entitled to locate them in the cord, especially in the lower portion, the lumbar region. The most obvious view is that which sup- poses that the physiological fatigue of the nervous elements, which always occurs after severe and protracted irritation, becomes exaggerated and assumes a fixed form ; in such a case we may suppose that the fatigue of the nervous elements does not become repaired in the prompt manner which is usual under physiological conditions." In making a diagnosis, these characters will be distinguished from those of disease of the vertebrae by eareful physical examination, and the age, sex and history of the case. HYSTERIA. Few diseases present at times greater difficulties to diagnosis than this protean complaint. Its counterfeits of various maladies will be considered elsewhere (see the Index) ; at present we shall seek for a pathognomonic symptom of the general condition. One is offered by Dr. Thomas Barlow.* Rejecting as unsatisfactory all statements depending upon the patient's veracity, he finds a diagnostic test in the presence of analgesia. If, while the patient's attention is directed to something else, a needle be introduced into the forearm and no wincing occurs, there is the strongest presumption that we have to do with a case of hysteria. Again, it has been long known that hysterical patients are * Medical Times and Gazette, February 1878. 116 DIFFERENTIAL DIAGNOSIS. often extremely tolerant of laryngoscopic examination. Great advantage will be found in examining a presumed hysterical patient's larynx, and thus fixing her attention while somebody at the same time inserts a needle into her forearm. Absolute tolerance of these two simple methods of examination is quite decisive. Another characteristic relates to the pain so frequently complained of. While it is stated to be exceedingly acute, and the part tender to the slightest pressure, if the attention of the patient is engaged, very firm pressure may be made without the patient wincing. Moreover, there is noted very often a co-existence of severe pain in the epigastrium, the left side and spinal column — the trepied hysterique, or hysterical tripod of French authors. The globus hystericus, a sensation of a foreign body in the throat caused by spasmodic contraction of its muscles, is a common symptom. The urine may be suppressed, or may be limpid and watery, and of unusual quantity. If with these traits are united youth and female sex ; ovarian or uterine disturbance; the general symptoms harmonious and exaggerated; the mind clear ; and the disappearance of contractions, etc., under anaesthesia; the diagnosis is complete. The most serious, mistake would be the confounding of a hysterical paroxysm with an epileptic fit. The following table of distinctions between the two is given after Charcot and Da Costa : — EPILEPSY. HYSTERIA OR HYSTERO- EPILEPSY. Gradual or only partial or ap- parent unconsciousness. Sudden and complete loss of con- sciousness. Livid face ; escape of frothy saliva from the mouth ; eyelids half open ; eyeballs rolling; grinding of the teeth ; biting of the tongue ; more or less insensibility of the pupils to light. Distortion of countenance. Patient evinces no feeling. Aura epileptica of short duration. Face flushed or complexion unal- tered; no froth on lips; eyelids closed ; eyeballs fixed ; neither grind- ing of the teeth nor biting of the tongue ; pupils react readily. No distortion of countenance. Patient sighs, or laughs, or sobs. Aura often prolonged one or two days. Globus hystericus. DISEASES OF THE NERVOUS SYSTEM. 117 EPILEPSY. Convulsions often more marked on one side than on the other ; and more tonic than clonic. Agitation maniacal and disorderly. Paroxysms generally of short du- ration. Paroxysm followed by a heavy, half comatose sleep, by headache, and dullness of intellect. Stertor. No hallucinations. HYSTERIA OR HYSTERO- EPILEPSY. No such differences; convulsions clonic. Agitation emotional, often en pose. Paroxysms generally of longer duration. Paroxysm not followed specially by sleep; patient often, after attack, wakeful and depressed in spirits. Little or no stertor. Hallucina- tions. Rarely occurs at night. Often connected with disorders of the uterus, or of menstruation. Frequently occurs at night. No particular connection with uterine disturbance ; although a pa- roxysm often takes place at the menstrual period. NEURALGIA. The positive signs which distinguish a case of pain to belong to the neuralgise are succinctly set forth by Dr. Francis E. Anstie,* as fol- lows : — (1) The first and most essential characteristic of a true neuralgia is that the pain is invariably either frankly intermittent, or at least fluctu- ates greatly in severity, without any sufficient and recognizable cause for these changes. (2) The severity of this pain is altogether out of proportion to the general constitutional disturbance. (3) True neuralgic pain is limited with more or less distinctness to a branch or branches of particular nerves ; in the immense majority oi cases it is unilateral, but when bilateral it is nearly always symmetrical as to the main nerve affected, though a larger number of peripheral branches may be more painful on one side than on the other. (4) The pains are invariably aggravated by fatigue or other depress- ing physical or psychical agencies. These four cardinal points of the diagnosis may be further supported * " Neuralgia and its Counterfeits," p. 565. 118 DIFFERENTIAL DIAGNOSIS. by the history bf the patient. Either (1) he has previously been neural- gic, or liable to other neuroses, or comes of a neurotic family ; or (2) there has been malarial poisoning of the blood ; or (3) there has been some long continued peripheral or central irritation ; or (4) finally, there has been constitutional syphilis. The pains with which neuralgia is most likely to be confounded are those arising from myalgia, spinal irritation, locomotor ataxia, cerebral abscess, alcoholism, syphilis, chronic rheumatism, and latent gout. In comparing the pains of myalgia and neuralgia the following are the more important points : — MYALGIA. Attacks a limited patch or patches that can be identified with the ten- don or aponeurosis of a muscle which, on inquiry, will be found to have been hard worked. NEURALGIA. Follows the distribution of a re- cognizable nerve or nerves. Accompanies an inherited or ac- quired nervous temperament which is obvious. Is usually not much or at all aggravated by movement. Is at first not accompanied by local tenderness. Painful points, when established Often occurs in persons with no special neurotic tendency. Is inevitably and very severely aggravated by every movement of the part. Distinguished from the first by localized tenderness on pressure as well as on movement. Tender points correspond to ten- in a later stage, correspond to the dinous insertions and origins of emergence of nerves. Pain not materially relieved by any change of posture. muscles. Pain usually completely and al- ways considerably relieved by full extension of the painful muscle or muscles. Treatment also offers a diagnostic means. The pains of myalgia will ordinarily disappear at once by retaining the affected muscle at full ex- te sion, surrounding it with moist warmth, and giving 20 or 30 grains of muriate of ammonia internally. Spinal irritation (spinal congestion or spinal anaemia) is almost cxclu- DISEASES OF TIIF NERVOUS SYSTEM. \V.) sively confined to women. There are nearly always hysterical symp- toms, marked superficial tenderness over large portions of the surface, often merely cutaneous and becoming less acute with firm pressure. There are nearly always tender spots along the spine, and also over the epigastrium and the left hypoehondrium. Locomotor ataxia is mentioned elsewhere, and its symptoms described in sufficient detail. (See page 100 et seq.) Cerebral abscess, though rare, may give rise to a regretable mistake, especially in its early stages, where severe pain in the head is almost the only conspicuous symptom. At this period the diagnosis from neuralgia must rest on the following points of contrast : — CEREBRAL ABSCESS. Often occurs secondarily to caries of internal ear, and purulent dis- charges, the result of scarlet fever, measles, etc., in childhood. Frequently follows a blow or in- jury. No true " points douloureux." Usually the pain does not com- pletely intermit. Pain often excruciating from a very early period. Pain often limited in situation, seems deep-seated, though as often as not it has no relation to the site of the abscess. No well localized vaso-motor or secretory complications. Very rare in old age; then usually traumatic. Relief from stimulant narcotics very transitory. NEURALGIA OF THE HEAD. Rarely appears before puberty. No local assignable cause. Comparatively seldom caused by a blow or other external injury, or caries of the bone. If severe, soon presents, in most cases, the "points douloureux." Intermissions of pain complete and of considerable length. Pain usually not very violent at first. Pain superficial ; follows distribu- tion of recognizable nerve branches belonging to the trigeminus or great occipital. Usually lachrymation, or conges- tion of the conjunctiva, etc. Severe neuralgia is commonest in advanced life. Relief from opium, etc., is much more considerable and permanent. 120 DIFFERENTIAL DIAGNOSIS. The pains of chronic alcoholism often closely simulate those of true neuralgia. The habits and history of the patient, when known, point to the true origin of the suffering; also the insomnia, loss of appetite, foul breath, furred tongue and haggard countenance of the drunkard ; and especially that the pains complained of encircle the limbs near the joints, rather than run longitudinally the course of the nerves in the limb, are all significant. The osteocopic pains of syphilis are usually symmetrical ; are aggra- vated by the warmth of the bed ; are generally referred to the superficial bones, aud do not exist long without some other and decisive symptoms of the poison manifesting themselves. Chronic rheumatism and gout are each attended with such marked collateral disturbances that the suspicion of their presence can readily be set at rest or sustained. INSANITY. The principal forms of insanity are commonly considered under the head of Mania, Monomania, Melancholia, Dementia, Idiocy and Imbe- cility; to which may be added emotional and impulsive insanity, which is now usually admitted. There is no ground for recognizing as a dis- tinct variety, moral insanity (Flint). The pathological anatomy of insanity is thus stated by Seguin : — (Anaemia. Hyperemia. Serous effusion. I. Acute Recent Cases. -j Old congestion. Hemorrhages into perivascular sheaths. Changes in gray matter (not demonstrable under the microscope). Congestion or anaemia. Atheroma of vessels. Membranes changed, diseased and thickened. Nerve elements degenerated and atrophied. General atrophy of convolutions ; most marked in ante- terior convolutions. II. Chronic Insanity and True Dementia... Similar to preceding, but differs in distribution of lesions ; particularly in neuralgia; also granular vent " changes. Often lesions in spinal cord co-exist, arachnoid hemorrhage not a frequent change. ttt r> 1 v> 1 • J particularly in neuralgia; also granular ventricular III. General Paralysis.. < changes . often lesions in spinal cord co-exist. Sub- IV. Syphilitic Insanity. DISEASES OF THE NERVOUS SYSTEM. 121 In mania, chronic alcoholism and general paralysis, pa'Jiy-meningilis hemorrhagica is often found. Section through the thickened dura reveals alternate layers of tissue and coagulated blood. Patients under twenty-five years of age seldom have chronic insanity ; when they do the vascular changes are less marked ; in older patients the vessels become fatty and atheromatous. The capillaries show fatty change, their nuclei being first affected ; in the arteries the muscular coat becomes fatty. Through large tracts of brain granular and amyloid bodies are found. Old inflammatory changes in the meninges are quite common. The arachnoid is opaque in spots. The causes of insanity are very complex; the Physical Causes are thus given by the same author : — Injuries to head. Concussion. Hemorrhages. Meningitis. Depressed fracture. Abscess. Tumor. {Gummy formations. Arteritis. Meningitis, etc. -Tk . f Malaria. Dyscrasiee < AT .... , J \ Narcotic poisoning, etc. A i t ! ( Delirium ebriosum. Alcohol { n ,. • , [ Delmuni tremens. ri t f Individual venery. sexual excess < ■**■ , u ,. J \ Masturbation. {Uterine difficulty. Vaginismus. Masturbation. The Moral Causes are misery, depression, emotions, excitement, remorse, fear, grief, religious fervor, excess of joy, the spirit of specula- tion, etc. The two forms, mania and melancholia, have their general distinctions, as follows : — L22 DIFFERENTIAL DIAGNOSIS. MANIA. Eyo elated ami over active. Joy and excitement generally pre- vail, sometimes comic emotions char- acterize attacks. Over-ideation and over-action. Resulting therefrom incoherence and delirium and violent acts : general restlessness. Insomnia. MELANCHOLIA. Ego is depressed and does not re- act normally on external world. Sadness and fear; religious feel- ings strongly developed. (few motions Reduced ideation. < and even abse- il lute silence. f Immobility -r> -i -, ,. relativeor total, Reduced action. < , and even cata- (^ leptoid state. Insomnia (less marked). PHYSICAL SYMPTOMS. Increased circulation. Increased calorification. Increased (?) assimilation. Increased voracity. Lessened circulation. Lessened calorification. Lessened assimilation. The earliest symptoms of insanity are a marked change in the habits ; proneness to excitement and loss of control ; an alteration in the emotions ; failure of memory ; untidiness of dress ; insomnia and disturbing dreams; unusual loquacity or taciturnity; defective reasoning; accepting as real various fancies and illusions ; a furtive, watchful air ; groundless sus- picions of those around. In combination with these mental symptoms, the pupils are often dilated, frequently irregular, and sluggish in obeying the stimulus of light; and a pulse hard, rapid and variable, 100 or over, a pulse which is not equal in both wrists (Henry Howard). The tongue is pasty, the breath foul, and the bowels constipated. The digestion is impaired, and the appetite irregular and capricious. There is encroachment of the senses upon each other; the sense of sight, for in- stance, is substituted by audition, and the patient will describe scenes with the greatest minuteness of detail as occurring in the neighborhood, even to the color of clothing, and peculiarities of appearance which could DISEASES OF THE NERVOUS SYSTEM. 123 only be learned by inspection, but which he knows, because he "heard the dogs barking/' or the noise of some fancied tumult. The hearing of inaudible voices calling opprobrious names is even popularly recognized as indicating insanity. Where no organic changes can subsequently be detected in the brain, we are forced to the conclusion that there is cither some non-recognizable defect, or that there must be functional disorder of the brain, as of other organs in the economy. 1 2 I DIFFERENTIAL DIAGNOSIS. CHAPTER II. DISEASES OF THE RESPIRATORY APPARATUS. Diseases of the Larynx. — Symptoms of Laryngeal Diseases — Diag- nostic table of Acute Laryngitis, Chronic Laryngitis, Syphilitic Laryn- gitis, Tubercular Laryngitis, Perichondritis, Benign Growths, Malig- nant Growths, and Neuroses of the Larynx — Croup and Diphtheria; Spasmodic Croup, Inflammatory Croup, Membranous Croup, and Diphtheria — Tonsillitis, Catarrhal and Parenchymatous. Diseases of the Lungs. — The Regions of the Chest — Normal Differ- ences between the two sides of the Chest — Methods of Physiccd Exami- nation — Normal Respiratory Sounds — Normal Votes Sounds — Abnor- mal Percussion Sounds — Abnormal Respiratory Sowuls — Abnormal Voice Sounds — General Rules for Diagnosis — The Forms of Phthisis (Catarrhal, Fibroid, Tubercular) — The Diagnosis of Incipient Phthisis — Diagnosis between Incipient Phthisis and Bronchitis — Clinical His- tory of Phthisis — Acute Phthisis — Syphilitic Phthisis — Bronchitis, Acute and Chronic — Capillary Bronchitis competed with Pneumonia — Pneumonia and Pleurisy — Pleurisy with Effusion and Pneumonia with Consolidation compared — Diagnosis between Pneumonia and Pulmonary Apoplexy — Pulmonary Embolism — Asthma — Pneumothorax and Pneumo-hydrothorax — Emphysema, Vesicular and Interlobular — Cancer of the Dung. In studying diseases of the respiratory apparatus, we find in addition to the disorders of the lung proper and its serous investment, the pleura, that there are associated organs which likewise may be the seat of disease; these are the bronchi and trachea, the larynx, pharnyx and upper air passages. We commence with : — DISEASES OF THE LARYNX. The general symptoms of laryngeal diseases, together with their causes and examples, may be arranged in the following tabular form : — DISEASES OF THE RESPIRATORY APPARATUS. 125 SYMPTOMS OF LARYNGEAL DISEASES. Dysphonia. Aphonia. Dyspnoea. Stridor. Cough. Alteration in the vocal cords from thickening, ulceration, diminished tension, morbid growths, etc. Non-approximation of the vocal cords, either me- chanical or due to para- lysis of some of the muscles attached to them. Narrowing of the orifice of the erlottis. Always accompanied by dyspnoea, and produced by the same causes. Irritation of the laryngeal mucous membrane, or the nerves of the larynx. EXAMPLES OF DISEASE. Acute and chronic laryn- gitis. Laryngeal phthisis. Papillomata, etc. Cicatrization. Swelling of arytenoid car- tilages. Tumors. Hysteria. Pressure on recurrent la- ryngeal nerves, etc. Paralysis of muscles open- ing glottis. Laryngismus stridulus. (Edema, growths and cica- trices contracting rima glottidis, and pressure external to larynx. As in dyspnoea. In most laryngeal diseases it is of a peculiar shrill, brazen character. Laryngitis has been divided by some writers into the followin| forms : — (Edematous laryngitis. Catarrhal laryngitis. Erysipelatous laryngitis. Croupous laryngitis. Diphtheritic laryngitis. Syphilitic laryngitis. Tubercular laryngitis. Exanthematous laryngitis. Traumatic laryngitis. Among authors who have paid especial attention to this subject, there are few that stand higher than Mr. Lennox Browne, of London, who in his recent work on the Diseases of the Larynx gives the diagnostic table presented in the following pages. 12(5 D1KFEREXTIAL DIAGNOSIS. SYMPTOMS. All IK LAB'S CTGITIS. .'UK. IMC I.AKVXi;iTlS. A.— Functional, or Subjective. Hoarse, becoming aphonic. Hoarse, uncertain, easily VoK'K. RESPIRATION. Coi'Gir. Deglutition. Pa ix axd Al- tered Sen- sation. Color. Form and Texture. Position. External. Not embarrassed prior to oedema ; then stridor, dys- pnoea, and even apneea. Dry, hard, shrill, metallic; aphonic; on exudation, moist. Painful when oedema has taken place, or from as- sociated pharyngeal in- flamation. Sensation of tightness and constriction ; tender to external pressure. B. — Physical, or Objective Intense, uniformly increas- Partial and modified sub fatigued. Seldom embarrassed. Irritative, with slight ex- pectoration of glutinous pellets. Rarely affected. Painless; sense of fatigue after vocal exercise. ing superficial hypere- mia ; translucent on event of oedema. Thickening and stenosis from oedema, loss of tis- sue rare, except in phleg- monous form. Unaltered. mucous hyperemia. Occasionally slight erosion, never ulceration, thicken- ing or narrowing 1 . Unaltered. C— Miscellaneous. Pharynx usually synchro- 1 Pharynx usually synchro- nously implicated. nously implicated. DISEASES OF THE RESPIRATORY APPARATUS. 127 SYPHILITIC LARYNGITIS. TUBERCULAR LARYNGITIS. Secondary. Hoarse. Tertiary. Characteristically raucous; seldom aphonic. Secondary. Unchanged. Tertiary. Increasing embarrassment according to amount of stenosis. Secondary. Slight hacking'. Tertiary. Infrequent, with but slight expectoration, unless peri- chondritis supervene. Secondary. Normal, unless deposit on epiglottis or arytenoids. Tertiary. Often difficult ; very rare- ly painful. Characteristic absence of pain ex- cept when cartilages are attacked. Sometimes aphonic in earlier stages ; completely lost in advanced dis- ease. Early hurried ; greatly embarrassed with advance of disease. Greatly influenced by amount of lung disease; painful. Expectoration variable ; generally frothy. Extremely difficult and painful, from early period to termination. Pain only experienced in functional acts. Secondary. Mottled, more or less symmetrical hyperemia. Tertiary. Hyperemia of portion at- tacked prior to ulceration ; per- manent infiltrated appearance. Secondary. Occasional superficial ulceration at vocal process ; slight general submucous infiltration. Tertiary. Deep, circumscribed de- structive ulcers, of yellowish color, followed by cicatricial nar- rowing, occasionally paralysis and quasi-new formations. Secondary. Unaltered. Tertiary. Deformity from intrinsic cicatrices and pharyngeal out- growths. Secondary. Pharynx and skin gen- erally recently implicated. Tertiary. Seldom synchronous im- plication, but usually scars of previous similar pharyngeal ul- ceration, and possible adhesion. Anemia followed by opaque grayish color ; margins of ulcers hypere- mia Solid submucous thickening of epi- glottis and aryepiglottic folds, elevation and ulceration of race- mose glands giving worm-eaten ulcers, which commingle and at- tack deeper tissues. No displacement; tendeney for thickened parts to transgress boundaries of pharynx. Lungs either primarily, synchro- nously, or subsequently involved. Generally anaemia, rarely ulcera- tion of pharynx. General emacia- tion. 128 DIFFERENTIAL DIAGNOSIS. SYMPTOMS. l'KUUHONDHITIS. BENIGN GROWTHS. A.— Functional, or Subjective. Voice. Respiration. Cough. Deglutition. Pain and Al- tered Sen- sation. Color. Form and Texture. Position. External. Painful, easily fatigued, but not necessarily im- paired. Variable, according to car- tilage attacked. Generally early spasmodic ; with caries characteristic. Purulent expectoration, un- less abscess is encysted. Varying from dysphagia to aphagia, according to pressure on gullet. Pain variable with cause ; most severe in gouty form, but not then constant. Very variable, from slight hoarseness to complete aphonia, even in the same case. Seriously embarrassed in one-sixth of cases ; de- pends on situation. Generally limited to effort to dislodge foreign body; may be expectoration of atoms of growth. Only impaired in rare cases, in which epiglottis or aryepiglottic fold is in- volved. Characteristically absent. B— Physical, or Objective. Hyperemia generally limit- ed to portion attacked, sometimes extending to contiguous vocal cord. Ulceration often absent, substituted by encysted abscess, causing narrow- ing, compression and pa- ralysis. May be considerable altera- tion of supra and infra- glottic space. C. — Miscellaneous. Occasional constitutional I manifestations. Variable with nature of neoplasm ; slightly in- creased vascularity of mucosa generally. Varies with situation, size, and nature of growth, never ulceration. May cause narrowing and pa- ralysis. Position of normal parts seldom changed. Nil. DISEASES OF THE RESPIRATORY APPARATUS. 129 MALIGNANT GROWTHS. Impaired by mechanical causes when invaded from pharynx ; may be early lost in primary disease. Early quickened on exertion ; later paroxysmal dyspnoea from ste- nosis or compression. Not necessarily present; expectora- tion scanty ; occasionally blood and portions of neoplasm. Always difficult and painful ; often the earliest symptom. Lost in bilateral paralysis of adduc- tors; impaired in other paralyses; not necessarily in spasm. Only embarrassed in paralyses of adductors and in spasmodic affec- tions. Paroxysmal, when recurrent is im- plicated and in spasmodic affec- tions. But slightly impaired or unaffected. Ever present and severe, extending : Only experienced when sensory sys- upward to the ears, and to sym- pathetic glandular enlargements. tern affected. Diminished sensa- tion in motor paralyses and in anaesthesia. Increasing localized vascularity tend- ing to lividity in any part except vocal cords or ventricles,when neo- plasm is whitish-gray or pale rose. May cause compression, narrowing and paralysis before ulceration, which is always accompanied by thickening. Extensive indolent, gray, greenish, or almost black ulcers. Early displacement, especially when ! Paralyzed cord not displaced, invading from pharynx, and when j often fixed in one position, neighboring; glands enlarged. In paralysis of abductors, occasional vascularity of affected vocal cords. Form of glottis varying with nature of paralysis, without extrinsic thickening. but Glandular infiltration, but complete Sympathetic functional disturbances immunity of other organs of body from similar disease both prior and subsequent to appearance in laryngo-pharynx. General ema- ciation. 9 in other organs, or organic disease of cardiac or lymphatic system, or associated cerebral disease or chronic toxaemia. L30 DIFFERENTIAL DIAGNOSIS. The chronic laryngitis of syphilis cannot with certainty l>e distinguished from the other forms of chronic laiyngitis withoul inquiry into the his- tory of the case; although a probable diagnosis may be made where treat- ment by anti-syphilitic remedies is successful. In tertiary syphilis there is deep and extensive ulceration, not neces- sarily preceded by thickening-; the epiglottis is attacked early, the ulce- ration is often followed by cicatrization and contraction, causing stenosis of the larynx. In the study of laryngeal diseases the use of the laryngoscope is indis- pensable to correctness of diagnosis. We take it for granted that the practitioner is conversant with this instrument, and the proper methods of employing it. It reveals the physical or objective local symptoms, which are of much more value than the subjective ones derived from the patient's statements. CROUP AND DIPHTHERIA. The general sign common to this class of diseases is a laryngeal stridor ; they are divided into those where there is a formation of false membrane and where there is uot. Without false membrane. Spasmodic croup or laryngismus stridulus. Imflammatory croup, simple catarrhal laryngitis. With false membrane. True croup or membranous croup. Diphtheria. The diagnosis between spasmodic and inflammatory croup is as follows : — SPASMODIC CROUP. INFLAMMATORY CROUP. Onset sudden, usually at night, I Onset gradual, with sore throat, with few or no prodromal symp- j tickling, tenderness of larynx and toms. catarrh. Difficulty of swallowing absent or Increasing difficulty in swallow- temporary, ing. Febrile" symptoms absent, or much ; Flushed face, hot, dry skin, high less marked. temperature (105°), frequent pulse. Larynx little affected. Mucous membrane of larynx red I and swollen, sometimes oadematous. Intermission complete, or nearly Remission but slight; local symp- so, between the croupous attacks. toms and pyrexia continue. Very rarely fatal. In early life a dangerous disease. DISEASES OF THE RESPIRATORY APPAKATUS. 131 Very considerable differences of opinion are entertained as to the formidable and frequent disease diphtheria. Some maintain its identity with membranous croup, others with scarlatina, while others believe it to be a malady distinct in origin, course, result and treatment from them both. The last mentioned opinion appears to have the most adherents, and the most facts on its side. The differences between the diseases are fully set forth in the table subjoined : — MEMBRANOUS CROUP. DIPHTHERIA. It is a local complaint. Rarely or never occurs after puberty. It is not contagious. Type sthenic. Commences with a cough, catarrh and hoarseness ; little or no sore throat and difficulty of swallowing. Cough shrill, metallic; breathing stridulous from the outset. The membranous affection begins m the larynx and extends to the throat. Fauces injected but rarely swol- len, and generally without exudation. Exudation never cutaneous. No swelling of the submaxillary glands. Epistaxis and albuminuria absent. Little and often no prostration of the general strength. Improves under emetics, local counter-irritants, expectorants and depressants. Is never followed by paralysis. Rarely fatal. Death from apnoea. Blood not changed. Spleen not affected. Is a general disease, common to all ages. It is decidedly contagious. Type asthenic. Commences with a chill, sore throat, difficulty of swallowing ; but neither hoarseness nor cough at the outset. Stridulous breathing a late symptom. The membranous affection begins in the throat and thence extends to the larynx (Da Costa). Fauces injected, swollen and pre- senting exudation. Exudation often cutaneous. Submaxillary glands swollen. Epistaxis and albuminuria fre- quent. Considerable, often extreme pros- tration. Demands a stimulating and sus- taining treatment. Subsequent paralysis not infre- quent. Frequently fatal. Death usually by asthenia. Blopd after death usu- ally fluid and dirty brown. Spleen enlarged and softened (J. \V. How- ard). L32 DIFFERENTIAL DIAGNOSIS. T( )XSILLTTIS. Inflammation of the tonsils assumes two forms, in one of which, the catarrhal form, the inflammation extends to the secreting tissues and Lining membrane of the crypts, and in the other to the parenchymatous structure of the gland. These two forms differ widely in cause, in symptoms, in treatment and result. Their diagnostic symptoms, as tabu- lated by Mr. Arthur Treiierne Norton,* are as follows: — CATARRHAL TONSILLITIS. Is a mucous inflammation of three or four days' duration. Is caused by exposure to draft, damp, cold, etc. Prostration and often profuse per- spiration. Pulse small and quick. Never runs on to abscess. Both tonsils affected. Lacunae filled with masses of mor- bid secretion resembling ulcers. No oedema around. Treatment. — Tonics, stimulants and astringent gargles. PARENCHYMATOUS TONSILLITIS. Is a fibrous inflammation of from two to four weeks' duration. Often caused by neighboring in- flammation, cutting wisdom teeth. High fever, with hot, dry skin. Pulse strong and hard. Commonly forms an abscess. Rarely both affected. Often covered with lymph, but no collection of secretion in lacuna?. Extensive oedema. Treatment. — Antiph logistics and depressants, but never gargles, ex- cept in the form of warm water. DISEASES OF THE LUNGS. In passing from the consideration of the disorders of the upper air- passages to the diseases of the lungs, it is thought advisable to discuss somewhat in detail the several methods of examination of the patient, and to consider systematically the various objective phenomena presented by them as introductory to the study of their alterations, which are char- acteristic of certain diseases. Palpation, mensuration, auscultation and per- cussion, therefore, furnish evidence of great clinical importance, which may be considered collectively under the head of physical diagnosis. The study of Physical Diagnosis necessarily commences with a correct appreciation of the location of organs, their functions and physical charac- *British Medical Journal, Jan., 1874. DISEASES OF THE RESPIRATORY APPARATUS. 166 ters in health; to which must follow a clear understanding of the specific and peculiar alterations which each of these elements undergoes when it becomes a factor in disease. To acquire this, we give on the following pages tabular arrangements of the following subjects : — I. The Regions of the Chest, their Contents and Normal Signs. II. The Normal Differences between the two Sides of the Chest. III. Methods of Physical Examination. IV. Normal Respiratory Sounds. V. Normal Voice Sounds. VI. Abnormal Resonance on Percussion, and its Causes. VII. Abnormal Intensity, Rhythm and Quality of Respiratory Sounds. VIII. Abnormal (dry) Respiratory Sounds. IX. Abnormal (moist) Respiratory Sounds. X. Abnormal (amphoric) Respiratory Sounds. XI. Abnormal Voice Sounds. I. THE REGIONS OF THE CHEST. 1. Cervical. 2. Supra-clavicular. 3. Clavicular. 4. Subclavian. 5. Mammary. contents. Vesicular struc- ture of lung. Heart on left side. resonance on percussion in health. Larynx and tra- chea. Apex of lung. Clear. Clavicles and ves- Clear, icular structure of luna;. Vesicular struc- Clear, ture of lung. Clear on right side. Dull on left in greater part of region. auscultation in health. Tracheal breathing and voice. Very pure vesicular murmur (scarcely audible) : voice scarcely uudible. Pure vesicular mur- mur and scarcely audible voice, ex- cept at the sternal end, where there are bronchial breathing and bronchophony. Pure vesicular mur- mur and scarcely au- dible voice. Heart sounds on left side below. Pure vesicular mur- mur above. Heart sounds below on left side, and feeble vesi- cular murmur o n right. Voice scarce- ly audible. 134 DIFFERENTIAL DIAGNOSIS. I. THE REGIONS OF THE CHEST— {Continued). REGION. CONTENTS. RESONANCE ON PERCUSSION IN HEALTH. ai SCULTATION IN HEALTH. 6. Infra-mammary. Anterior portion Generally tympa- 1 ►istincl re si c u 1 a r of base of lung. nitic o n left murmur. V o i c e Stomach below, side ; dull on scarcely audible. on left s i il e, right. liver on right. 7. SlTEKIOR STERNAL. Division of tra- Clear. Bronchial breathing chea, aorta, and and brOnchopony. great vessels. 8. Inferior sternal. Anterior medias- Clear above : tym- Pure vesicular mur- tinum above. panitic below. mur al>o\ e. becom- Stomach below ing feeble be 1 w . Voice scarcely au- dible. '.i. Axillary. Vesicular struc- Clear. Pure vesicular mur- ture of lung. mur. Voice scarcely audible. 10. Lateral. Vesicular struc- Clear above ; dull Pure vesicular mur- ture of lung. below on right mur. Voice scarcely side. audible. 11. Supra-scapular. Apex of lung. Clear. Pure vesicular mur- mur. Voice scarcely audible. 12. Scapular. Vesicular struc- Rather less clear. Pure vesicular mur- ture of lung. mur. Voice scarcely audible. 13. Inter-scapular. Roots of hum and Clear. Bronchial breathing large bronchi. and bronchophony. 14. IXFRA-SCAPCLAR. Base of lung. Clear. Very pure vesicular murmur. Voice scarcely audible. II. NORMAL DIFFERENCES BETWEEN THE TWO SIDES OF THE CHEST. (A. H. Smith.) /' reussion Resonance. Vocal lli'siinmue. Bronchial Whisper. Inspiratory Sound. Expiration. RIGHT SIDE. Decidedly greater on the right side. More intense than on the left, and a little lower in pitch. Fn (juently prolonged i n healthy individuals on this side. LEFT SIDE. A little more intense than on the right side. A little lower on this side, more vesicular in quality, and lower in pitch. DISEASES OF THE RESPIRATORY APPARATUS. III. METHODS OF PHYSICAL EXAMINATION. 1 35 METHODS OF EXAMI- NATION. 1. Inspection. 2. Palpation. {Application of the Hand. ) 5. Mensuration. (a) Of Size. (6) Of Movement. 4. Percussion. 5. Auscultation. 6. Succussion. snows. Form, symmetry and capacity of the chest. Local bulging, depression or l'etraction. Conditionof intercostal spaces. Character and frequency of respiratory movements. Comparative size and degree of movement of the two sides. Position and extent of im- pulse of heart. Comparative movement of the two sides. Vibration communicated to the chest wall by the voice (vocal vibration or vocal ■ fremitus ). Force of the heart's impulse. Occasionally certain morbid phenomena, as pleural and pericardial friction, valvular thrill. Comparative size of the two sides of the chest. Actual and comparative move- ment of the chest in respi- ration. Degree of resonance in vari- ous parts of the chest. Extent of cardiac dullness. Character of respiratory mur- mur. Abnormal respiratory sounds. Heart sounds. Abnormal cardiac sounds. Presence of air and fluid in pleural cavity. [INSTRUMENTS USED. Graduated tape. Cyrtometer. Dr. Sibson's stethometer. Dr. Quain's " Dr. Edward's chest calipers. Dr. Hutchinson's spirometer. Plessor — A hammer tipped with india rubber. The first and second fingers of the right hand will be found to be the best plessor. Pleximeter — A thin plate of ivory or bone. The forefinger of the left hand will be found to be the best pleximeter. Stethoscope — Made of wood, metal, or vulcanite. Dr. Scott Alison's bin-aural steth- oscope. 136 DIFFERENTIAL DIAGNOSIS. I'i.ki ossion may be — Immediate. — Where the chest is struck direeffy, without tin 1 interposition of any pleximeter. (2) Mediate. — Where an instrument termed a pleximeter is interposed between the chest and the substance with which the stroke is made. Tin's may be either a thin plate of ivory or hone, or, still better, the first and second fingers of the left hand. AUSCULTATION may he — Immediate. — Where the car is applied directly to the walls of the chest. (2) Mediate. — Where the stethoscope is interposed between the ear and the walls of the chest. IV. NORMAL RESPIRATORY SOUNDS. VesK ILAIi BREATHING. Puerile Breathing. Bronchial Breathing. Tracheal ^ or V Breathing. Laryngeal j SITUATION' WHERE HEARD. All over the chest except the upper part of the sternum and the space between the scapulae, the inspiratory sound be- ing louder, and three or four times longer than the expiratory. Is the loud vesicular breathing of chil- dren, audible over the same parts of the chest as the ordinary vesicular breath- ing. Upper part of the sternum and the space between the scapuke in many healthy persons. Over the trachea and larynx. V. NORMAL VOICE SOUNDS. Ordinary Vocal Reso XAN'CE. SITUATION AND CHARACTER. Is the voice-sound heard over the pulmo- nary regions where vesicular murmur is audible. A muffled, diffused sound ; the articulation of the voice is not ap- preciable. Nai ural Bronchophony. Heard over the upper part of the sternum, and between the scapuhc in a certain number of healthy persons. A more distinct and concentrated sound than the last variety. DISEASES OF THE RESPIRATORY APPARATUS. VM V. NORMAL VOICE SOUNDS— {Coniinved). SOUNIJ. SITUATION AM) CHARACTER. Laryngophony and Trachophony. Voice-sounds heard over the larynx and trachea. Voice transmitted imper- fectly articulated to the ear of the <>!)- server, with so much loudness and con- centration as even to be painful. VI. ABNORMAL RESONANCE ON PERCUSSION. RESONANCE. Diminished in various degrees, or altogether Absent. Increased. Tympanitic. Amphoric. Box-like. Cracked-pot Sound. 'Deficiency of air, or ab- normal deposit, in the lung beneath the part percussed, or solid or liquid matter between the walls of the chest and the lung contain- ing air; or extreme distention of the chest with air. Air increased in quantity, or air in pleural cavity. A large cavity (or con- ditions resembling it) with very tense walls, containing air. Air expelled from cavity by sudden pressure. EXAMPLES OF DISEASE. Pneumonia, first stage. Phthisis; contracted lung, with thickened pleura. (Edema and congestion of lung. Tumors. Collapse of lung. Pneumonia, second and third stages. Intra-thoracic tumors and aneurisms. Effusions into pleural cavity, or its extreme distention by air. Emphysema. Tubercular cavity, hav- ing thin walls, and sit- uated near the surface. Pneumothorax. Extreme emphysema. Upper part of lung com- pressed by fluid below. Pneumothorax. Cavities. Cavity of considerable size, with large bron- chus opening into it, mouth of patient being open during percussion 138 DIFFERENTIAL DIAGNOSIS. VII. A.BXOKMAL INTENSITY, RHYTHM. AND QUALITY OF RESPIRATORY SOUNDS. r Feeble Breathing. S EXTINCT BREATHING. Pcerile, or SUPPLEMEN- TARY Breathing. Inter- III 1TED, Jerking, Cogged- wheel - Breathing. Prolonged Expiration. CHIEF CAUSES. Air entering the air-cells in di- minished quan- tity and force. The presence of a non-conduct- ing medium be- tween the lung and the chest- wall, or some impediment to the entrance of air into the bronchi. Air entering the air- cells w i t h increased rap- idity and force. Respiratory movements re- stra i n e d by pain, or mental emotion, o r some tempo- rary local ob- struction of the air-tubes. Loss of elasticity in the lung tis- sue. condition op ORGANS. Lu n g partially solidified either by increase of solid or fluid within it, or by pressure from without; dilata- tion of the air- vesicles; in some cases lungs not affec- ted. Lung solidified by pressure up- on its surface ; plug of mucus, fibrinous exu- dation or for- eign body in the bronchi, or tumor compres- sing the bron- chi. Healthy, but ex- aggerated in function. Varies with the disease causing it. Thinning of the walls of the aii- vesicles, with dilatation and destruction o f the alveolar septa. EXAMPLES OF DISEASE. Incipient phthisis. Bronchitis. Pneumonia, first stage. Tumors. Pleurisy. Kinphysenia. Pleurodynia. Pleuritic effu sion. Pneumothorax. Plastic bronch itis. Tumors. Foreign body in bronchus. Disease of oppo- site lung or of other parts of the same lung. Met with as a normal condi- tion in child- hood. Pleurodynia. Pleurisy. Debility, with palpitation. Hysteria. Incipient phthisis. Spasmodic asthma. Emphysema. DISEASES OF THE RESPIRATORY APPARATUS. 139 ' ExAGGER- ~\ ated, > Breathing. Coarse J Blowing, " Tubular, or Bron- chial Ca- vernous J Amphoric Breathing. - Breathing. chief causes. condition of organs. 'Lung not solidi- fied (soft sound). ABNORMAL INTENSITY, IMIYTIIM AND QUALITY OF RESPIRATORY SOUNDS— (Continued). EXAMPLES of MS EASE. Generally eon- istent with health a n d supplement- ary. Eeard in cases of uraemia and other blood poisoned dis- eases, and in hysteria and nervous dis- eases. Incipient phthisis. Phthisis. Pneumonia. Tumors. Tubercularand other cavities. Pneumotho- rax. Dilated bron- chi. Large cavities. Increased fric- tion in the air- cells and small- er bronchial tubes. Friction of air in the bronchial tubes, or in cav- ities of the lung. Air passing into a large cavity with dense walls. Lung solidified or bronchial tubes obstructed(harsh sound). Condensation of the lung between the chest wall and the larger bronchi or cavities. Cavities with dense walls. VIII. ABNORMAL DRY RESPIRATORY SOUNDS. SOUND. SITUATION. CAUSE. EXAMPLES OF DISEASE. SlBILUS. Lesser bronchial Vibration of thick mucus attached Bronchitis. tubes. to the wall of the tube, or con- Emphvsema. traction of the tube, due either Asthma. Rhonchus. Larger bronchial to swelling or spasm ; not easily removed by cough. Vibration of thick mucus in tubes ; Bronchitis. tubes. generally easily removed by cough. Dry Crackling. Humid Crackling. Pleural Friction Sound. Creaking Sound. CLICKING OR Smaller Bronchi. Smaller Bronchi. Layers of pleura. CRACKLING. ' Separation of the ad- herent walls of the bronchi — the dry tending to pass in- to the moist variety. Movement of opposed surfaces of pleura roughened by the de- posit of lymph or tu- bercle. Incipient phthisis. Phthisis, first stage. Pleurisy before ef- fusion has com- menced, or after absorption of the fluid. 140 DIFFERENTIAL DIAGNOSIS. IX. m:Xui;mai. moist i;i:si'h:at<>i;y SOUNDS. EXAMPLES OF SOUND. SITUATION. CAUSE. DISEASE. Crepitant 1! u.e. Air-vesicles. Opening up of collapsed Pneumonia in first i /■ ine or pneumo- air-cells, or separation stage. nic crepitation I. of their adherent walls CEdema of lungs. Collapse. S B CB K P IT A XT Smaller bronchial Bursting of air bubbles Capillary bronchi- Rale {Medium tubes. in fluid. tis. crepitation). Phthisical bronchi- tis. Resolution ofpneu- tnoma. CEdema of lung. Pulmonary apo- Mucous Rale Larger tubes and Bursting of air-bubbles plexy. Phthisis. i L.n-'ie Crepita- small or moderate- in fluid. Bronchitis. tio i. sized cavities. Haemoptysis. Gurgling or Ca- Large cavities (or Bursting of air-bubbles Phthisis (3d stage). vernous Rale. number of small cavities). in fluid. Bronchiectasis. Churning Sound. Lung in a state of Abscess of lungs. disorganization. ( i-angrene of lung. X. ABNORMAL AMPHORIC SOUND. Sim. ash on Suc- CUSSION. Bell Sound. Amphoric Echo and -M E TALLIC Tinkling. SITl'ATION. Cavity of pleura or large cavity. Cavity of pleura. Cavities. I'AI'SF.. Pneumothorax with effusion. Very large cavity. Pneumothorax. Sudden disturbance of air and fluid existing together. Auscultation of an air- containing cavity wh lie an assistant uses two coins, one as a ham- mer, the other as a pleximeter. Vibration of air in large Phthisis with very EXAMPLES OF DISEASE. cavities with tense walls. The former may be produced by rales and rhonchi in the chest, by the voice, and by the act of coughing; the latter requires, in addition, a little fluid at the bot- tom of the cavity, set in vibration by a mo- mentary impulse, such as ih" fall of a drop of fluid, and is essentially the echo of a bub- ble. large cavities. Pneumothorax with effusion. DISEASES OF THE RESPIRATORY APPARATUS. XL ABNORMAL VOICE SOUNDS. 1 II SOUND OF VOICE. Feeble or absent Vocal Reso- nance. Exaggerated V o cal Resonance. Bronchophony. Pectoriloquy. Amphoric R e s o • nance or Echo. CEgophony. CHARACTER OP SOUND. The obscure hum- ming or buzzing noise heard over the normal chest either very feeble or altogether ab- sent. Voice sounds unal- tered in quality or distribution, but louder and of greater intensity than natural. Voice-sounds heard louder, clearer, and more vibra- tory than natural, but unattended with articulation or tactile sensa- tion to the ear. Voice-sounds d i s - tinctly articulated and concentrated and as if spoken into the end of the stethoscope. A ringing metallic sound resembling that produced by speaking into an empty jar. A tremulous vibra- tory sound resem- bling the bleating of a goat, or the nasal Punchinello CAUSE. Primary bronchus obstructed; non- conducting m e - dium in pleura or rarefied condition of lung. Increased resound- ing or conducting power due to con- solidation of the lung, or to the for- mation of abnor- mal spaces. Much increased re- sounding or con- ducting power. Large abnormal cav- ity with dense walls. The voice reverbe- rating in a large cavity with a small aperture. A thin layer of fluid in the pleural cav- ity, with condensed lung behind. EXAMPLES OP DISEASE. Tumors compre or foreign body in bronchus. Pneumothorax. Pleuritic effusion. Emphysema. Incipient phthisis, Dilatation of bron- chi. Cavities due to phthi- sis or dilatation of the bronchi. Consolidation of the lung resultingfrom collapse, hasmor- rhagic infarctions, pneumonia, phthi- sis, cancer, etc. Phthisis, dilated bronchi, etc. Phthisis. Pneumothorax. Pleurisy with effu sion. 1-12 DIFFERENTIAL DIAGNOSIS. The quality and pitch of the vocal resonance varies g-rcatly in different individuals, and as a diagnostic aid is almost useless in women. Whis- pering, sometimes, will give more satisfactory results than the loud "one, two, three," that is so constantly heard in our clinical amphitheatres. The use of a small reed whistle, such as is found in childrens' rubber toys, will often give more uniform effects for comparison than the voice. GENERAL RULES FOR THE DIAGNOSIS OF DISEASES OF THE RESPIRATORY SYSTEM. The late Dr. John Hughes Bennett laid down the following prac- tical rules : — 1. A friction murmur heard over the pulmonary organs indicates a pleuritic exudation. 2. Moist or dry rales, without dullness on percussion, or increased vocal resonance, indicate bronchitis. 3. Dry rales accompanying prolonged expiration, with unusual reso- nance on percussion, indicate emphysema. 4. A moist rale at the base of the lung, with dullness on percussion, and increased vocal resonance, indicates pneumonia. 5. Harshness of the respiratory murmur, prolonged expiration and in- creased vocal resonance confined to the apex of the lung, indicates in- cipient phthisis. 6. Moist rales with dullness on percussion, and increased vocal reso- nance at the apex of the lung, indicate either advanced phthisis or pneu- monia, generally phthisis. 7. Circumscribed bronchophony or pectoriloquy, with cavernous dry or moist rales, indicates a cavity. This may be dependent on tubercular ulceration, a gangrenous abscess, or a bronchial dilatation. The first is generally at the apex, and the last two about the centre of the lung. 8. Total absence of respiration indicates a collection of fluid or of air in the pleural cavity. In the former case there is diffused dullness, and in the latter diffused resonance on percussion. 9. Marked permanent dullness, with increased vocal resonance and diminution or absence of respiration, may depend on a chronic plastic pleurisy, a thoracic aneurism, or a cancerous tumor of the lung. DISEASES OF THE RESPIRATORY APPARATUS. 1 U? TPIE FORMS OF PHTHISIS. The most recent writers, both in the United Slates and Europe, are agreed in recognizing three principal varieties of phthisis.* It is of import, both to the prognosis and therapeutics of the case, to distinguish these aspects of the disease; and although in many cases the typo is by no means prominently defined, in the majority there is no great difficulty in assigning them to one or another class. The three forms are: — 1. Catarrhal or inflammatory phthisis: "Desquamative pneumonic phthisis." (Buhl.) Chronic broncho-pneumonia. 2. Fibroid phthisis. Cirrhosis of the lung. Chronic pneumonic phthisis. Bronchial phthisis. Chronic interstitial pneumonia. 3. True primary tuberculosis. Tubercular phthisis. Tubercular pneu- monia (Da Costa). On the clinical recognition of these three varieties, Dr. Alfred L. Loom is says : — If a case of phthisis present himself for examination, and it is found that the disease began with the ordinary symptoms of a cold, and that this cold periodically improved and relapsed, but that the cough never left him, but became more pronounced and deepened into what we usually find in advanced phthisis, accompanied with emaciation and occa- sional haemoptysis, we are in a position to say that the patient presents the usual characteristics of catarrhal phthisis. If, however, he gives a history of persistent cough for many years, as is found in chronic bronchitis, and eventually furnishes the rational history of advanced phthisis, with the presence of cavities in the lung, we may consider him as having the disease of the fibrous form, in which cavities are the result of dilated bronchi. Finally, if the patient says that an early symptom was emaciation, with impaired digestion, accompanied by a dry, hacking cough, and if, more- over, there was a steady rise in the temperature, we are justified in sus- pecting the presence of tubercular phthisis. * Dr. A. B. Shepherd, Medical Press and Circular, July, 1876 ; A. L. Loomis, New York Medical Journal, February, 1877; Roswell Park, Chicago Medical Journal, September, 1878; Prof. Bartholow, Mediccd News and Abstract, etc. 144 DIFFERENTIAL DIAGNOSIS. Temperature. Physical Signs. THE FORMS OF PHTHISIS — CHRONIC CATARRHAL PNEUMONIA. t Period of Invasion... Precursory catarrh, sometimes pneumonia, croup, measles, or other inflammatory disease; cough "deepens," proceeding from the trachea to the alveoli and bronchioles, indicated by dark yellow streaks in the sputum. Fever and wasting not marked at outset. Haemop- tysis not common at this period. The hectic is more of a remittent or inter- mittent than of a continued type; with a range of, say, 1.1° C between evening- and morning temperature; the evening elevation being a constant feature. The fever may present all possible variations in the same individual. A sudden accession may be regarded as an indication of some fresh inflammatory process; e. g., pleuritis, pneu- monia. With marked evening rise of temperature, the rate of respiration does not correspondingly accelerate ; hardly ever more than six or eight breaths per minute. In the first stage, feeble, harsh or puerile respiratory sounds are heard, with all the signs of catarrh at apices and elsewhere. Dullness usually marked; when its area accords with the other signs it is a compara- tively favorable feature. The presence of lobular infiltration may, in some cases, cause a hollow or tympanitic note. "Cracked-pot" resonance over a cavity with thin walls. Fremitus is intensified over cavities connect- ing with bronchi and containing air. Bronchial respiration, bronchophony, and sonorous rules are heard after extensive indu- ration. Not impaired in the early stage, but when cavities form, hectic and emaciation set in and we have "pneumonic phthisis." May continue for years, until pneumonic phthisis is developed, when it lasts only a few months. G ENERA L NUTRITK >N. . DISEASES OP THE RE3PIRATORY APPARATUS. 1 1 3 COMPARISON OF THE FORMS OF PHTHISIS. TUBERCULAR. More or less dyspnoea, gradually increasing. Cough, worse in winter, sometimes absent in summer. Hae- moptysis frequent. Pulse slightly rapid, perhaps irregular. Expecto- ration often profuse, mucous or muco-purulent. Elevation of temperature and other febrile symptoms very varia- ble, sometimes wholly absent (Bris- towe). No special type. Notable dullness on percussion, resonance sometimes tympanitic. Respiration bronchial, or broncho- vesicular. Bronchophony and in- creased vocal resonance. The af- fected side becomes contracted either entirely or in part. Bronchial dilatation (fusiform) gives the physical sign of a cavity. Not incompatible with apparent good health. Duration indefinite. Commences in the alveoli, bron- chioles, or connective tissue. Pallor, fever, emaciation and night-sweats early. Cough hoarse and hard, voice hoarse or inaudible, distress- ing laryngitis. The sputa retain the crude character of the mucous sputa of acute bronchitis. Spleen somewhat enlarged. The hectic is of a continued type ; temperature always above normal, but not much higher in the evening than in the morning ; i. e., the re- missions not well marked; more- over it resists treatment. Signs not well marked, not suffi- ciently so to account for the symp- toms. Solidification not extensive. Expansion unequal. Cavities form after softening, with destruction of lung tissue. Health obviously impaired. Lasts about a year. THE DIAGNOSIS OF INCIPIENT PHTHISIS. There is no absolutely sure symptom of phthisis previous to percussion dullness, but a very strong presumption of its approach can be drawn from the presence of the following changes : — 1. Emaciation. Where there is progressive emaciation without assign- able cause, and especially if the appetite continue good, phthisis should always be suspected. The loss of flesh first shows itself in a retraction of the skin over the cheeks, a thinning of the lips and ears, and a 146 DIFFERENTIAL DIAGNOSIS. pinched appearance of the nose. The nostril on the affected side is usu- ally slightly more dilated than the other. 2. Ancemia, seen in the bluish hue of the sclerotic, and in the pallor of the cheeks. 3. Sore throat and hoarseness. A very early symptom. On exami- nation the pillars of the fauces are found hyperamiic, the throat con- gested and the bronchial glands enlarged. 4. Sitrlling of mucous membrane of larynx, especially forming a tur- ban-shaped epiglottis, which at the same time assumes a horse-shoe bend; and pyriform enlargement over the arytenoid cartilages (Seiler).* 5. Depression of the acromial end of the clavicle, on the affected side. In health the acromial end is slightly higher than the sternal end. 6. Rheumatoid pains in the arms coming suddenly at night or in the early morning, not increased on moving the arms. 7. Pityriasis versicolor, in the form of pale yellow or reddish spots appearing on the skin of the chest, neck and arms. This is considered by Aufrecht a very characteristic symptom. 8. In regard to the breathing, what is considered as suspicious are weak, jerking, " cogged wheel " or sonorous sounds, rough breathing, a lengthened strong expiration after soft inspiration, especially when in cir- cumscribed regions these sounds differ from those on the other side of the chest. The most appropriate spot to note the duration of expiration is over the larynx or trachea. In proportion as the tubercular deposit is more extended, the expiratory murmur becomes more tubercular in qual- ity and higher in pitch (Armor). In normal cases the respiratory sound becomes weaker in the supra-spinous region outward from the vertical column. Dr. Heitler considers it, therefore, strong evidence of incipient pulmonary phthisis if the respiratory sounds during expiration are more sonorous over these regions than nearer to the vertebral col- umn.f 9. Unequal expansion of chest is an early sign of commencing disease of the apex. The expansion is less on the diseased side. 10. Alterations in temperature curve frequently take place early. The temperature may be low, but its characteristic range will be : (1) a * Proceedings Philadelphia Co. Medical Society, vol. ii, p. 101, Philada., 1880. f Dobell's Reports on Diseases of the Chest, 1877. DISEASES OF THE RESPIRATORY APPARATUS. 1 17 marked rise after 2 p.m.; (2) a rapid fall after 10 p.m.; (3) minimum about 7 a.m.; (4) recovery to normal about 10 a.m. (C. T. Williams). Such a curve must always excite grave suspicions. 11. Rapidity of pulse. A persistent and sustained increase in the pulse rate, without cardiac disease, is a valuable rational sign, present very early in most cases. 12. The cough of incipient phthisis is usually short, hacking, and dry, or with a slight, glairy, mucous expectoration only. From the presence of fragments of the pulmonary fibrous tissue in the sputum, "we are sometimes enabled to suspect the existence of consumption before the physical signs of even its early stages are well defined." (Da Costa.)* 13. Haemoptysis. The appearance of haemoptysis is always a serious element of diagnosis. Light, frothy, red blood, rising without apparent exertion, is an indication which, in America at least, has proved of graver meaning the more it has been investigated.f On the other hand, cases will be met with sometimes, in whom there may be considerable haemop- tysis, with marked dullness at the apex, without the significance of tubercle.J 14. Clubbing of the finger ends, when associated with incurvation of the sides and tips of the nails, means obstruction of the subclavian veins, which is one of the earliest effects of tuberculosis ; but clubbing without this incurvation is rather against the probability of tubercle (Dobell). 15. Amennorrhea is, in young females, often one of the earliest signs of phthisis. 16. A red line is occasionally noticed on the gums at the base of the teeth. 17. Arthritis. M. Laveran§ has drawn attention to the occasional occurrence of arthritis as the first symptom of a general tuberculosis. * To examine sputa for elastic fibres, mix it with a soda solution : — R . Liquor soda?, 1 part Aquas destill., 2 parts. M. And boil for four or five minutes. Then dilute with an equal quantity of distilled water, and pour into a flat porcelain vessel. The particles suspended in the water may then be taken out and examined under the microscope. The fibres in this process are brown, slightly reticulated, and a fraction of a millimetre in length (Sokoi.owski). f See second Report of the New York Mutual Life Insurance Company, 1877. % See Prof. Da Costa, in Medical and Surgical Reporter, July 13, 1878. I Le Progres Medical, October 25, 1876. Quoted by Dr. M. Axderson. 148 IWI'IF.KKNTIAI. DIAGNOSIS. DIAGNOSIS BETWEEN INCIPIENT PHTHISIS AND BRONCHITIS. INCIPIENT PHTHISIS. 1. The cough commences gradu- ally, without marked disturbance or coryza, often preceded by slight loss of flesh and strength. 2. The cough is generally dry and hacking at commencement, followed by the expectoration of a thin mu- cous fluid, which soon becomes thick and opaque, or is slightly streaked with blood. 3. Examination by the micro- scope shows portions of lung tissue (yellow elastic fibres) in the sputa. 4. Pain of a wandering character about the chest, especially under the clavicles or between the shoulders. 5. Evening rise of temperature. 6. The morbid physical signs usu- ally confined to upper lobe of one side; are very persistent, and if on both sides at first, apt to subside on one and increase on the other. 7. Family history and general appearance indicate tuberculous ca- chexia. Most frequent in youth. 8. Essentially chronic. While these points of difference between tubercular disease and catar- rhal inflammation of the mucous membrane lining the bronchial tubes are in the main reliable, yet it must not be forgotten that chronic bron- chitis is often attended by structural changes in the lung, leading in one set of cases to increase of connective tissue, with dilated bronchiae-fibroid degeneration, chronic broncho-pneumonia — and in another to deposits, chiefly epithelial, in the air cells, producing spots of consolidation. BRONCHITIS. 1. The cough commences sud- denly, and is usually ushered in by | feverishhess and coryza. 2. The cough is accompanied with expectoration almost from the first; generally abundant; frothy or muco-purulent; not often blood- stained. 3. No evidence of destruction of lung tissue. 4. A feeling of tightness and raw- ness behind the sternum, aggravated by coughing. 5. Elevation of temperature not particularly marked toward evening. 6. Morbid signs usually predomi- nate in the lower lobes; are on both sides; are of temporary duration, and subside gradually and equally on both sides. 7. No marked hereditary tend- ency; common at all ages. 8. Has an acute beginning. DISEASES OF THE RESPIRATORY APPARATUS. I I 'J The general clinical history of phthisis may he summed up in the fol- lowing brief table : — PULMONARY PHTHISIS. (CHRONIC TUBERCULAR PNEUMONIA.) STAGE OF DISEASE. 1st stage (incipient). Stage of invasion. 2d stage (confirmed), stage of deposit. 3d stage (advanced). Stage of soft- ening and formation of cavities. Cough at first dry, then with expectoration of mu- cus, frequently streaked or dotted with blood, or with copious haemoptysis. Dys- pnoea. Pains in the various parts of the chest, especi- ally on the affected side. Dislike to fatty articles, and other dyspeptic symp- toms; tendency to vomit- ing after paroxysms of coughing;. Night-sweats. Emaciation. In females, disturbance of the catame- nial functions. Occasion- ally hectic. Cough more severe, with puriform expectoration, of a yellow or greenish hue, and often bloody. Pro- fuse night-sweats and rap- idly progressive emaciation. Pinched and anxious ex- pression. Loss of appe- tite. Thirst. Diarrhoea. Sometimes hectic. Cough rather looser, still with puriform (nummular) expectoration, or attacks of copious haemoptysis. Ex- treme emaciation and debil- ity, with or without night- sweats. Voice husky and hollow. Aphthae on mouth and fauces. Hectic. Clubbed fingers and talon-like nails. PHYSICAL SIGN'S. Diminished movements. In- creased vocal fremitus. Loss of percussion resonance, rise in pitch, or a boxy, wooden note beneath the clavicle or in the interscap- ular region. Feeble, coarse, or interrupted vesicular murmur, with prolonged ex- piration. Increased vocal re- sonance. Occasional sibilus or creaking friction sound. Heart sounds abnormally loud over affected side. Subclavian murmur. Pue- rile (exaggerated) respira- tion on sound side. Greater diminution of move- ment of the affected side, and some amount of flat- tening. Increased vocal fremitus. Increased dull- ness, extending downward. Bronchial breathing, mixed with mucous rales or with click at the end of each in- spiration. Bronchophony. Scarcely any movement of the affected side. Marked flattening. Increased vocal fremitus. Dullness less marked. Box-like reso- nance or cracked-pot sound. Cavernous breathing, with gurgling and splash on cough. Occasionally metal- lic sounds. Pectoriloquy. 150 DIFFERENTIAL DIAGNOSIS. PHTHISIS— (Continued ). COMPLICATIONS NOT RESTRICTED TO ANY PARTICULAR STAGE OF PHTHISIS. The chief of these are: Affections of the larynx and trachea, especially ulceration ; bronchitis, intercurrent pneumonia, or pleurisy ; perforation of the pleura, with pneumo-hydrothorax or empyema; enlargement of the external absorbent glands, or of those in the chest and abdomen ; tubercular peritonitis; ulceration of the intestines, especially the ileum; fatty or amyloid liver; fistula in ano; various forms of Bright's disease; diabetes; pyelitis; tubercular meningitis, or tubercle in the brain, and thrombosis of the veins of the legs. POST-MORTEM APPEARANCES. First stage. Usually most marked at, or even confined to, one apex, Avhere are to be seen gray, semi-transparent nodules, varying in size from a small pin's head to a hemp-seed ; the lung-tissue around these nodules may be healthy, but is generally hypersemic and congested, slightly in- creased in density. In more advanced cases, in addition to the miliary nodules, there may be small yellow masses, less defined, but larger than the gray variety. Both kinds may either be scattered or several in one group, forming a considerable mass. Second stage. Commencement of caseation and softening in the cen- tre of the consolidated portions, inflammation of the surrounding paren- chyma, together with obliteration of the blood-vessels and formation of cicatricial tissue. TJtird stage. Cavities of various sizes and forms, and either single or numerous, generally containing puriform fluid. Ulceration and dilation of the bronchial tubes. Lung indurated and puckered in proportion to chronicity of disease. ACUTE PHTHSIS, ACUTE MILIARY TUBERCULOSIS, GALLOPINQ CONSUMPTION. The formidable disease known under these names is probably, as M. Bouchut remarks, more common than is generally supposed, as it is gen- erally mistaken either for capillary bronchitis or typhoid fever, especi- ally the latter. Its duration is brief, sometimes less than a fortnight (Da Costa), and its termination almost invariably fatal. Its features DISEASES OF THE RESPIRATORY APPARATUS. 151 are thus so entirely distinct from the chronic form, from the clinical point of view, as to really constitute it a separate disease. Its onset is marked by chills and feverishness, nausea, vomiting and diarrhoea. There is a rapid pulse; dyspnoea; slight pain in the chest; cough, usually with profuse expectoration. Great exhaustion, sweats, rapid emaciation, and delirium, soon follow. One or both lungs exhibit unusual dullness, while the auscultatory sounds differ greatly in different cases. The following are the marked diagnostic features of the disease : — 1. Facial expression. The countenance is livid, indicating plainly an impediment to the passage of blood through the lungs. In severe typhoid fever the cheeks are slightly flushed, the facial muscles tremulous, the eyes dull, and the mouth partly opened, presenting an appearance charac- teristic of the disease.* 2. The delirium of acute phthisis is restless and often violent, but the rambling and wild talk is connected usually with things present or near. In typhoid fever the delirium is generally muttering and low; the mind deals with things absent, and the patient "is like a man talking in his dreams" (Watson). 3. The tongue in acute phthisis, at first covered with a white fur, soon becomes red, glassy and dry. In typhoid it usually changes to a brownish hue. 4. The ophthalmoscope is a most positive aid to the diagnosis, accord- ing to M. Bouchut. In all cases of acute, general, miliary tuberculosis, an ophthalmoscopic examination will reveal the presence of tubercular granulations in the choroid,f thus placing the nature of the disease be- yond doubt. 5. Abdominal symptoms. Diarrhoea and gastric and abdominal pains are often present in acute phthisis ; but the red spots of typhoid are not seen. 6. Chest symptoms. Dyspnoea is present always, but the orthopncea of capillary bronchitis is rare (Shaw). The respiration is greatly cmickened, and the proportion to the pulse averages 1 : 3 (Walshe). The presence of percussion dullness, a sinking in at the upper part of the chest, and the occurrence of hemorrhage, are conclusive evidence of tubercle (Da Costa). * L. J. "Woollen, American Practitioner, July, 1871. t Medical Times and Gazette. January, 1875. 152 DIFFERENTIAL DIAGNOSIS. 7. The sputum shows the characteristic serous and rauco-purulent character, and may contain the elastic fibre of lung tissue. DIAGNOSIS OF SYPHILITIC PHTHISIS. The distinctive traits of this form of consumption have lately been separately studied by Dr. MacSwinney, of Dublin,and Dr. Pentimalli, of Naples. Their results are combined in the following scheme: — 1. Absence of hereditary tendency, of a phthisical habitus, and of pre- ceding pulmonary affections. 2. History of syphilitic disease in other organs, and presence of the syphilitic cachexia in its tertiary stage. 3. The disease never begins in the apex, and is limited in its seat, being unilateral and generally posterior (Pentimalli). 4. Haemoptysis rare, febrile symptoms absent or slight. 5. Slowness in development, the acuter phthisical symptoms not manifest. 6. Exacerbation of pain during the night. 7. A peculiarly fetid breath. 8. Reference of the feeling of oppression to the larynx rather than to the chest. 9. Failure of ordinary measures, and improvement under specific medi- cation. BRONCHITIS, ACUTE AND CHRONIC. In most cases of bronchitis the inflammation is seated in the larger bronchial tubes. There is more or less swelling of their lining mucous membrane, not generally sufficient to prevent a free passage to the breath- ing air. The characters of the acute and chronic form are set forth in the tables, in the following pages. There is a variety of chronic bronchitis, in which the material exuded on the surface of the air passages contains a large proportion of a fibrinous constituent which makes it tough and consistent, so that when expelled the substance appears as a perfect cast of the bronchial tube in which it was formed. This is called fibrinous bronchitis, and does not differ in pathology from the ordinary chronic variety, but is less sus- ceptible to treatment. Its diagnosis is made from the appearance of the casts, and needs no further mention here. DISEASES OP THE RESPIRATORY APPARATUS. L5 ACUTE BRONCHITIS. 1st or Dry Stage. 2d or Moist Stage. 3d Stage. (Termina- tion favor- able.) Unfavorable. Chilliness, followed by fre- quent pulse and febrile symptoms ; pains in limbs. Substernal pain. Hoarse dry cough. Feeling of oppression and tightness about the chest. Cough, with expectoration of frothy, transparent mucus, mixed with air- bubbles of various sizes, and occasionally tinged or streaked with blood. Urgent dyspncea, often amounting to orthopncea. Lividity and febrile symptoms increased. Restlessness at night. Gradual remission of the symptoms. Expectora- tion becomes thick, green- ish, and opaque, and sometimes nummulated. Dyspnoea very urgent, signs of impending suffocation. Profuse cold sweats. Sink- drowsiness and de- Less cough, ab- sence of expectoration. lirium. I'UYHICAI, ,sh;xs. Breathing hurried. Rhon- chal fremitus may be felt. Resonance on percussion unimpaired. Feeble vesi- cular murmur, mixed with rhonchus and sibilus. Puerile breathing in un- obstructed parts of lung. Vocal resonance not ma- terially altered. Breathing hurried. Rhonchal fremitus may be felt. Re- sonance on percussion clear or only very slightly impaired. Feeble vesicu- lar murmur mixed with rhonchus, sibilus and mu- cous rales. Vocal reson« ance unaltered. Less amount of sonoro-sibil- ant and mucous rales, with return of normal vesicular breathing. In addition to the signs of the second stage, tracheal rales may be heard. The -post-mortem appearances are : Congestion of mucous membrane of bronchial tubes, with some degree of swelling and dryness of surface. Lungs do not collapse when the chest is opened ; nor do sections sink in water. The mucous membrane of the bronchi is red and swollen, and the tubes filled with frothy, adhesive mucus. 154 DIFFERENTIAL DIAGNOSIS. CHRONIC BRONCHITIS. PHYSICAL SIGN'S. Respiration labored and abdom- inal. Vocal fremitus not materially altered ; rhonehal fremitus can gener- ally be felt. Impairment of reson- ance or a hyper-resonant note, ac- cording as collapse of lung and con- solidation, or emphysema predomin- ate, the former most marked at the bases, the latter at the anterior part. Feeble vesicular murmur. Rhou- chus, sibilus, and mucous rales. Vo- cal resonance varies. Two chief forms : the one characterized by the sputa being expectorated with great difficulty, consisting of small, gray, semi-trans- parent pellets, and tending toward emphysema; in the other the sputa are abundant, muco-purulent, and brought up with ease; dilatation of the bronchi frequently associated with this form. The cough gener- ally comes on at the approach of winter ; with the history of former attacks. Dyspnoea; lividity of sur- face ; and in some cases the symp- toms resemble those of chronic phthisis, as wasting, with night sweats and hectic. The post-mortem appearances are : — Lungs generally much congested, presenting a dark livid hue, with portions collapsed, and others emphysematous. Bronchial tubes fre- quently dilated. Mucous membrane thickened, uneven, sometimes ulcer- ated, covered by a thick, puriform secretion, or sparingly coated by a tenacious, glairy, semi-transparent substance. The principal diseases with which bronchitis may be confounded are pneumonia, pleurisy and phthisis. But each of these is characterized by the presence of definite physical signs, which are not to be found in ordinary bronchitis. For instance, in this disease there is no disparity between the two sides of the chest in the resonance obtained by percus- sion, nor in vocal resonance, the bronchial whisper and fremitus. The swelling of the bronchial mucous membrane may cau->e some diminution of the intensity of the vesicular murmur ; but as the affection is bilateral and the bronchial tubes on both sides are affected equally, both in degree and extent, there is no appreciable disparity between the two sides. Sometimes temporary weakening or suppression of the murmur may be caused by a plug of mucus, which will be detected on a second examina- tion (Flint), or by instructing the patient to cough, so as to dislodge it. DISEASES OF THE RESPIRATORY APPARATUS. 155 CAPILLARY BRONCHITIS. Acute capillary bronchitis may, however, be taken for some of the forms of pneumonia, and in fact the descriptions of some writers would lead to the belief that they have committed this error. The following distinctions will make the diagnosis easy in most cases : — PNEUMONIA. CAPILLARY BRONCHITIS. Commences in the external air passages as a common cold and ex- tends downward. Always bilateral. Normal or exaggerated resonance on percussion unless collapse has commenced. Sub-crepitant rales on both sides of the chest. Respiration not bronchial, 50 or more; pulse 150 or more. Muco-purulent expectoration ; no plastic lymph. Dyspnoea intense ; cyanosis early. No pain or but little. Death from asphyxia; mortality more than half. A disease of children. Commences suddenly with a chill, and attacks the lungs directly. Generally unilateral. Dullness on percussion more or less extensive at the outset. Crepitant rale. Respiration bronchial, 25 to 40 per minute. Pulse 100 to 130. Rust-colored expectoration ; plas- tic lymph in pulmonary air cells. Dyspnoea less ; cyanosis late if at all. Pain in the side. Death from asthenia; mortality ten per cent. A disease of adult life. PNEUMONIA AND PLEURISY. Ordinary acute inflammation of the lungs in its early or first stage is well marked by the presence of a moderate or slight dullness on percus- sion over the affected lobe, and the detection on auscultation of the crepitant rale. The latter is indeed not invariably present, but w r hen it is, taken in connection with the symptoms, it is pathognomonic. Later in the disease the rust-colored expectoration of pneumonia on the one hand, and the physical signs of effused liquid into the pleural cavity in pleurisy on the other hand, offer distinctive features. The general clinical histories of the diseases are given in the following tables : — 156 DIFFERENTIAL DIAGNOSIS. PNEUMONIA. 1st Stage. (Engorge- ment.) 2d Stage. (Red hepatization.) 3d Stage. a (Gray hepatization.) or b (Resolu- tion.) SYMPTOMS. Single, severe rigor (or convul- sions in children), followed by heat of skin. Increased fre- quency of pulse. Respiration greatly accelerated, with con- sequent disturbance of the pulse-respiration ratio. Dysp- noea. Pain in the side, in- creased by cough or deep in- spiration. Cough, at first dry, with rusty sputa about the second or third day. Inability to lie on affected side. Dilated alee nasi. Herpes about lips. Increased distress and dysp- noea. Respiration and speech panting. Cough more urgent, and sputa still rust-colored, extremely viscid, and tena- cious. Absence or deficiency of chlorides in the urine. Aspect much distressed. Face pale and livid. Great failure of vital powers. Hectic and delirium. Cough continues, and the sputa are either absent, or sometimes they remain rust- colored ; at others become like prune-juice, even fetid. Symptoms yielding about 7th day of disease. Cough less troublesome, expectoration easier. Patient evidently con- valescing. l'll\ SICA1. SHINS. Diminished movement on the affected side. Respiration abdominal. Vocal fremitus normal. Percussion note not ma- terially affected. Feeble vesicular breathing. Fine crepitant rale, most frequently heard at base of lung and at the end of inspiration. Very slight movement. Vocal vibrations well marked. Dullness on percussion. Tubular breathing and broncho- phony, generally accom- panied by some rales, if at the commencement of the 2d stage of a crepitant character, and afterward of a mucons nature. Absol ute dullness on percussion . Tubular breathing and broncho- phony, frequently with gurgling rales where the lung is disorganized. Dullness diminishing by absorption. Broncho- vesicular breathing with crepitant redux rales yielding to normal vesi- cular murmur, and per- cussion-note. DISEASES OF THE RESPIRATORY APPARATUS. 157 Post-mortem Appearances. — Lungs: 1st stage. Engorged with frothy and bloody serum. Dark-red eolor externally, and on section. Crepitating less, and heavier, than sound lung, but still floating in water. Pulmonary tissue slightly softened. 2d. Red externally, red or mottled and granular on cut surface, and of liver-like solidity. Easily torn, and with fluid exuding on pressure less abundant than in first stage, but thicker, and towards the end of this stage becoming purulent. Not crepitating, and sinking in water. 3d. Reddish-yellow or gray. More rotten and friable. Purulent fluid exudes from the cut surface; and, on pressure, the whole lung may be reduced to a pulp-like mass. PLEURISY. The symptoms of pleurisy are attributed to inflammation of the serous covering of the lungs, and is to be distinguished from passive effusion into the pleural sac, which is known as hydrothorax, which is readily recognized by the following points of difference : — PLEURISY. Due to inflammation (active). ' Has an acute beginning, accom- panied by stitch in the side, cough, constitutional disturbance, pyrexia, etc. May be traced to traumatic causes, or to exposure to wet and cold; or may complicate zymotic diseases. One side only affected, as a rule. Runs its course in a few days, ter- minating in chronic pleuritic effu- sion, or in absorption of fluid. No complications generally. HYDROTHORAX. Due to transudation (passive). Effusion takes place insidiously, without local or general symptoms, beyond those caused mechanically by pressure on the thoracic viscera. Due to blood disorder, accom- panying renal disease, or more rarely to obstruction to circulation by morbid growths, or valvular disease of heart. May be bilateral. Remains stationary for months, or may slowly increase. Accompanied by albuminuria, heart disease, and dropsy elsewhere in the body. 158 DIFFERENTIAL DIAGNOSIS. PLEURISY. Pleurisy : 1st Stage, or Stage of Hy- peremia. 2d Stage, or Stage of Ef- fusion. Rigors, or more fre- quently mere chilliness. Sharp, stabbing pain in the side, increased by deep inspiration or cough, accompanied by more or less ten- derness on pressure. Breathing short and hurried. Respiration chiefly abdominal, with inability to lie on the affected side. Short, dry cough, or none at all. Pulse full and bounding. Febrile symptoms. Cough, dyspnoea, sense of weight and fullness of the affected side. Fe- brile symptoms less marked. Patient lies toward, not on, the af- fected side. Complex- ion inclined to be dusky. PHYSICAL SKiXS. Diminished movement on the af- fected side. Friction fremitus may sometimes be felt. Percus- sion sound not materially alter- ed. Vesicular murmur feeble and jerking in rhythm. To- and-fro-friction sound. Almost total absence of move- ment of the affected side, which is unduly prominent, the inter- costal spaces being obliterated or even bulging. Integuments occasionally oedematous. Vocal vibrations absent. Complete dullness on percussion, most marked in the dependent por- tions of the chest, and some- times altered by change of pos- ture. Heart pushed over to sound side, and diaphragm pushed down, so that the liver and stomach descend lower into the abdomen than in health. Vesicular murmur almost, or quite, absent. Frequently bron- chial breathing near the spine. Voice sounds absent or feeble, except when the layer of fluid is thin, and then there may be segophony. No friction sound. Puerile breathing in sound 1 ung. DISEASES OF TIIE RESPIRATORY APPARATUS. 1 59 PLEURISY— ( Continued ) . 3d Stage (Res- olution after Effusion). SYMPTOMS. Gradual diminution of the cough, dyspnoea, and other symptoms. Returning ability of the patient to lie on the sound side. Gradual return of displaced or- gans to their normal position. IMIYSIOAI, SIGNS. The movement of the chest grad- ually increases. Return of vocal vibration and friction fremitus. The dullness on percussion di- minishes from above down- ward, but the resonance gener- ally remains box-like for a considerable period. Gradual restoration of the vesicular murmur, at first weak and dis- tant, then somewhat harsh, and subsequently of a normal char- acter. Reappearance of the friction sound for a time. Pseud o rales occasionally to be heard. iEgophony sometimes to be heard, more often bron- chophony, and ultimately nor- mal vocal resonance. Post-mortem Appearances. — 1st stage. Pleura opaque and drier than natural, roughened and highly vascular, and presenting a close net- work of blood-vessels with ecchymoses. 2d. Fluid, either serous or purulent, mixed with shreds of creamy lymph, in the cavity of the pleura. Lung pushed upward and back- ward towards the spine, its surface coated with a layer of lymph of the same kind as that mixed with the fluid. The lung collapsed and carnified. 3d. If the effusion has been of long duration the lung remains carni- fied and bound down by adhesions, and the chest-wall undergoes retrac- tion or depression, the ribs overlap, and there is more or less lateral curvature of the dorsal spine toward the diseased, and of the lumbar toward the healthy, side. The diagnosis can be made by drawing off part of the fluid from the chest by means of a hypodermic syringe. If purulent, it should be evacuated, or it may lead to amyloid change in the liver and kidneys. The effusion may become purulent at first; there are no reliable means of recognizing the exact time when this occurs, but later it assumes all the characteristics of empyema, as follows : — 1G0 •DIFFERENTIAL DIAGNOSIS. Empyema. PHYSICAL SIGNS. More decided febrile dis- turbance of a hectic type, night sweats. Morning remission and evening exacerbations. Face puffy and semi- transparent. Clubbing of the finger ends. If pointing inwardly, abundant purulent sputa. The physical signs are those of the stage of effusion. The di- agnosis is often to be deter- mined only with the aid of the aspirator, or the hypodermic needle. DIAGNOSIS BETWEEN PLEURISY WITH EFFUSION AND PNEUMONIC CONSOLIDATION. PNEUMONIA. 1. Begins with a severe and pro- tracted rigor. PLEURISY. 1. Begins with chilliness or seve- ral slight rigors. 2. Sharp, catching, stitch-like pain in the side. 3. Cough, dry or with little mu- cous expectoration, very painful, and repressed by the patient. 4. Pyrexia is not great and the skin may be moist. 5. Excretion of chlorides not affected. 6. Pulse-respiration ratio not af- fected, except in excessive effusion. 7. Affected side rounded; dis- placement of heart. 8. Feeble or absent vocal fremi- tus. 9, sion Absolute dullness on percus- transgressing the median line in front. 10. Feeble or absent vesicular breathing; bronchial breathing at the root of the lunsr. 1 1 . Vocal resonance absent, some- times segophonic. I. Pain does not catch the breath ; is more of a dull character. 3. Cough frequent and severe, with rusty, viscid expectoration. 4. Great febrile disturbance, skin hot and pungent. 5. Diminution or absence of chlor- ides in the urine. 6. Pulse-respiration ratio may fall to 2 : 1. 7. No alteration in shape of the chest or of the intercostal spaces ; heart not displaced. 8. Vocal fremitus usually much intensified. 9. Less intense dullness, not trans- gressing the median line. 10. Marked tubular breathing, often of a metallic character. II. Loud bronchophony. DISEASES OF THE RESPIRATORY APPARATUS. Hil DIAGNOSIS BETWEEN PNEUMONIA AND PULMONARY APOPLEXY. (PULMONARY EMBOLISM.) PULMONARY APOPLEXY. Nearly always associated with heart disease or pyaemia. Fever absent ex- Pulse irregular Onset sudden, cept in pyaemia, and intermittent. Expectoration small dark clots. blackish, with Dyspnoea severe at first, after- wards diminishing;. Dullness distinctly circumscribed ; respiration bronchial, with moist rale. A peculiar acid and alliaceous odor to the breath " like the smell of tincture of horse radish" (Gue- NEAU DE MUSSY). PNEUMONIA. Generally an independent disci-'; in robust individuals. Onset with malaise and chill, ver. Pulse rapid. Fe- Expecto ration clots. rust-colored ; no Dyspnoea gradually grows in in- tensity. Dullness larger and extending. Crepitant rale. Tubular breathing, bronchophony. Not present. THROMBOSIS OF PULMONARY ARTERY. The symptoms of an immediately fatal attack are: Sudden extreme dyspnoea with open tubes, cough and thoracic pain, lividity or pallor, rapidly failing pulse, cold sweats, intense anxiety, and attacks of faint- ing or unconsciousness, with or without spasms. In the diagnosis, the suddenness of the conditions being of the chief interest, all those forms of suffocation requiring time for their production may be disregarded, and there remain : — 1. Closure of the greater air passages or of a large number of small ones, from without or from within. 2. Nervous lesions, particularly intra-cranial, affecting respiration and circulation. 3. Obstruction to the pulmonary circulation from emboli, of blood and air particularly, fat being more gradual in its effects. Physical and rational evidence of open air passages eliminate the first series. In intra-cranial origins of suffocation the predominant early 162 DIFFERENTIAL DIAGNOSIS. symptoms are those of cerebral amemia, namely, pallor, relaxed muscles, disturbed Inuring- and vision, contracted pupils, fainting and convul- sions. Dyspnoea may sometimes preeede these symptoms, but it is not of so severe a character as in the other series. In favor of the third is the history of an antecedent thrombus, or of a disease of the heart likely to be associated with thrombosis or of septi- caemia. ASTHMA. SYMPTOMS. PHYSICAL SIGNS. There may be premonitory sy mp- ! Chest generally distended, though tonis, such as gradually increasing there is scarcely any expansive move- dyspnoea or the passing of a large iment. Recession of the intercostal quantity of limpid urine; but the spaces, supra-sternal and supra-cla- attacks usually come on suddenly at ' vicular fossa? and epigastrium dur- an early hour in the morning; the ing inspiration, which is short and patient * awakes in a start, with a I jerky, while expiration is prolonged sensation of suffocation and oppres- | and wheezing. Vocal vibration not siveness of the chest; he either sits markedly affected. Rhonchal frem- upright in bed, or sometimes itus may be felt. Resonance on per- stands holding on to a piece of cussion increased all over the chest, furniture, so as to bring into play Almost complete absence of vesicu- the accessory muscles of respira- lar murmur. Every variety and tiou. Countenance pale and anx- i kind of sibilus and rhonchus, whis- ious; in bad cases cyanotic. Skin tling, squeaking, cooing, snoring covered with sweat; extremities sounds, and occasionally mucous cold. Pulse frequently feeble. The rales towards the termination, attacks generally terminate with the expulsion of tough, ashy gray pel- lets of mucus. Post-mortem Appearances. — The appearances found after death are principally the result of chronic bronchitis and emphysema, with di- latation of the right side of the heart. PNEUMOTHORAX. This condition is generally found with serous effusions — pneumo- hydrothorax; but occasionally presents itself as an independent affection. The characteristics of the two forms are as follows : — DISEASES OF THE RESPIRATORY APPARATUS. 163 Symptoms. Physical Signs. PNEUMOTHORAX. Generally sharp, stabbing pain, with the sensation of something having given way. Urgent dyspnoea and evidences of shock. More or less cyanosis. Pos- ture assumed by patient varies. Pulse frequent, weak and small. Respira- tion may be 40 to 60 in the minute. Troublesome cough without expectora- tion. In some cases of phthisis, or where there are extensive pleural adhe- sions, pneumothorax may come on quite impercepti- bly. Dilatation of the affected side, with obliteration or bulging of the intercostal spaces. Movements of res- piration diminished or ab- sent. Increased elasticity of the walls of the chest. Feeble or absent vocal fremitus. Clear tympan- itic resonance on percus- sion. If the amount of air is extreme there may be high-pitched dullness. No true vesicular murmur ; bronchial breathing may be heard along the spine. Amphoric sounds, with inspiration, voice, and cough, also a metallic echo ; the bell sound may be elicited. The neigh- boring viscera are dis- placed to a variable degree. PNEUMO-HYDROTHORAX. Symptoms the same, except that the cough is usually at- tended by fetid, puriform expectoration. The patient lies on or toward the af- fected side. Same as in true pneumotho- rax, except that percussion is dull in the lower part of the chest, and tympanitic above the level of the fluid. Metallic tinkling and splashing sounds on suc- cussion are also frequently heard. 1G4 DIFFERENTIAL DIAGNOSIS. PNEUMOTHORAX— [Cntim/cl). PNEUMOTHORAX. Post-mortem appearance. Lung collapsed, lying near vertebral column, unless bound down by old adhesions to some other part of the chest wall. The gas is com- posed chiefly of carbonic acid and nitrogen, containing but little oxygen, and occa- sionally some sulphureted hydrogen. I • N 1 : 1 M(>-IIYI>i:c>TIIOKA\. Lung collapsed. Air, mixed with fluid, in pleural cavity. Mostly arises as a termination to phthisis, a superficial cavity becoming rup- tured. May occur in pneumonia, emphyse- ma, or gangrene of the lung, and more rarely in other diseases. EMPHYSEMA. This affection presents itself in two forms, the vesicular and the inter- lobular, which are distinguished as follows : — Symptoms. VESICULAR EMPHYSEMA. Habitual shortness of breath, with occasional paroxysms of urgent dyspnoea, most fre- quently supervening on ca- tarrh. Cough, with or with- out expectoration of thin, transparent, frothy mucus. In the last stage of the dis- ease there are symptoms due to interference with the cir- culation, as palpitation, cyan- osis, general dropsy, and con- gestion of the abdominal vis- cera. The disorder is essen- tially chronic in its course, and may progress so slowly as not to materially shorten life. It generally occurs in persons who are otherwise vigorous, and is hence sup- posed to grant immunity from consumption. INTERLOBULAR EMPHYSEMA. Urgent dyspnoea and oppression, generally occurring suddenly after some violent effort, the subcutane- ous areolar tissue fre- quently becoming oedematous. DISEASES OF THE RESPIRATORY APPARATUS. 165 EMPHYSEMA— ( Continued). Physical Signs. Post-mortem appearance. VESICULAR EMPHYSEMA. Chest " barrel shaped" and al- most circular. Sternum pro- jecting forward. Sea puke and clavicles raised and ill- defined. Ribs more horizon- tal and intercostal spaces widened. Respiration ab- dominal. Movement of chest much diminished. Heart beating in the epigastric re- gion. Resonance on percus- sion greatly increased or tympanitic. Feeble inspira- tion, prolonged expiration, the former wheezing, the latter generally with rhon- chus or sibilus. Vocal fre- mitus and resonance usually deficient. Lung does not collapse as usual when the chest is opened, but, on the contrary, may rise up and bulge out of its cavity. It is pale and ansemic, and does not crepitate when pressed, but feels soft and downy, and is drier than or- dinary. The air cells are dilated, or several have be- come one cavity from the rupture of the septa between them. Cells vary from the size of a millet-seed to that of a swan-shot, or larger. INTERLOBULAR EMPHYSEMA. Percussion tympanitic over the affected part. Bead-like bubbles of air seen through the pleu- ra, or partitions be- tween the lobules much widened. Sometimes air is found beneath the areolar tissue of the neck. CANCER OF THE LUNG. The principle obstacle in recognizing this disease is the liability to confound it when primary and unilateral (as it usually is when primary) 166 DIFFERENTIAL DIAGNOSIS. with phthisis. Similar cough, emaciation, haemoptysis, night sweats, etc, occur in both. The points of difference are: — PULMONARY CANCER. PHTHISIS. Sides of chest more markedly asymmetrical ; the tumor may bulge through the intercostal spaces. Percussion dullness very great; may extend beyond median line. Frequent changes in the signs of auscultation, rales, bruits, etc. Hsemoptoic sputa, " resembling currant jelly." Pain constant, severe, lancinat- ing. Cancerous cachexia, tinge of skin, etc. One side may be sunken ; never bulging. Percussion dullness moderate; never extends beyond median line. Changes much more gradual. Sputa never present this appear- ance. Pain variable, intermittent. Absent. Pulmonary cancer is sometimes so masked that its diagnosis requires the closest attention. It may be present without the characteristic sputa, without cachexia, and even without pain at cancerous spot.* Such in- stances are, of course, very rare. It is liable to be mistaken for chronic pleurisy, or vice versa. The distinguishing features are, that in cancer there is an absence of the com- plete consolidation of chronic pleurisy; the consolidation of the latter is at the lower portion of the lung; the expectoration of cancer is quite dif- ferent from that of pleurisy and bronchitis; and the previous history, both of the individual and his family, in cancer, points to this disease, while chronic pleurisy has as an antecedent an acute attack. The deposits of gummatous nodules in the lungs consequent on second- ary syphilis, together with the cachexia attendant on that disease, may simulate a cancerous deposit. The history of the case, the presence of syphilitic signs in other organs and tissues, and the fact that cancers tend to spread and infiltrate the surrounding tissue, while the syphilitic nodule remains isolated and circumscribed, are the distinctive points. * See case recorded in the Boston Medical and Surgical Journal, January, 1876. DISEASES OF THE CIRCULATORY APPARATUS. 1 07 CHAPTER III. DISEASES OF THE CIRCULATORY APPARATUS. Contents. — The Prcecordial Region — Normal Sounds and Impulse of the Heart — Endocardial Murmurs — General Rules for the Diagnosis of Heart Diseases — Constitutional Symptoms of Heart Disease — Club- bing of the Fingers — Differential Signs Between Anoemic and Organic Blood Murmurs — Pain at and near the Heart — Aphorisms Regarding Angina Pectoris — Differential Signs of Aortic Obstruction and Aortic Incompetency; of Mitral Obstruction and Mitral Incompetency; of Pulmonary Obstruction and Tricuspid Regurgitation — Pericarditis — Diagnosis Between Acute Endocardial and Exocardial Sounds; Between Cardiac Dilatation and Pericarditis with Effusion; Between Simple Hypertrophy, Hypertrophy with Dilatation, and Simple Dilatation — Fatty Degeneration of the Heart. The anatomical positions of the several parts of the heart are as follows : — RELATIONS OF THE HEART TO THE PRECORDIAL REGION. REGION. Apex of Heart.... Base of Heart Tricuspid Orifice. Mitral Orifice.... SITUATION. Between fifth and sixth ribs on left side, about two inches below the nipple and one inch on its sternal side. On a level with the third costal cartilages. Extends from the junction of the fourth left costal cartilage with the sternum, behind that bone to the articulation of it with the sixth right cartilage. To the left of the tricuspid valves, immedi- ately behind the fourth costal cartilage ; but less superficially placed than the tri- cuspid. 168 M ll'Ki: KNTIAL DIAGNOSIS. TIIK l'K.ECORDIAL REGION— {Continued i. REGION. Pulmonary Orifice. Aortic Orifice. Immediately behind the left border of the sternum at the junction of the third costal cartilage with that bone. About half an inch lower than and to the right of the pulmonary orifice, behind the sternum, on a level with the third inter- space. Let it be remembered that the tricuspid orifice is the most superficial, then the pulmonary, next the aortic, and deepest of all is the mitral orifice. Ranged from above downward, the pulmonary orifice comes first, then the aortic, then the mitral, and lastly the tricuspid. PHYSICAL EXAMINATION OF PRECORDIAL REGION. EXAMINATION- BY Inspection Form of chest. Point at which the apex of the heart strikes the wall of the chest. Regularity of impulse, and extent over which it is perceptible. Palpation Force and regularity of impulse. Presence or absence of purring tremor or of friction fremitus. Percussion Auscultation Extent and intensity of precordial dullness. Character of rhythm. Character of sounds, normal or abnormal, THE AREA OF SUPERFICIAL CARDIAC DULLNESS Is roughly triangular in shape, the right side of the triangle being the mid-sternal line from the level of the fourth chondro-sternal articulation downward; the hypothenuse being a line drawn from the same articula- tion to a point immediately above the apex-beat; the base being a line drawn from immediately below the apex-beat to the point of meeting be- tween the upper limit of liver dullness and the mid-sternal line (Dr. Gee). DISEASES OF THE CIRCULATORY APPARATUS. 169 NORMAL SOUNDS AND IMPULSK OF FIKAKT. POINT OF „ CONDITION OFCIRCCT- SOUND. CHARACTER. GREATER IN- TENSITY. CAUSE. TJ.MK. J.ATION. First Sound. Dull and pro- Fourth and Closure of auri- A Contraction of ven- (Systolic). longed. fifth inter- culo-ventricu- tricles, following costal lar valves, and, that of auricles. spaces just perhaps, mus- Closure of auricu- within left cular contrac- 1 o - ventricular nipple line. tion of the ventricles themselves; also impact of apex against the chest-wall, and vibration of papillary muscles and chorda ten- dineae. valves, open aor- tic and pulmonary valves; propul- sion of blood into the arteries. Im- pulse of the heart immediately fol- lowed by pulse at the wrist. First Pause. 1 Auricles dilating. Second Sound Short and Base ofheart, Sudden closure 2 Filling of both au- (Diastolic). clear. opp o site of the aortic ricles and ventri- the third and pulmo- cles. Closure of right costal nary valves. arterial valves, cartilage. opening of auri- c u 1 o- ventricular valves. Second Pause A Complete distention of auricles, fol- lowed by their contraction, and distention of ven- tricles. Auriculo- ventricular valves open, arterial valves closed. Impulse. Between fifth and sixth ribs on left side, about one and a half or two inches be- low the nipple, and one inch to its inner side. In part due to the tilting upward of the apex, but chiefly to the recoil of heart and change in shape, for during the sys- tole it becomes harder and more globu- lar. 170 DIFFERENTIAL DIAGNOSIS. ENDOCARDIAL MURMURS. TIME. SITUATION'. ORIFICE. NATURE. SvSTOl.li' 1 . 2 3 ! 4 . DlASTOl H 1 . Presystolic 1 . Basic (right). •■ licit). Apical. Basic. Apical. Aortic. Pulmonary. Mitral. Tricuspid. Aortir. Mitral. Obstructive. a Regurgitant. a Obstructive. Pulmonary regurgitant murmur (diastolic) and tricuspid obstructive murmur (presystolic) are very rarely met with clinically, and for all practical purposes they may be disregarded. The most frequent combinations of these murmurs are: — 1. Combined aortic obstruction with regurgitation. 2. Mitral obstruction and regurgitation. 3. Various combinations of the two preceding forms, the aortic and mitral valves being both diseased. 4. Mitral obstruction with dilated right ventricle, and consequently tricuspid regurgitation (Dr. Aitkex). Order of frequency of endocardial murmurs, commencing with the most common : — 1. Mitral regurgitant. 2. Aortic constrictive. 3. Aortic regurgitant. 4. Mitral constrictive. 5. Tricuspid regurgitant. 6. Pulmonary constrictive. 7. Pulmonary regurgitant. 8. Tricuspid constrictive. Order of relative gravity as "estimated not only by their ultimate lethal tendency, but by the amount of complicated miseries they inflict." — Dr. AValshe. 1. Tricuspid regurgitation. 2. Mitral constriction and re- gurgitation. 3. Aortic regurgitation. 4. Pulmonary constriction. 5. Aortic constriction. GENERAL RULES FOR THE DIAGNOSIS OF HEART DISEASE. Dr. John - Hughes Bennett* gives the following rules : — 1. In health the cardiac dullness, on percussion, measures, immediately * " Lectures on the Principles and Practice of Medicine." DISEASES OF THE CIRCULATORY APPARATUS. 171 below the nipple, two inches across, and the extent of dullness beyond this measurement commonly indicates either the increased size of the organ or undue distention of the pericardium. 2. In health the apex of the heart may be felt and seen to strike the chest between the fifth and sixth ribs, a little below and a little to the inside of the left nipple. Any variations that may exist in the position of the apex are indications of disease either of the heart itself or of the parts around it. 3. A friction murmur synchronous with the heart's movements indi- cates pericardial or ex-pericardial exudation. 4. A bellows murmur with the first sound heard loudest over the apex indicates mitral insufficiency. 5. A bellows murmur with the second sound heard loudest at the base indicates aortic insufficiency. 6. A bellows murmur with the second sound heard at the apex is rare. It indicates — 1st, aortic disease, the murmur being propagated downward to the apex ; or 2d, roughened auricular surface of the mitral valves ; or 3d, mitral obstruction. 7. A murmur with the first sound loudest at the base, and propagated in the direction of the large arteries, is more common. It indicates — 1st, an altered condition of the blood, as in anaemia ; or 2d, dilatation or dis- ease of the aorta itself; or 3d, stricture of the aortic orifice, or disease of the aortic valve. 8. Hypertrophy of the heart may exist independent of any valvular lesion, but this is rare. 9. The pulse as a general rule is soft and irregular in mitral disease, but hard, jerking, or regular in aortic disease. 10. Cerebral symptoms are more marked in aortic disease ; pulmonary symptoms in mitral disease. Various constitutional symptoms should, in default of other obvious causation, lead to the suspicion of disease of the heart. These are mainly : 1. Symptoms referred to the circulation. Violent, continued pulsation may arise from cardiac hypertrophy, and especially aortic regurgitation. Cyanosis, blueness of the lips, coldness of the finger tips, etc., are common in many cardiac cases. Dropsy is a late and dangerous symp- tom. 172 DIFFERENTIAL DIAGNOSIS. 2. Symptoms referred to the lungs. These are frequent cardiac com- plications, especially dyspnoea, orthopnoea and cough. 3. Symptom* referred to the brain. Vertigo, languor, chorea, epilepsy, apoplexy and paralysis may all be brought about by heart disease. In sudden cerebral attacks in patients suffering with valvular disease, embol- ism is often at work. 4. Stomach symptoms. Dyspepsia and hemorrhoids may find their origin in cardiac lesions. 5. Throat symjytoms. Pain in the throat is complained of in angina; hoarseness and aphonia sometimes signify pericarditis. 6. Renal symptoms may follow heart disease. In all cases of cardiac disease the urine should be tested for albumen, as this condition may excite cardiac symptoms.* CLUBBING OF THE FINGER ENDS IN CHRONIC HEART DISEASE AND PHTHISIS. The following aphorisms on this point are laid down by Dr. Horace DoRELL:f — Aphorism I. Clubbing of the finger ends on one or both sides of the body, with or without incurvations of the nails, may occur whenever the return of blood by one or both subclavian veins is seriously obstructed for a considerable length of time. II. Symmetrical clubbing of the finger ends of both hands without incurvation of the sides and tips of the nails, is presumptive evidence of the existence of heart disease. III. Clubbing of the finger ends without incurvature of the sides and tips of the nails is presumptive evidence against the existence of phthisis. IV. Symmetrical clubbing of the finger-ends conjoined with incurv- ation of the sides and tips of the nails, is a sign that obstruction of the return blood by the subclavian veins and wasting of adipose tissue have co-existed. *See also paper by Prof. Da Costa and Dr. LoNGSTRETH in Am. Journal for Med. Scieiices, for July, 1880, for pathological relationship of heart disease and chronic kidney disorder. f " Affections of the Heart.'' London, 187G. DISEASES OF THE CIRCULATORY APPARATUS. 173 DIFFERENTIAL SIGNS BETWEEN ANiEMIC AND OEGANIC CARDIAC SOUNDS. ANiEMIC SOUNDS. First sound heard over the right ventricle is distinct, second ringing; a soft murmur is heard over the left ventricle. Sounds vary in character. Sounds increase in intensity in following the aorta. Pressure with the stethoscope in- creases or developes the sound. Bruit du (Liable, a continuous musical hum, can be heard in the hollow above the right clavicle. Co-existence of pallor or anaemia; amenorrhoea; leucorrhoea; nervous exhaustion; chorea; renal disease; phthisis. ORGANIC SOUNDS. Murmur generally harsh and blowing, and takes the place of one or both sounds of the heart. It may be distinctly located* at apex or base. Sound the same after several ex- aminations. Sounds diminish in intensity in receding from the heart. Not affected by pressure. Not present. Co-existence of alteration in size of the heart; other organic signs; history of rheumatism. PAIN AT THE HEART. Pain is by no means a common symptom of heart disease. Not more than one in a dozen cases of chronic organic cardiac disease complain of pain at all.* In acute cardiac affections it is more frequent. In most cases of alleged pain at the heart, it is found on examination to proceed from dyspepsia, muscular rheumatism, intercostal neuralgia, enlarged spleen, or the like. APHORISMS OF DR. HORACE DOBELL.f I. Pain in the region of the heart and down the left arm does not necessarily indicate heart disease. II. The conjunction of pain in the region of the heart and pain in the left arm may be a most important symptom of heart disease, and is never to be disregarded. * Sansom, " Diagnosis of Diseases of the Heart," p. 3. f " On Affections of the Heart." London, 1876. 174 DIFFERENTIAL DIAGNOSIS. III. It' pain is excited by exercise taken when the stomach is not dis- tended with food <>r gas, and especially if it comes on quickly and iu- creases steadily in severity with the continuance of exercise, it is almost certain there is some serious disease of the circulatory organs. IV. When it is found that flatulence or a full meal embarrasses the heart painfully, a careful investigation should be made into the condition both of the organ itself, and of the blood. V. Important heart disease may exist, and yet pain at the heart aud in its neighborhood be absent. VI. The appalling import of pain in the throat in heart disease in- creases in proportion as the period of its onset deviates from the follow- ing order of severity : — 1. Pain under the left breast. 2. Pain extending from under the left breast to mid-sternum. 3. Pain extending from mid-sternum toward the left shoulder. 4. Pain extending from the left shoulder down the left arm. 5. Pain extending from mid-sternum toward the right shoulder. 6. Pain extending from the left shoulder down the right arm. 7. Pain extending up the sternum toward the region of the throat. 8. Pain in the thyroid cartilage. AVhen this order of advance is maintained as the exciting cause is con- tinued, pain in the throat expresses the degree of dangerous persistence in the exciting cause of heart distress, rather than the degree of danger in the disease itself. VII. In proportion as the right side of the chest and right arm take precedence in the order of extension of pain at the heart and its neigh- borhood, the probability increases that the aorta is more diseased thin the heart. VIII. The volume of blood and other conditions being normal, the facility with which the pulse at the wrist is stopped by inspiration measures the loss of heart power. ANGINA PECTORIS. This disease is usually epioted as oue typically connected with pain at the heart. This is by no means the case, as in many instances there is merely a sense of precordial distress, but no actual pain (Sansom). The diagnostic characters are : — DISEASES OF THE CIKCULATOEY APPARATUS. 175 1. The attacks arc paroxysmal, coming on at varying intervals and duration (from a minute to an hour), without assignable cause. 2. There is always a sensation of coldness experienced, and often a cold sweat. 3. The heart's action is not increased, and may be diminished. 4. The chest is fixed and the breathing slow. 5. The pain, when present, may be of great intensity, of a cold, sick- ening character, directly referred to the heart, with an accompanying sense of impending dissolution. Though at first a neurosis, probably of the sympathetic (cardiac ganglia) angina pectoris, is generally associated with some progressive defeneration of the muscular texture of the heart. DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND AORTIC INCOMPETENCY. AORTIC OBSTRUCTION. Hypertrophy of left ven-E tricle. To left. To left greatly. Forcible. To left of sternum. Onward, ventriculo-aortic. Systolic ; loudest at begin- ning of systole. Right border of sternum, in second intercostal space. Upward to right sterno- clavicular articulation. Apex Displaced. Cardiac Dullness Increased. Character of Im- pulse. Impulse Felt. Murmur, its Direc- tion. Time of Murmur. Point of Greatest Intensity. Direction in which Propagated. AORTIC INCOMPETENCY. Hypertrophy and dilatation of left ventricle. Downward and to left. Downward and to left, more increased than in obstruction. More forcible than in ob- struction, and over wider area. To left of sternum. Backward ; aortic-ventri- cular. Diastolic; post-systolic; loudest at beginning of diastole. Right border of sternum opposite third intercostal space. Downward along sternum and toward apex. 176 DIFFERENTIAL DIAGNOSIS. DIFFERENTIAL SIGNS OF AORTIC OBSTRUCTION AND AORTIC INCOMPETENCY— (Continued). AORTIC OBSTRUCTION. Loud, harsh, or blowing. Replaces first at base. AORTIC INCOMPETENCY. Character of Sound (very uncertain and of little value for diag- nosis). Relation to Normal Heart Sounds. Depends on condition of Effect on Second valves, but aortic second, Sound, sound generally feeble. Systolic; in second right Thrill, intercostal space. Effects on Pulse Normal, or perhaps de- creased. Diminished. Diminished. Regular. Slow. Arterial amemia ; angina pectoris often present. Frequency. Volume. Power. Rhythm. Duration. General Tendency. Of higher pitch than in obstruction, ami loudness decreases rapidly from commencement. Replaces second at base, and occupies more or less of the pause. Apparent intensification of pulmonary second. Down sternum ; diastolic. Visible pulsation in arteries (locomotive pulse). Normal, or perhaps de- creased. Increased. Increased. Regular. Quick. As in obstruction, but sud- den death more common than in any other form of valvular disease. DIFFERENTIAL SIGNS BETWEEN MITRAL OBSTRUCTION AND MITRAL INCOMPETENCY. MITRAL OBSTRUCTION'. Hypertrophy and dilata- Effect on Heart, tion of left auricle andj right chambers. To left and slightly down- Apex Displaced, ward. MITRAL INCOMPETENCY. Hypertrophy and dilata- tion of all four cham- bers. To left and downward. DISEASES OF THE CIRCULATORY APPARATUS. 177 DIFFERENTIAL SIGNS BETWEEN MITRAL OBSTRUCTION AND MITRAL INCOMPETENCY— {Continued ). MITRAL OBSTRUCTION. To right of sternum, also to left at base, greatly. Feeble, undulating, and diffused. To right of sternum and in epigastrium. Onward ; auriculo-ventri cular. Diastolic, presystolic, loudest at termination of diastole. A little within and upward from apex beat. Upward and inward to- ward right base. Cardiac Dullness Increased. Character of Im- pulse. Impulse, where? Murmur, its Di- rection. Murmur, Time. M ITRAL INC M I' BTE N'C Y. Generally harsh. rough and Immediately precedes the first at apex, which is often very loud. Intensification of pulmo- nary second. Presytolic ; upward and inward from apex. Increased. Diminished. Diminished greatly. Very irregular. Quick. Pulmonary and venous congestion and slow death by asphyxia. Point of Greatest Intensity. Direction in which Propagated. Character of Sound (very uncertain and of little value for diagnosis). RelationtoNormal Heart Sounds. To right of sternum, and also to left and down- ward. Even more deficient in force. Generally increased all over cardiac region. Backward; ventriculo-au- ricular. Systolic, loudest at begin- ning of systole. A little outward and up- ward from apex beat. Upward toward left base, and backward into ax- illa, and behind. Blowing, bellows murmur. Effect on Sound. Thrill. Second Effect on Pulse. Frequency. Volume. Power. Rhythm. Duration. General Tendency Replaces first at apex. Intensification nary second. At apex and ilia. of pulmo- toward ax- Increased. Somewhat diminished. Diminished a little. Somewhat irregular. Nearly normal. As in obstruction, but there is more tendency to dropsy. 178 DIFFERENTIAL DIAGNOSIS. DIFFERENTIAL SIGNS BETWEEN PULMONARY OBSTRUCTION AND TRICUSPID REGURGITATION. PULMONARY OBSTRUCTION. Systolic, on ward, ventri- Murmur, culo-pulmonary. Left border of sternum, in second interspace. Generally anaemia. Some- times pressure of solidi- fied lung (phthisical or pneumonic) upon the artery. Rarely organic, and then usually con- genital. Frequently Bruit de diable in the jugular veins. Point of greatest intensity. Cause. Associated Signs. TRICUSPID REGURGITATION. Systolic, backward, ven- triculo-auricular. Base of ensiform cartilage. Generally secondary to dis- ease of the lung: or of left side of the heart. Systolic pulsation of the distended jugular veins. Endocardial murmurs can be distinguished from pericardial by atten- tion to the following physical signs : — PERICARDITIS. 1st Stage. Inflammation without effu- sion). SYMPTOMS. If occurring during the course of acute rheumatism the dis- ease come on may insidiously. Pain and tenderness in the cardiac re- gion. Palpitation. Increased frequency of the pulse. Short- ness of breath. Anxiety. Pyrexia. PHYSICAL SIGNS. Greater extent of visible impulse than natural, and on palpation the impulse is found to be more forcible, but unequal. Friction fremitus rare. Area of dullness not altered. Single or double friction sound, often preceded by a cantering action of the heart.* Heart sounds may be unchanged or even louder than in health, or they may be masked by the fric- tion sounds. * Cantering action of the heart, beside being met with in commencing pericarditis, is also caused by reduplication of the first or second sound of the heart against the thoracic wall at the moment of diastole, generally due to pericardial adhesions. DISEASES OF THE CIRCULATORY APPARATUS. 170 PERICARDITIS— {Continued ). 2d Stage. (With effu- sion). SYMPTOMS. 3d Stage. (Resolution). Less pain. Pulse small, frequent, and sometimes irregu- lar. Dyspnoea and often orthopncea. Irritable cough. Loss of voice. Dys- phagia. Fullness of veins in the neck. Duskiness of com- plexion. Great anxiety. Sleepless- ness. Delirium. A gradual subsidence of the symptoms of the second stage. PHYSICAL SIGNS. Bulging of the precordial region. Impulse displaced upward and outward ; undulatory. On palpation, feeble and some- times not perceptible; irregu- lar. Area of cardiac dullness increased, first noticed at the base of the heart, and after- ward extending to left of apex beat, increased by the recumbent posture. Heart sounds feeble, distant and muffled at apex, louder and more superficial at base. Fric- tion may or may not be heard. Diminution of the dullness from above and laterally. Heart sounds become clearer. Fric- tion sounds may be heard with increased intensity. Post-mortem Appearances. — 1st. Pericardium is dry, inflamed and has lost its polish. Exudation of lymph on both surfaces, but more on the visceral. The membrane may have a shaggy appearance. 2d. Fluid in variable quantity in the sac of the pericardium. Usually sero-fibrinous, containing flocculi of lymph. It may be purulent or bloody. 3d. Organized lymph on the pericardium, with or without adhesions between the two surfaces, adherent or united by mesh-like adhesions. The Pain of Pericarditis. — Rheumatic pericarditis is more or less painful ; but secondary pericarditis developing in the acute stage of in- fectious or the chronic period of cachectic diseases, is invariably painless. Peripheric pain nearly equal on both sides of the chest ; or remaining localized at the precordial region, at the epigastrium, or at the left side of the xyphoid cartilage, does not increase the danger of the pericarditis. But if central, giving rise to disturbance of circulation and respiration, and simulating that of angina pectoris, it means acute inflammation of the cardiac nerves, and marks an exceptionally bad case of pericarditis. (Dr. Wertheimer, "These de Paris," 1876 ; Dobell's Reports.) ISO DIFFERENTIAL IMAGXosiS. DIAGNOSIS BETWEEN ACUTE ENDOCARDIAL AND EXOCARDIAL (PERICARDIAL) SOUNDS. The sounds respectively perceptible in endocarditis and pericarditis and allied disorders, may he discriminated by the following table: — ENDOCARDIAL. 1. A blowing sound, soft and bellows-like; not affected by pres- sure. 2. A thrill may be felt on palpa- tion. 3. The sound appears distant. 4. May exist only with the sys- tole or the diastole. 5. Accompanies the heart sounds. 6. Heard along the course of the great vessels, or conducted round to the back 7. Persistent character. 8. Area of cardiac dullness not altered. 1. A creaking, to-and-fro EXOC LRDIAL. rubbing, rough, sound, intensified by pressure of the stethoscope and by the patient bending forward. 2. On palpation friction fremitus may be felt. 3. The sound appears near. 4. Exists with diastole as well as systole. 5. Does not correspond with the rhythm of the heart. 6. Confined to the region of the heart and limited to site of produc- tion. 7. Rapid and frequent change in character; here to-day and gone to- morrow. 8. Increased area of dullness, if fluid be also present. DIFFERENTIAL SIGNS OF CARDIAC DILATATION AND PERICARDITIS WITH EFFUSION. CARDIAC DILATATION. Dullness increased in the hori- zontal axis, of a square outline. Heart sounds feeble but clear. Transition from dullness to lung resonance more gradual No friction sound. Limits of dullness persistent. Apex beat felt at lower limits of cardiac dullness. PERICARDITIS WITH EFFUSION. Precordial dullness extends up- ward and is of a rounded pyramidal outline, with apex above. Heart sounds feeble, and distant sounding. Transition from dullness to luug resonance abrupt. Occasionally friction sound. Limits of dullness often vary from day to day or week to week. Apex beat some distance above lower limit of cardiac dullness. (Sansom). DISEASES OF THE CIRCULATORY APPARATUS. 181 There is no doubt but that the general rules laid down for diagnosing pericardial effusion have been too vague. Dr. T. M. Rotch, of Boston, has lately re-examined the subject, and succeeded in fixing a more perfect diagnostic sign than any hitherto mentioned. He shows that an area of flatness at from two to three centimeters from the right edge of the sternum in the fifth intercostal space is almost absolutely sufficient to mark the presence of an effusion, and differentiate it from enlarged heart.* DIFFERENTIAL SIGNS OF HYPERTROPHY AND DILATATION. Palpation. Percussion. Auscultation. Pulse. General symptoms. SIMPLE IIYPERTKOPIIY. Cardiac area extend- ed. Impulse strong, lifting, or forcing. Dullness increased laterally and down- ward. First sound dull, pro- longed, intensified ; second sound inten- sified. No respira- tory murmur over prsecordium Strong, full, ] pressible. Fullness in the head, epigastric weight, short breath, rarely debility ; disease. HYPERTROPHY WITH DILATATION. Extent of visible impulse great- 1 y increased. Action regu- lar, strong. Dullness lateral and down- ward. Both sounds pro- longed. Less strong, vari- able. Bright's SIMPLE DILATATION. Extent of impulse greatly increased, but feeble, without lifting or forcing character. Dullness increased in the horizontal axis of the heart. Both sounds short, abrupt and feeble. Feeble respiratory murmur. Weak, compressi- ble, irregular. Dyspnoea, cough, palpitation, portal congestion, debil- ity, ascites. FATTY DEGENERATION OF THE HEART. This condition of the heart is frequently associated with dilatation. Generally the area of precordial dullness is normal or slightly increased ; the impulse weak; the apex beat indistinct; the action irregular; the first * " Medical Communications of the Massachusetts Medical Society." 1878. 182 DIFFERENTIAL DIAGNOSIS. sound short and feeble; the second prolonged and intensified; pulse is irregular. These physical signs obviously offer very little ground for a diagnosis. Of rational signs the following have been mentioned: — 1. Attacks of faintness attended with sensations of great coldness, re- curring without obvious cause. (Da Costa). 2. A re us senilis. For this to be significant of cardiac degeneration, the riug must be ill-defined, rather yellowish than white, and the rest of the cornea be slightly cloudy or opaque, not clear and translucent, a tinge of jaundice being present. When this is the case, "the chances of cardiac degeneration are formidable" (Sansom). 3. Paroxysms of severe pain across the upper part of the sternum, and in the region of the heart. 4. Stomach derangements, accompanied sometimes by constipation, but more generally by diarrhoea and frequent vomiting. This Dr. L. H. J. ITayne thinks " almost pathognomonic of this disease." (Lancet, January, 1875.) 5. The "Cheyne-Stokes" Respiration of ascending and descending rhythm is present in about one-third of the cases, and is probably de- pendent on atheroma of the aorta (Hayden). This symptom was first described in a case by Dr. Cheyne, in 1818, as follows: — "For several days his breathing was irregular; it would entirely cease for a quarter of a minute; then it would become perceptible, though very slow; then, by degrees, it became heaving and quick; and then it would gradually cease again. This revolution in the state of breathing occupied about a minute, during which there were about thirty acts of respira- tion." In this case fatty disease of the heart was very marked, while the valves were healthy, and the aorta was "studded with steatomatous and earthy concretions." No general attention, however, was directed to the peculiarity and striking character of this symptom, until, in 1846, Dr. Stokes urged its significance as a sign of fatty degeneration of the heart, believing that its presence was pathognomonic of this affection, and that it always betok- ened a fatal and not far distant termination. That it did not necessarily depend on fatty degeneration of the heart itself, was soon shown by Dr. Seaton Reid, who described a case in which the muscular structure was DISEASES OF THE CIRCULATORY APPARATUS. 1 83 healthy, while the mitral and aortic valves were both incompetent, the left ventricle was hypcrtrophied, and the aorta dilated and atheromatous. It remains an important and significant, if not pathognomonic sign. Dr. Hayden is of opinion that the absence of the impulse, or its ex- tremely feeble character; the brief duration of the first sound, whether marked or sharp, in primary cases, and its almost complete or absolute extinction in those preceded by hypertrophy ; the restriction of the sounds within a very limited area; and the occasional irregularity of the heart's action, will suffice, in the majority of cases, to establish the diagnosis of fatty heart from the physical signs alone. He adds that the incipiency of primary fatty degeneration may be suspected, if the pulse, previously regular, becomes weak and irregular; if the surface be pale, the patient subject to dizziness or syncope, and the cardiac impulse feeble; although the sounds of the heart may not appreciably differ from their normal character. A slow pulse sometimes is associated with fatty heart ; but it also occurs as a result of disorders of the vagus nerve, following diphtheria ; or after an attack of malarial fever; or after the administration of certain drugs, such as digitalis or aconite. In all cases it is necessary to exclude a slow pulse which is natural and peculiar to the patient. Irregular or slow pulse due to adherent pericardium may be distinguished by the history and physical signs. 184 DIFFERENTIAL DIAGNOSIS. CHAPTER IV. DISEASES OF THE DIGESTIVE SYSTEM. The Stoma < n and Bowels. — Principal Symptoms — The Tongue — The Appetite — Acidity (I) from Fermentation, (2) from Hypersecretion — Pain — Flatulence — Vertigo, (1) Stomachal, (2) Cerebral — Vomiting, (1) Stomachal, (2) Cerebral — Comparison of Atonic Dyspepsia, Chronic Gastritis, Gastric Ulcer and Gastric Cancer — Indigestion or Dyspep- sia — Abdominal PJdhisis — Obstruction of the JBoivels, Enteritis and Colitis. The Liver. — Method of Examination — Significance of Pain in the Liver — Significance of Jaundice — Jaundice with Obstruction — Jaundice without Obstruction — Diseases Characterized by Enlargement with Smooth Surface ; Enlargement ivith Uneven Surface ; with Diminution of the Organ — Hepatic Abscess. Internal Parasites. — Tape-worm — Hydatids — Round Worms — Thread Worms — Trichinosis. The principal symptoms to which the attention is directed in the diag- nosis of diseases of the digestive organs are those connected with the tongue, the appetite, pyrosis, vomiting, flatulence, vertigo and pain. THE TONGUE. Late writers have shown considerable skepticism on the accuracy of the appearance of the tongue as indicative of the condition of the lining membrane of the stomach. It is true that a white and furred or a red and cracked tongue is occasionally seen in healthy subjects; but the standard of comparison should not be an ideally cleau tongue, but the condition of the organ in the patient under inspection when in health. Local causes, such as carious teeth and irritating agents (tobacco, tea, mercury, etc.), must be allowed for in the examination. When these and similar considerations are weighed together with the repeated instances of simultaneous affections of the stomach and tongue revealed by post-mor- tems, no question remains that the appearance and state of the latter organ often is of high diagnostic worth. DISEASES OP THE DIGESTIVE SYSTEM. 185 Dr. Robert Farquitarson states, in a recent lecture on the diagnosis of dyspepsia,* that in his experience the class of tongue which coincides most commonly with digestive disturbance is that in which the tongue seems to be covered with a thin, white fur, which on minute inspection is seen to be composed of a series of minute raised dots, and this usually coincides with pain immediately following meals. If the tongue is raw and quite stripped of epithelium, with enlarged and prominent papillae, as we often see in phthisis, pain immediately after food and vomiting are usual symptoms, or large, red papillae may stand in bold relief through a pale coating, or the tongue may be simply large and pale and flabby, as though too big for the mouth. Dr. Wilson Fox specifies the following conditions of the tongue as valuable aids to diagnosis in this class of diseases : — Dyspepsia with distinct atony of the stomach. The tongue broad, pale, and flabby, the papillae generally enlarged, more especially on the tip and edges. Dyspepsia from irritative causes. The tongue is redder than usual, often of a bright florid color, or even raw looking. It is often pointed at the tip, which, together with the sides, presents an extreme degree of injection, the papillae standing out as vivid red points. This form is often associated with aphthae, and is most common in scrofulous children and phthisical adults. Dyspepsia from excessive or hurried eating is apt to present a tongue uniformly covered throughout the greater part of its surface with a thick fur, whitish or brownish, with some degree of enlargement and redness of the papillae at the tip and edges. Neuroses of the stomach display a tongue which, as a rule, is clean, though often pale, broad and flabby. THE APPETITE. Anorexia, or loss of appetite, is observed in cancer, in most inflamma- tory states of the stomach, in obstinate constipation, as well as in the pyrexial state. Boulimia, or excessive appetite, is found associated with enlargement of the stomach, induration of its coats, also in diabetes and various forms of mental alienation. * Medical Press and Circular, July, 1877. 186 DIFFERENTIAL IUAONOSIS. ( hpridous and depraved appetite is met with in sufferers from intes- tinal worms, in some cases of chronic inflammation of the stomach, as well as in chlorosis, pregnancy and hysteria. ACIDITY OF THE STOMACH, (1) FROM FERMENTATION, (2) FROM HYPER-SECRETION. Acidity of the stomach, pyrosis, heartburn, and water-brash, are dis- turbances of the digestion frequently included in one category. In all, an excessive amount of acid is formed in the stomach; but in some cases the origin of the acid is to be sought in fermentative action, and in others in hypersecretion from the coats of the stomach, thus calling for different lines of treatment. The following differential table, based on one given by Dr. Wilson Fox, exhibits in a concise form the distinction between the two forms of acidity: — ACIDITY FROM FERMENTA- TION. Occurs in connection with causes which impede digestion. Usually attains its height some hours after food, and is more marked in proportion to the size of the meal, and inversely to the digestive powers. Flatulence is common. Pain not severe, and but slightly or not at all relieved by eating. Vomiting is rare. Vomited matters may contain or- ganic acids, torulre and sarcinse. Urine frequently shows an alka- 1 escent reaction. ACIDITY FROM HYPER-SECRE- TION. Is most common as a reflex symp- tom, or in connection with other nervous disturbance, or with ulcer and cancer of the stomach. Occurs in the empty stomach, or rapidly after food, and is often of great intensity after a small meal. Flatulence is rare. Pain more severe, most felt when the stomach is empty, and is relieved by food. Vomiting is common. Vomited matters apt to show hydrochloric acid in excess. Urine rarely alkaline. DISEASES OF THE DIGESTIVE SYSTEM. 187 In both forms the process of digestion is impaired, hut to a more marked degree in the fermentative variety, in which also, as a natural consequence, the impairment of nutrition of the patient is more obvious. As the fermentative action interferes with the functions of the liver, the stools are apt to be pale, and the patient suffer from constipation. The frequency with which attacks of gout and rheumatism are preceded by this form of acidity points to a diathetic process involving the general constitution. PAIN. Pain in the stomach is indicative of one of the following conditions : — 1. The presence of irritating foreign bodies, as mechanical substances, corrosive poisons, blood or bile in large quantities, inflation from air or gases, etc. 2. Organic diseases altering the anatomical structure of the coats, especially gastritis, chronic ulcer, cancer and thickening of the pylorus. 3. Perverted secretions, as in acidity. 4. Perverted innervation, which may be a local neurosis, as in forms of dyspepsia where pain is the prominent symptom, or as in cramp of the muscles of the stomach; or it may be from general disorders, as in patients of a rheumatic or gouty diathesis ; or it may be referable to the general nervous system, as in pure neuralgia of the stomach and hysteria. Pain in the stomach must be distinguished from rheumatic and other pains in the abdominal muscles immediately over the stomach. In the latter the superficial tenderness is much greater; it is usually more marked in the left recti and obliqui abdominis muscles, and especially near their attachment to the ribs, where moderate pressure cannot affect the stomach, and by its independence of the digestive acts (Bricquet). Pain in the stomach is also liable to be simulated by pain in the course of the transverse colon, especially when the colon is distended with gas. The diagnosis may usually be made by gentle percussion, the note arising from tapping a distended colon being less prolonged and of a higher pitch than that elicited from the stomach. The pain from the colon is also less felt at the ensiform cartilage than in the hypochondriac regions, and often extends toward the sigmoid flexure, and is associated with other signs of intestinal flatulence. Pain in the stomach depending on diseases of the spinal cord is dis- 188 DIFFERENTIAL DIAGNOSIS. tinguished by its superficial tenderness, by the presence of other painful points in the affected nerve, and by the co-existence of other nervous, and the absence of digestive symptoms. FLATULENCE AND ERUCTATION. Dyspeptics generally suffer from gases in the stomach, producing eruc- tations. These gases are either generated from imperfectly digested food or are secreted from the capillaries. Eructations having the taste or odor of spoiled eggs, and occurring during the process of digestion, indicate the presence of sulphuretted hy- drogen, from the decomposition of food. When the eructations are odorless, and occur chiefly in an empty state of the stomach, they indicate a gaseous secretion of carbonic acid, hy- drogen or nitrogen from the coats of the capillaries. In the former case the indications are to use anti-ferments; while in the latter relief is often attained by simply regulating the hours of meals, so as to avoid long intervals between the times of taking food. VERTIGO. (VERTIGO E STOMACHO LGESO.) Stomachal vertigo is not uufrequently difficult to distinguish as such, because in all severe vertigoes the stomach is disturbed. In undoubted examples the vertigo always bears some distinct relation to the condition of the stomach, coming on only when that organ is full, or only when it is empty, or only after certain articles of food, as shell-fish, strawberries, coffee, fresh bread, etc. There are also generally some dyspeptic symp- toms other than vertigo complained of. Some other points are mentioned in the following table: — STOMACHAL VERTIGO. CEREBRAL VERTIGO. Usually appears in definite re-| Occurs without relation to the lation to taking food; either after a meal, after particular ingesta, or on an empty stomach. Generally occurs in middle life. The apparent motion is felt to be subjective, not real (Gowers). Special senses not involved be- yond perverted vision. Conscious- ness never lost. taking. Occurs in advanced life. A sense of movement or actual turning of objects. Deafness and tinnitus aurium often present. Sometimes loss of consciousness. DISEASES OF THE DIGESTIVE SYSTEM. 189 VOMITING, (1) FROM DISEASE OF THE STOMACH, (2) FROM DISEASES OF THE BRAIN. Persistent vomiting is a frequent symptom of obstinate gastric disturb- ance; and it has also been frequently noted as a symptom associated with organic diseases of the brain and cord, not unfrequently masking them and diverting the attention of the practitioner from the real seat of lesion. Thus in suddenly induced cerebral anaemia, in the commencement of the paralysis which follows diphtheria, in tubercular meningitis, in concus- sion of the brain, in poisoning affecting the brain and cord, and in fact in almost any disease of the cerebral centres, but especially the meninges, it is possible that one of the earlier and prominent symptoms will be obstinate vomiting. A comparison of the leading clinical features of these two forms shows that they may be readily distinguished. In a general way it may be stated that vomiting arising from the stomach is attended with more or less pain, with a furred tongue, with constipation or diarrhoea, sense of weight at the epigastrium, and pre- ceded for a considerable period by a sense of nausea. Vomiting from cerebral causes, on the other hand, is usually character- ized by an absence of these symptoms, by a clean tongue and a history of freedom from digestive disturbance. Dr. Romberg has given the following criteria for its discrimination when the vomiting is of cerebral origin : — 1. The influence of the position of the head ; the vomiting is arrested in the horizontal, and recurs and is frequently repeated in the erect position. 2. The prevailing absence of premonitory nausea. 3. The peculiar character of the act of vomiting ; the contents of the stomach are ejected without fatigue or retching, as the milk is rejected by babies at the breast. 4. The complication with other phenomena, the more frequent of which are pains in the head, and irregularity of the cardiac and radial pulse, increased during and subsequent to the act of vomiting. The following differential table further exhibits the points of contrast (from Dr. W. Fox) :— 190 DIFFERENTIAL V>I At ; N< (SIS. GASTRIC VOMITING. Epigastric pain and tenderness are common, and in some cases very marked. Nausea is constant. Oppression and weight at the epigastrium are constant. Bowels are variable. The tongue is loaded, except in certain cases of cancer or ulcer. Headache is absent, or not in- tense, chiefly frontal, of gradual in- vasion, and relieved by vomiting. Vertigo is rare and relieved by vomiting. Other nervous phenomena are rarely present, and then only in slighter forms, and relieved by vomiting. CEREBRAL VOMITING. Epigastric pain and tenderness are rare. Nausea is frequently absent. These are rare. Bowels are constipated. The tongue is usually clean. Headache often violent, the inva- sion sudden, and not relieved by vomiting. Vertigo is very frequent and not relieved by vomiting. Indistinctness of vision and diplo- pia. Confusion of ideas. Loss of memory. Not relieved by vomiting. Anaesthesia or paresthesia, paralysis or cramp, convulsion or coma, are common or soon supervene. The indications derived from the nature of the matters thrown up in vomiting are as follows : — Ingesta. The food is returned unaltered, or but slightly changed, in nervous vomiting ; in a half digested state and strongly acid in chronic inflammation and cancer of the stomach; mixed with the microscopic forms known as sarcinse and torulse in chronic gastritis, gastric ulcer and cancer. JTucus is vomited in a catarrhal or sub-inflammatory condition of the stomach. Bile appears whenever the retching is long and violent, and does not indicate any special disease. Pus is not formed in the stomach, and when present in the vomit in- dicates disease in the cesojjhagus. Fceces also indicates a disease elsewhere than the stomach, usually an obstruction of the intestinal canal. Blood is thrown up in gastric cancer and ulcer, in severe gastritis, in ex- DISEASES OP THE DIGESTIVE SYSTEM. 191 ternal injuries, vicariously (of the uterus), and frequently from disease of the heart or liver, producing distention of the capillaries. The presence of blood directly proceeding from the stomach, says Dr. Fox, if accom- panied by severe pain, is almost pathognomonic of either gastric ulcer or cancer. ATONIC DYSPEPSIA, INFLAMMATORY DYSPEPSIA, GASTRIC ULCER, GASTRIC CANCER. The chief points in the diagnosis of diseases of the stomach are those connected with the differentiation of simple dyspepsia (atony of the stomach), inflammatory dyspepsia (gastritis, gastric catarrh, catarrhal in- flammation of the stomach), gastric ulcer and gastric cancer. From this group the nervous disturbances of the stomach are broadly marked off by the superficial character of the pain in these latter, its independence of the acts of digestion and the nature of the food, the co- existence of other neuralgise, the frequent absence of emaciation and other disturbances of nutrition, and the sex and age of the patients. In reference to the value of percussion in diagnosing gastric cancer, Professor Peter, of Paris, has directed attention to the fact that when superficial percussion, percussion en dedolant, is made over the stomachal region somewhat distended by gas, there is found at certain points, especially in the region of the greater curvature, a certain obscurity of the note alternating with the zones of sonority. But this sign is abso- lutely wanting on deep percussion such as is ordinarily employed. Prof. Peter, by this means, diagnosed a cancer of the stomach situated at the posterior surface of the greater curvature, with some cancerous nodules probably disseminated through the epiploon below the splenic region and also in the hypogastric region. At this last point also superficial percus- sion gave the same results. An early sign of gastric cancer is the presence of enlarged glands in the skin of the navel (Maunder). To ascertain the mobility and outline of the stomach, the patient may be desired to drink one or two tumblers of soda water. This distends the stomach and makes the tumor prominent. The following comparative table, drawn from the works of Drs. W. Fox, William Brinton and Da Costa, illustrates the main points of difference in the four diseases named : — 192 DIFFERENTIAL DIAGNOSIS. ATONIC DYSPEPSIA. No pain or soreness at the epigas- trium. Sensation of weight or load, rather than tenderness. Symptoms of indigestion. Appe- tite impaired. Thirst generally ab- sent. Tongue pale and flabby. Vomiting rare. CHRONIC GASTRITIS. Pain at the epigastrium somewhat augmented by food ; also soreness. Both constant, though not severe. No hemorrhage. Bowels may be regular. Indigestion present. Appetite capricious. Thirst increased. Tongue furred and red at edges. Sometimes vomiting. Hemorrhage absent, or rare and trifling. No febrile symptoms. Nutrition not materially inter- fered with. Not confined to any age. Course of disease uniform ; may be cured. No tumor. Percussion resonant. Bowels constipated. Occasional slight pyrexia (Fox). Slight emaciation ; slightly earthy tint to skin (Fox). More common in middle or ad- vanced life. Disease with marked exacerba- tions and remissions. May be re- lieved or cured. No tumor. Percussion resonant. DISEASES OF THE DKJ I0STIVE SYSTEM. 1 93 GASTRIC ULCER. Pain at the epigastrium much augmented by food; is intermittent; subsides after digestion ; pain in pa- roxysms, but not lancinating; epi- gastric soreness strictly localized. Sometimes a painful spot over lower dorsal vertebra. Symptoms of indigestion slight. Vomiting may be present or not. Usually relieves the pain. Abundant hsematemesis. Bowels slightly or not consti- pated. No fever present. Frequently extreme pallor and debility. May occur in middle-aged per- sons, but is frequently seen in young adults, especially females. Duration uncertain ; may get well; may run on rapidly to perforation ; or may last for years. No tumor. Percussion resonant. GASTRIC CANCER. Pain paroxysmal, radiating, often severe and lancinating; rarely re- mitting; never intermitting; little or not at all affected by food ; not always accompanied by soreness. Symptoms of indigestion more marked. Extreme acidity of the stomach. Vomiting a very frequent symp- tom. Does not relieve the pain. Hsematemesis not very abundant; but occasioning frequently vomiting of a substance resembling coffee grounds. Constipation obstinate. Fever not uncommon. Gradual and progressive loss of flesh and debility. Most common in elderly people ; rarely occurs in persons under forty years of age. Duration about one year; very rarely reaches two. Termination fatal. Generally a tumor. Percussion variable. 19-t DIFFERENTIAL DIAGNOSIS. INDIGESTION AND DYSPEPSIA. Although the distinction is not generally drawn in ordinary language between dyspepsia and indigestion, it should not be forgotten that they arc not synonymous. Dyspepsia lias reference to an altered condi- tion oi* the digestive fluid, its deficiency or excess, or to an organic affection of the muscular walls of the stomach, which has for its result imperfect or difficult chymification of the food; indigestion merely expresses a disturbance of function, and refers to the result rather than the cause. In dyspepsia the peptic glands or muscular apparatus of the stomach arc defective, in indigestion they may be normal, but have their functions interfered with by improper and unaccustomed articles of food, or by reflex influence from other organs. The symptoms of INDIGESTION are tabulated by Dr. Murchison as follows* : — 1. A feeling of weight and fullness at the epigastrium and in the region of the liver. 2. Flatulent distention of the stomach and bowels. 3. Heartburn and acid eructations. 4. A feeling of oppression, and often of weariness and aching pains in the limbs, or of insurmountable sleepiness after meals. 5. A furred tongue, which is often indented at the edges, and a clammy, bitter, metallic taste in the mouth, especially in the morning. 6. Appetite often good; at other times anorexia and nausea. 7. An excessive secretion of viscid mucus in the fauces, and at the back of the nose. 8. Constipation, the motions being scybalous, sometimes too dark, at others too light, or even clay colored. Occasionally attacks of diarrhoea, alternating with constipation, especially if the patient be intemperate in the use of alcohol. 9. In some patients attacks of palpitation of the heart, or irregularity or intermission of the pulse. 10. In many patients occasional attacks of frontal headache. 11. In many, restlessness at night and bad dreams. 12. In some, attacks of vertigo and dimness of sight, often induced by particular articles of diet. * "Functional Derangements of the Liver." London, 1874. DISEASES OF THE DIGESTIVE SYSTEM. ] 95 DYSPEPSIA may be due to impaired motion as well as to deficient secretion. The following table will give the distinctive points for diagnosis :* 1. Dyspepsia from impaired motion. Constant symptom, generally soon replaced by sense of tension accompanying ulency. Characteristic symptom. Uneasiness after meals. Flatulence . Gastric pain. Constipation , Treatment. lat- Infrequent, but occurs occa- sionally, as a result of flatu- lence, and is peculiar in kind. Almost always symptom. a marked Strychnia, carbolic acid, thy- mol, charcoal. 2. Dyspepsia from defective secketioh. Not infrequent, but commonly soon merged into acute pain. Comparatively infre quent; some of the worst cases, in which pain after food and other symptoms are particu- larly severe, are entirely free from flatus. The tend- ency is to lactic, butyric, and perhaps other forms of fermentation, in which gases are not evolved. Variously described as sharp, shooting, dull, or dragging, is the most characteristic symptom of defective secre- tion of gastric juice. Not generally present, and the bowels are in many cases relaxed. Diet, tonics, pepsin acids, hygienic treatment. Hyperperistalsis, dyspepsia of fluids, flaccid stomach, and other states remain for discussion. ABDOMINAL PHTHISIS. Abdominal phthisis (tubercular peritonitis) in its acute forms, closely simulates typhoid fever. There are febrile symptoms attended with re- missions, heat and dryness of the surface, pains in the limbs, drowsiness and disordered secretions, and diarrhoea. It differs from typhoid in these particulars : — 1. The pain is diffused over the abdomen, not limited to the csecal region. 2. There are no red spots (with rare exceptions). 3. There is generally tubercular disease in other organs. 4. The temperature has not the morning remissions of typhoid. * Arthur Leared. "Dyspepsia." British Medical Journal, May, 1879. p. 660. 196 DIFFERENTIAL DIAGNOSIS. OBSTRUCTION OF THE BOWELS. The causes of a mechanical stoppage of the bowels are principally the following - : intussusception; impaction of fsecesj strictures; twisting of the bowel (volvulus); hernia?; pressure of tumors. The symptom first noticed is constipation with colicky pains, which do not yield to ordinary remedies; slight distention of the abdomen and some soreness on pressure. Vomiting follows, very severe, even becom- ing fecal. It is liable to be confounded with peritonitis and strangulated hernia. The following rules for diagnosis have been laid down by the eminent surgeon, Mr. Jonathan Hutchinson, of London : — 1. When a child becomes suddenly the subject of symptoms of bowel obstruction, it is .probably either intussusception or peritonitis. 2. When an elderly person is the patient, the diagnosis will generally rest between impaction of intestinal contents and malignant disease (stric- ture or tumor). 3. In middle age the causes of obstruction may be various; but intus- susception and malignant disease, both of them common at the extremes, are now very unusual. 4. Intussusception cases may be known by the frequent straining, the passage of blood and mucus, the incompleteness of the constipation, and the discovery of a sausage-like tumor, either by examination per anum or through the abdominal walls. 5. In intussusception, the parietes usually remain lax, and, there being but little tympanites, it is almost always possible, without much diffi- culty, to discover the lump (or sausage-like tumor) by manipulation under ether. 6. Malignant stricture may be suspected when, in an old person, con- tinued abdominal uneasiness and repeated attacks of temporary constipa- tion have preceded the illness. It is to be noted also that the constipa- tion is often not complete. 7. If a tumor be present and pressing on the boAvel, it ought to be discoverable by palpation, under ether, through the abdominal walls, or by examination by the anus or vagina, great care being taken not to be misled by scybalous masses. 8. If repeated attacks of dangerous obstruction have occurred with long intervals of perfect health, it may be suspected that the patient is the sub- DISEASES OF THE DIOESTIVE SYSTEM. 107 ject of a congenital diverticulum, or has bands of adhesion, or that some part of the intestine is pouched and liable to twist. 9. If, in the early part of a case, the abdomen become distended and hard, it is almost certain that there is peritonitis. 10. If the intestines continue to roll about visibly, it is almost certain that there is no peritonitis. This symptom occurs chiefly in emaciated subjects, with obstruction in the colon of long duration. 11. The tendency to vomit will usually be relative with three condi- tions and proportionate to them. These are (1) the nearness of the im- pediment to the stomach, (2) the tightness of the constriction, and (3) the persistence or otherwise with which food and medicine have been given by the mouth. 12. In cases of obstruction in the colon or rectum, sickness is often wholly absent. 13. Violent retching and bile vomiting are often more troublesome in cases of gall-stones or renal calculus simulating obstruction than in true conditions of the latter. 14. Fecal vomiting can occur only when the obstruction is moderately low down. If it happen early in the case, it is a most serious symptom, as implying tightness of constriction. 15. The introduction of the hand into the rectum as recommended by Prof. Simon, of Kiel, may often furnish useful information. INFLAMMATORY DIARRHXEA (ENTERITIS) AND DYS- ENTERY (COLITIS). These diseases, both alike in being inflammations of the mucous mem- brane of the intestinal tract, are frequently associated. But for thera- peutic as well as prognostic purposes, it is desirable to recognize the distinctions which they present in well marked types. They are — ENTERITIS. DYSENTERY. Seat of inflammation is in the Seat of inflammation is in the small intestine. large intestine. Usually begins with colic, nausea Usually begins with painless, slight and vomiting, constipation (rarely diarrhoea, followed by chill, slight diarrhoea), chilliness soon followed or no fever, sense of weight near the by high fever, thirst and hot skin. anus. No colic. L98 lUFFEKENTlAI. [»1A«:.N«>SIS. ENTERITIS. Pulse at first tense and full j soou becomes small, wiry, quick. Pain paroxysmal, local tenderness marked, greatly increased by pres- sure. Stools mucous, rarely blood, very rarely pus. Noscybala. No tenes- mus. Aortic pulsation felt by the pa- tient on the right of the umbilicus. DVSKXTHUY. Pulse often little excited ; or if fever is high, full and rapid. Pain more moderate, usually dis- tinctly over the colon, moderate ten- derness. Stools scanty, bloody, contain pus, scybala, little faeces. Marked tenes- mus. Aortic pulsation not noticed by the patient. DISEASES OF THE LIVER. Previous to an examination of the liver, the patient should have a free action of the bowels, as fecal accumulations are a constant cause of diag- nostic errors. Pie should lie on his back on a firm bed, with his knees drawn up and the abdominal muscles relaxed. Palpation should be upon the skin directly, uot on the clothing. The physician, seating himself on the patient's right side, should apply the tips of the fingers of the right hand just below the free border of the ribs, and request the patient to make full inspiration and expiration. He will thus be able to feel the upper edge and surface of the liver and ascertain the condition of its sur- face, whether smooth or nodular. By percussion, which should be made while the patient is in the same position, the size of the liver cau be quite accurately mapped out. These two facts are the first steps to a diagnosis; as most hepatic diseases can be assigned to one of these classes — 1. Liver enlarged, with smooth surface. 2. Liver enlarged, with nodular surface. 3. Liver atrophied. Pain iu the hepatic region should be examined ; whether dull or acute, persistent or intermittent, etc. The condition of jawndine is ascertained, iu light cases, by examining the under surface of the tongue and the con- junctiva of the eye, which will display the icteric discoloration when the general surface does not. A still more delicate test of the presence of jaundice is derivable from examination of the urine. The following three teste are employed by Pro!'. Hardy, of Paris: — DISEASES OF THE DIGESTIVE SYSTEM. 199 1. Chloroform. When this is poured upon normal urine it sink-, by reason of its great density, to the bottom of the test-glass, exhibiting there a crystalline transparency. If we pour it on the icteric urine, and having shaken the test-tube plugged by the thumb, leave it quiet for a moment, the chloroform deposit contrasts strongly by its dull color with the yellow of the superficial layers — the yellow color being deeper in proportion to the quantity of bile in the urine. It is an excellent test of icteric urine. 2. Iodine. When the iodine is poured upon the icteric urine the mix- ture must not be shaken. At the upper part of the tube three very dis- tinct colors are observable — the first layer formed by the tincture is violet; below this is a kind of diaphragm of sea-green color; and the third layer, consisting of the urine, and occupying the lowest part, is yellow. 3. Nitric Acid. When this agent has been poured in, the mixture after shaking assumes a bottle-green color, passing into an olive. This is an entirely special aud very characteristic appearance.* With these hepatic symptoms determined, a study of the following tables will in most instances readily supply a correct diagnosis. THE SIGNIFICANCE OF PAIN IN THE LIVER. Pain having its source in the liver is divided by Dr. Charles Mur- CHisoNf into three varieties, each of diagnostic significance : — CHARACTER OF PAIN. DISEASES FOUND IN. Obstruction of the bile duct by gall-stones, etc. (hepatic colic); hep- atic neuralgia (when jaundice is ab- I. Pain severe, paroxysmal, with distinct intermissions; little or no local tenderness; no fever; often associated with jaundice. II. Pain moderate, continuous, slightly increased by pressure, often associated with pain in the right shoulder, slight febrile symptoms and jaundice. III. Pain severe, constant, greatly increased by pressure, motion, cough- ing, etc. More or less fever; per- haps jaundice. sent, probably the latter). Congestion and commencing in- flammation of the organ; catarrh and partial obstruction of the bile ducts; acute atrophy. Always indicates inflammation of the capsule (peri-hepatitis), which may supervene in various diseases (cirrhosis, hydatids, etc.). * Revue cle Tlierapeutique, August, 1878. f "Lectures on Diseases of the Liver." 200 DIFFERENTIAL DIAGNOSIS. Hepatic pain may be simulated by various other conditions. The principal ones, with their characteristic differences, are as follows: — 1. Pleurodynia. The pain is strictly localized to a small spot. Ab- sence of hepatic disturbance. •_'. Intercostal Neuralgia. Tender points along the course of the inter- costal nerve. Chiefly referred to three points in the course of the nerve: (1) The vertebral groove; (2) The axillary region; (3) The termination of the nerve in front. Co-existence of neuralgia elsewhere. Absence of hepatic symptoms. 3. Pleurisy. Presence of pyrexia and physical signs of the disease. 4. Gastrodynia. Comes on with relation to food (stomach always either full or empty). Pyrosis. 5. Intestinal Colic. Pain referred to the umbilical region. No jaun- dice. Blue line of lead poisoning. Errors of diet. 6. Penal Colic. Pain chiefly referred to one kidney, when it shoots to the testiele and down the thigh. No jaundice. Hematuria and renal calculus. Little or no hepatic pain is felt in — 1. The waxy, lardaceous, or amyloid liver. 2. The fatty liver. 3. Simple hepatic hypertrophy. 4. Hydatid tumor. THE SIGNIFICANCE OF JAUNDICE. The common and obvious symptom of jaundice results either (1) from obstructions of the common bile duct ; or (2) independent of any obstruc- tion of the duct. The diagnosis of these two conditions may be presented as follows : — JAUNDICE FROM OBSTRUC- JAUNDICE WITHOUT OBSTRUC- TION. TION. When persistent, speedily be- comes int( The stools are elay-eolorcd. Tumor in the region of the gall- bladder often present. May appear suddenly in a person in good health. Persists and continues slight. The stools are natural. No tumor there. Appears gradually, unless there is a history of shock. DISKAKKH OF TIIIO Did KSTI VK SVS'I'KM. 201 JAUNDICE FROM OBSTRUC- TION. Intermittent jaundice in advanced life signifies gall-stones. Pain, usually, in severe parox- ysms. Co-existence of ascites, pregnancy, pyloric cancer (obstruction from without). JAUNDICE WITHOUT OBSTRUC- TION. Intermittent jaundice in youth signifies catarrh of the duodenum. Pain usually more or less con- stant. Preceding severe mental emotion, pyaemia, malarial fevers, phospho- rus poisoning, epidemic prevalence. The principal diseases which are associated with these varieties of jaundice are the following : — JAUNDICE FROM OBSTRUCTION MAY BE DUE TO 1. Gall Stones. 2. Hydatids. 3. Cancer and Tumors. DIAGNOSIS. Biliary colic present. Pain acute, paroxys- mal, referred to the gall bladder, and from this round to the right scapula. Tenderness absent or slight. Irregular rigors. No fever. Severe vomiting. Jaundice appears after a day or two. Pathognomonic; the presence of gall stones in faeces. Liver enlarged and altered in form but painless. Biliary colic with fever, quick pulse and high temperature. Pathognomonic; hy- datid vesicles in the faeces. Antecedent history of visceral cancerous disease. Pain and nausea after taking food. A hard and sensitive tumor in the epigastric or right hypochondriac region. Hemorrhage from the stomach or bowels. JAUNDICE WITHOUT OBSTRUCTION MAY BE DUE TO 1. Malarial Fevers. Yellow Fever, Pyaemia. 2. Epidemic Jaundice. DIAGNOSIS. History of malarial or specific poisoning, or actual presence of one of the diseases named. Gastric catarrh; stools pale; epigastric sore- ness; nausea or vomiting; loss of appetite; often commences with a chill after exposure. Most epidemics of jaundice seem to have been due to malarious poison or vitiated atmosphere. Infantile jaundice is of the latter character. 21 >2 DIFF E RENT1AL DIAG XOSIS. JAUNDICE WITHOUT OBSTRUCTION MAY HE DEE TO— (fW/« M <-,/) 3. Nervous -Jaundice. Jaundice from Con- gestion'. DIAGNOSIS. History of severe menial emotion, great suffering or sudden shock. Onset rapid; often cerebral symptoms. Feeling of weight and soreness over liver. Bad breath; poor appetite; furred tongue; vertigo. Right decubitus. Urine scanty and high colored. Slight dyspnoea. Bowels slug- gish. Acute atrophy, mineral poisons (especially by phosphorus), and very obstinate constipation, are other occasional causes of this form of jaundice. CLASSIFICATION OF HEPATIC DISEASES WITH REGARD TO THE SIZE OF THE LIVER.* 1. LIVER ENLARGED, SURFACE SMOOTH. Simple Hyperplasia. Hyper Liver enlarged, smooth, painless; absence of other symptoms. Liver enlarged and smooth. Spleen en- larged. Pallor of the skin. Pathognomonic; presence of a marked increase of the white blood globules, 1:20 and upward. Enlargement moderate. Tenderness; con- junctiva jaundiced; stools pale; bowels irregu- lar; tongue coated; low spirits; headache; vertigo; noises in the ears. No jaundice or dropsy. Liver enlarged, smooth. Slight jaundice. Some dyspnoea. Dropsical effusions. Mitral or aortic disease. Emphysema or induration of the lungs. Enlargement slight. Enlarged spleen. History of malarial disease. Pathognomonic: the malarial pigment tn the blood. Enlargement considerable, uniform, of slow growth, borders sharply defined, feel firm. Pain slight. Patient emaciated and cachectic. Splenic enlargement common. Diarrhoea and dyspepsia. History of phthisis, syphilis or protracted suppuration. * Partly taken from E. J. Janeway. "Diagnosis of Hepatic Affections." N. Y., 1877. Leukemic PLASIA. Congestion. (a) Simple. (b) From cardiac dis- ease. (c) From malaria. Waxy Deg ester ation. DISEASES OF THE DIGESTIVE SYSTEM. 203 CLASSIFICATION OF HEPATIC DISEASES WITH IiEOAI.'O TO THE SIZE OF THE LIVER. 1. LIVER ENLARGED, SURFACE SMOOTH-( Continued). Enlargement considerable, borders rounded, feel doughy. No tenderness nor pain. Spleen small; jaundice slight or absent. Diarrhcea. A pale, smooth, greasy skin. History of in- temperance, phthisis or indolent life. Enlargement considerable, irregular, pain- less; usually of the left lobe of the organ. Feel elastic or fluctuating. Jaundice rare. Increase of size slow. No constitutional symptoms. Liver small, surface even. Preceded by ascites, dyspnoea, serious disease of heart or lungs, or signs of congestion. Rare. Jaundice always present, though rarely intense. Pain considerable. Tender- ness. Generally vomiting ; splenic dullness. Pulse irregular. The typhoid state common. Urine dark, acid, sp. grav. 1.012-1.024; ab- sence of urea, uric acid and the chlorides ; presence of leucine and tyrosine (pathogno- monic). Intestinal ^hemorrhage and hseina- temesis common. II. LIVER ENLARGED, SURFACE NODULAR OR IRREGULAR. Fatty Degeneration. Hydatid Tumors. Simple Atrophy. Acute Yellow Atro- phy. Abscess or Tropical Hepatitis. Cancer. Liver enlarged, irregular surface bulging. Dull, heavy pain. Jaundice rare. Pyrexia and chills. History of residence in a warm climate. Enlargement often very great, progressive, irregular; nodular excrescences often to be felt. Feel hard and resistant. Pain lancin- ating and tenderness acute. No febrile symp- toms. Jaundice. " The co-existence of en- larged liver with persistent jaundice ought always to raise the suspicion of cancer" (Murchison). Dyspepsia, nausea, vomiting, constipation, or diarrhoea, short, dry cough, ascites. Patients over 40. In suspected can- - I DIFFERENTIAL DIAGNOSIS. CLASSIFICATION OF HEPATIC PISFASFS WITH REGARD TO THE SIZE OF THE LIVER. II. LIVER ENLARGED, SURFACE NODULAR OR IRREGULAR-( Continued). ( Ianceb (Continued). Syphilitic Liver. cer of the liver the urine should always be examined; half a drachm of strong nitric acid should be added to half an ounce of the urine. If the fluid changes to a dark or black hue, and especially if no albumen is present, and the liver is either increased or diminished in size, the diagnosis of melanotic cancer is rendered very probable. (Dr. ElSELT, of Prague.) Liver enlarged, surface nodulated, lobes irregular, separated by deep fissures. III. LIVER DIMINISHED IN SIZE. Cirrhosis, or Chronic Atrophy. Liver small, sometimes only half size, sur- face granular or nodulated ; " hob-nail liver." Outset insidious, with signs of disordered di- gestion. Dull pain and slight tenderness in hepatic region. Ascites common. Spleen often enlarged. Superficial veins of the ab- domen enlarged. Hemorrhoids frequent. Jaundice rare or slight. Progressive emacia- tion and debility. History of spirit drinking almost invariably. HEPATIC ABSCESS. It has lately been shown * that an obscure and chronic form of hepatic abscess is a far more common disease in the United States than is generally supposed, and that it is often exceedingly difficult of diagnosis. These abscesses may exist without any local symptoms or such general disturbance of the system as is commonly regarded as indicating their presence, and are a very common concomitant of prolonged malarial poisoning. The pathognomonic sign of their presence is the discovery of pus on aspiration of the parenchyma of the liver. This operation is not dangerous, and there need be no hesitation in its performance. The place of election is one of the intercostal spaces. The rational symp- toms may be collated as follows: — J ., SCKT, Med. Record, April 20th, 1878; Hammond, St. Louis Clin. Record, Juno 1878 ; Bykd, N. Y. Med. Journal, July, 1878, etc. DISEASES OF THE DIGESTIVE SYSTEM. 205 1. Gastric and intestinal derangements ; dyspeptic symptoms of various kinds. 2. Slight jaundice, conjunctivae yellow; complexion sallow. 3. Depression of spirits, hypochondria or melancholy. This is a very usual symptom, and so important that Dr. Hammond recommends that in all cases of hypochondria or melancholia the region of the liver should be carefully explored, and even if no fluctuation be detected, or any other sign of abscess be discovered, aspiration, with proper precautions, should be performed. If pus be evacuated, the operation may be expected to be followed by a cure of the mental disorder, as well as by the preservation of the life of the patient from the probably fatal consequences of hepatic abscess. 4. Sense of weight or pain in the right side ; more or less tenderness on pressure (all local symptoms often absent). 5. Circumscribed fluctuation over the hepatic region. This is a posi- tive sign, but is by no means always to be discovered. 6. Cerebral symptoms, as vertigo, cephalalgia, insomnia hysteria and hyperaemia. 7. Slight rigors, and feverishness, simulating some of the more chronie forms of intermittent fever. INTERNAL PARASITES. The symptoms to which parasites in the intestinal canal and other organs give rise are numerous, but by no means specific or definite. The following tabular arrangement sets forth the more prominent : — Tape Woem. Taenia Solium. Taenia Saadnata. Pain and discomfort in the belly ; variable appetite; constipation and diarrhoea alternat- ing; itching at the nose or anus without local cause, low spirits, loss of flesh, nervous seiz- ures. Stools unusually dark or light. Pathognomonic: The discovery of joints in the stools, or about the anus, or of eggs in the faeces (microscopic). 206 DIFFERENTIAL MACNOSIS. Hydatid ( Iysts. Taenia Echinococci. Round Worms, Lum- brici. Ascaris Lumbricoides. Thrf.ad Worms. Ascaris Vermicularis or Oxyuris Vermicularis. Trichinosis. (Trichinae in the blood and muscular system). Trichina Spiralis. These occur chiefly in the lungs and liver. (Sir Diseases of the Liver.) They begin with a rounded, tense, smooth, clastic swelling, painless until inflammation begins, and with- out other symptoms than those caused bytheir size. They are often attended with the " hydatid thrill." This may be felt by plac- ing the left hand flat and closely upon the tumor, then percussing sharply with the fingers of the right hand. A long sustained tremor is observed, "like that experienced on an iron railway bridge during the passage of a train." Pathognomonic: Echinococci or microscopic hydatids in the contained fluid, which may safely be drawn by aspiration. Symptoms of intestinal irritation. Capri- cious appetite. Pain of a gnawing or griping character. Tenderness on deep pressure over the abdomen. Tumid condition of the belly. Alternate constipation and diarrhoea. The tongue pale, flabby, indented by the teeth, and often has a peculiar shiny appearance. Pupils generally dilated. Squinting, nervous twitch- ings, or even convulsions. Sleep is restless, with grating of the teeth and waking with sudden starts. Fever may appear, often of a remittent type (worm fever, verminal fever). Pathognomonic: Worms found in alvine evacuations. Violent itching and irritation at the anus and vagina, increased at night. Tendency to strain. Itching at the nose. Leucorrhcea. Pathognomonic : Worms found upon ex- amining the parts, also seen in patient's bed and his under-clothing. First Stage: Gastro-intcstinal disturbances; thirst; loss of appetite; nausea; colicky pain in the abdomen; constipation or diarrhoea; coated tongue; feverishness. Second Stage: Swelling and stiffness of the muscles; muscu- lar soreness ; oedema of the subcutaneous tissue; copious sweating; debility and increased DISEASES OF THE DIGESTIVE SYSTEM. 207 Trichinosis (Continued), fever; dyspnoea; hoarseness and loss of voice; dropsy commencing in the eyelids and face, and proceeding to the extremities; difficulty of motion and respiration. Pathognomonic: Presence of trichinae in the fasces; or in the muscular structure. The differential diagnosis from rheumatism is in the soreness being in the muscles and not the joints; from typhoid fever' in the un- usual pain and stiffness; the early swelling, dropsy, etc. Trichinae do not colonize equally through- out a muscle, but in groups here and there. It is best, therefore, to dissect out a muscle lengthwise in order to judge of their number. The very large number of symptoms attributed to the presence of worms in the intestinal canal is the irritation they cause, implicating the general nervous system. This, occasionally, extends so far as to produce a "worm fever," which in many respects resembles a mild remittent with unusually pronounced nervous symptoms. The tongue is pale and flabby, and often has a peculiar shiny appearance (Date). The pupils are gene- ally dilated. Squinting sometimes occurs, and nervous twitchings of a choreic character. The fever is often high, with great heat of skin, and the cerebral manifestations being marked, may lead to the suspicion of hydrocephalus. From this it can be distinguished by the mere direct remissions; by the previous history, showing the primary symptoms to be referable to derangements of the alimentary canal ; by the less obstinate constipation; and by the expulsion of worms. It has also been confounded with tubercular disease. Here the most important diagnostic point is the temperature. This in tubercular disease is always high; but when the irritation is from worms it is either normal or but temporarily elevated above the normal standard. 208 DIFFERENTIAL DIAGNOSIS. CHAPTER V. DISEASES OF THE URINARY SYSTEM. The Early Signs of PrighCs Disease — Comparative Diagnosis of the Dijf'erent Forms of Brighfs Disease (Acute Parenchymatous Nephritis, Chronic Tubal Nephritis, Yellow Fatty Kidney, Secondary Contraction of Kidney, Interstitial Nephritis or Renal Cirrhosis, Albuminoid or Amyloid Renal Degeneration, Parenchymatous Renal Degeneration) — Diabetes Mellitus and Glycosuria — Diabetes Insipidus and Hydruria — Pile in the Urine — Urinary Calculi. General methods for the examination of the urine, and the chemical reagents and manipulations required in its analysis, are to be found in so many text-books and treatises that we may omit them here, and confine ourselves to the differential symptoms of some of the most prominent and frequent renal diseases. THE EARLY SIGNS OF BRIGHT'S DISEASE. The early progress of Bright's disease is often remarkably insidious, and readily escapes recognition. Nor is it to be detected by the familiar and easy plan of testing for albumen ; for this substance is by no means invariably present in the urine, even in advanced and well marked cases. Fothergill justly observes that the progress of interstitial nephritis is often without the albuminous secretion for long periods. On the other hand, it has been abundantly shown that albumen is occasionally and transiently present in the urine of persons who present no traces of nephritis; who, in fact, may be in excellent health. Hence the value of other means of determining the existence of these forms of renal disease becomes manifest. Of these the presence of hyedine casts has recently been urged as pathognomonic of renal hyperemia and inflammation, and invariably present.* These must be sought for with considerable care, as from their transparent character, and the fact *Dr. B. A. Segur, Proceedings of the Medical Society of King's Co., 1878, p. 241. DISEASES OF THE URINARY SYSTEM. 209 that they do not form a sediment, they are readily overlooked. The di- rections given for their search are that the urine to be examined is placed in a tall, conical glass; after three to six hours it is inspected; from the visible deposits, whether floating or sedimentary, with the pipette a quantity is taken sufficient to fill a concave slide or a shallow cell. This little pool is first searched with a four-tenths objective, and in a little time any cast or other microscopic object it contains is found. A more careful observation is made of the object thus found with the one- fifth. When the examination of deposits has been made in this way, the conical glass of urine should be set aside (a little chloral may be added, to prevent decomposition), and after twelve hours more the examination should be repeated. Of course, it will be remembered that the hyaline cast may be found when the condition of the kidney is only one of tran- sient hyperemia. The effort has also been made to call in the aid of the ophthalmoscope. The presence of minute white exudations in the retina, principally around the macula? luteee, are believed to point to the presence of Bright's dis- ease, and to be found in its early stages (retinitis albumin urica). The appearance of the retina in these cases is characteristic. It consists in the grouping of small white spots, the outline of each being clearly defined ; they are invariably circular, of extremely small dimensions, and present the appearances of a pearl of an intensely bright color, and stand out from the retina in a marked manner. The grouping of the spots is symmetri- cal in each eye, and is generally in the form of a crescent. Often the urine will only yield signs of the minutest quantities of albumen — some- times none at all ; but hyaline casts and these white spots may be detected by the processes here described. We shall now proceed to classify the diagnostic points in the differen- tiation of the seven forms into which the varieties of Bright's disease are now divided, premising that more than one form may exist in the same patient. 210 DIFFERENTIAL DIAGNOSIS. COMPARISON OF THE DIFFERENT History. Appearance. Urine. Prognosis. Pathology. ACUTE DESQUAMATIVE NEPHRITIS. Sudden onset after Bcarlel fever or ex- posure to wet and cold; OSdema of the face the sign first noticed; headache, feverishness, pain in the loins, gastric disturbance. Dropsical. more or less swollen about the face ; skin generally dry. Scanty, smoke color- ed, dark when acid, red if alkalized. Highly albuminous. Specific gravity high, 1.025-1.030. Reddish brown sedi- ment of epithelial, blood and hyaline casts. Recovery frequent. May lead to chronic tubal nephritis. Kidneys enlarged, congested, vascular; cortical substance increased. Tubules dark and dense. CHRONIC TUBAL NEPHRITIS. Symptoms of more than six weeks' du- ration. Often his- tory of acute ne | ih li- tis. Uremic symp- toms; abnormal ly 1 o w temperature. Serous inflamma- tions. Cardiac hy- pertrophy. More or less oedema, and general anasar- ca. A pale, almost characteristic, waxy look. Generally scanty, though variable. Pale, albumen about one-fourth, specific gravity low, 1.005- 1.015 ; white sedi- ment of hyaline and epithelial casts. No blood casts. Recovery not likely. Kidney enlarged, cor- tical substance in- creased, capsules easily separated. "Large white kid- ney." YELLOW FATTY KIDNEY. Often follows alcohol- ism. Dropsy considerable and persistent; re- nal cachexia often marked. Scanty, pale, low spe- cific gravity, with abundant sediment of oil casts and cells filled with oil. Al- bumen abundant. Almost certainly fa- tal. Kidneys e nl arge d, fatty, mottled, the tubes full of fat and oil cells. DISEASES OF THE URINARY SYSTEM. 211 FORMS OF BRIGHT'S DISEASE. SECONDARY CONTRAC- TION OF KIDNEY. Symptoms of more than a year's dura- t i o n . Headache. Coma o r convul- sions. Cardiac hy- pertrophy. E p i s - taxis. Generally some dropsy, but not very extensive. Face sallow. Scanty, pale, specific gravity about 1 015. Albumen moderate. Sediment of pale casts, dark granules, fatty cells and waxy products. Generally fatal, but of slow progress. Kidneys contracted, dense, capsule ad- herent; atrophy of the tubules. INTERSTITIAL NEPHRITIS. RENAL CIRRHOSIS. Symptoms few and faint. Often the arthritic diathesis. Exposure to cold and fatigue. Sense of weariness. Fre- quent headaches. Amaurosis. Car- diac hypertrophy. Little or no dropsy. Nerve implications, as paralysis, loss of sight or hearing, etc. Largely increased, pale ; albumen trifl- ing; sediment little, of finely granular casts, or minute oil drops. Specific gravity low. With care, not imme- diately dangerous, but predisposes to uraemic attacksfrom exposure. Kidneys at first en- larged, later con- tracted ; connective tissue increased capsule adherent diminished and cor rugated. "Chron ically contracted ' kidney. ALBUMINOID OR AMYLOID RENAL DEGENERATION. Antecedent syphilis, phthisis or osseous disease of chronic suppuration. En- larged liver or spleen. Chronic diarrhoea. Dropsy generally amenable to treat- ment. Emaciation. Face sallow or pal- lid. Dyspnoea. Largely increased. (50-60 oz.) pale or golden ; albumen considerable, per- haps one-half. Spe- cific gravity 1.007- 1.015 ; little or no sediment ; casts hy- aline and waxy. Incurable, though the patient may live for years. Kidney enlarged, smooth, waxy look- ing. PARENCHYMA- TOUS RENAL DEGENERATION. Pregnancy, diphtheria, or acute fever. Generally dropsy. Normal in amount. Al- bumen t 1 ^ to \ bulk. Recovery fre- quent. Kidney en- larged, the parenchyma more or less hypertro- phied. 212 DIFFERENTIAL DIAGNOSIS. In the form of amyloid degeneration the difficulties of diagnosis are considerable, as not only has it been generally recognized that albumen may be absent for considerable periods while the disease is steadily ad- vancing, but it has been abundantly shown that it may never appear at all in fatal cases.* It seems, therefore, certain that we possess at present no sure diagnostic sign of amyloid degeneration of the renal vessels; that on the one hand, it is likely to be confounded with, or mistaken for, chronic parenchymatous nephritis arising under identical etiological conditions; on the other, it runs a great risk of being altogether overlooked. But both of these evils may be avoided with a little care. Bartels points out that the differ- ential diagnosis between amyloid disease and chronic parenchymatous nephritis depends upon the distinguishing characters of the urine, which, in the former, is clear, with little sediment and few casts, mostly hyaline, and scarcely ever blood-corpuscles ; in the latter it is always more or less turbid, with considerable sediment, is dirty colored, contains many casts of every variety, and not uncommonly blood-corpuscles. In those cases in which no albumen was present, there have been signs of amyloid dis- ease in other organs; and, in order to escape error, it will be enough to know that the absence of albumen from the urine does not exclude a slight degree of amyloid disease of the kidneys. Cystic kidney is not considered worthy of special remark, since ordi- nary cysts are not to be recognized with any certainty during life, nor can they always be distinguished from the chronic varieties of Bright's Disease, in which they frequently are developed (Da Costa). DIABETES MELLITUS AND GLYCOSURIA. The presence of sugar in the urine is characteristic of both these condi- tions. The most convenient simple test is caustic potash (Moore's test), either in solution or small fragments. Heated with urine containing sugar, this substance immediately produces a more or less yellow or brown color, the intensity of which is in proportion to the quantity of sugar present, and a peculiar sweet smell (melassic acid). The test usually preferred is Trommer's or Fehling's, which depends upon the reduction of a salt of copper by the sugar. The Fehling's *Lecorch£, " Maladies des Reins, Paris, 1875 ; Littex, Berliner K tin. Wochenschrift. DISEASES OF THE URINARY SYSTEM. 2i:s test may be obtained in a solid form as "cupric test pellets," as suggested by Pavy.* Apart from this test, the presence of sugar in the urine is revealed by many indications. We may often recognize it by grayish patches on the clothing or linen, which are reduced to powder when scratched with the nail. In women the chemise, from prolonged contact with the urine, may become spotted and stiffened, as if by drops of syrup. Another circumstance indicating the sugary savor of the urine, especially in the country, is the great number of flies or ants that will be attracted around the vessel containing it. The presence of sugar once determined, it remains to decide whether it arises from simple glycosuria, which is a comparatively common and not dangerous condition, or from saccharine diabetes, which is more rare and a very perilous affection. This distinction has lately been insisted upon by M. Gerin Rozes. The contrasting features of the two disorders may be presented as follows : — DIABETES MELLITUS. Onset gradual ; occurs at all ages, and without reference to known pre- disposing causes. The amount of sugar varies very little. The absence of saccharine food makes little or no change in the urine. Volumetric analysis by Fehling's method is easy. Polyuria, polyphagia, polydipsia, and impotence common and well marked. Nervous complications frequent. Treatment of little avail ; result usually fatal. SIMPLE GLYCOSURIA. Onset sudden; more common in the aged ; in persons consuming saccharine food ; in the insane ; in those taking chloral ; in the parox- ysms of ague ; after sudden excite- ment ; blows on the head ; cerebral affections. The amount of sugar varies greatly from day to day (pathogno- monic, Rozes). The withdrawal of saccharine food diminishes the sugar. Such analysis is obscure, owing to the quantity of creatinine and similar substances present. All these may be, and generally are, absent, or slightly marked. Rare. Treatment eflicient ; result usually favorable. * See Article by Dr. Neff, in Medical and Surgical Reporter, for May 10th, 18S0. 21-1 DIFFERENTIAL DIAGNOSIS. "With the knowledge of the very fatal character of diabetes mellitus, a recognition of its earliest symptoms becomes of immense importance for treatment. Its invasion is seldom sudden, and at the very outset may be curable, which it rarely or ever is when once developed. Various nervous symptoms are among- the earliest noted, and it is a wise rule in all nervous disorders of a doubtful character to examine the urine for sugar. Changes in the character of an individual, an abnormal irritability of temper, insomnia, and extreme feeling of fatigue, disorders <>j vision, itching of the skin, pruritus of the genital organs, especially the vulva, and more or less protracted headache, are often premonitory symp- toms. Intense and obstinate neuralgic pains, without obvious cause, especially in the foot and leg, should lead to the suspicion of diabetes. Recurrent boils and carbuncles arc well known to accompany the diabetic condition. Genital impotence is one of the first signs of approaching diabetes; and whenever individuals are met with who, previously virile, become weak and impotent without coinciding disease, especially of the spinal marrow, diabetes w r ill usually be found to be the cause. Valuable infor- mation is derivable from the mouth ; for besides the insatiable thirst and dry mouth, some patients complain of a disagreeable taste, which is sometimes acrid, and at others faint, or bitter, or sugary ; and it is this perverted taste which contributes to maintain the thirst. The mouth frequently exhibits an aphthous condition, while the edges and tip, and even the whole surface of the tongue, may present a red aspect, as if the aphtha? had been removed. The gums, also^ are often softened, fungous or bleeding; while in some the teeth become loose, or fall out without being decayed, and in others become carious. The breath is frequently of a bad, acid smell, and the saliva, on examination, is acid instead of neutral. Another fact which has sometimes led to the diagnosis is the existence of intertrigo at the commissure of the lips. This intertrigo labialis is not exclusively connected with diabetes, but when met with should always lead to an examination of the urine. With regard to the digestive organs, boulimia on the one hand, and a complete repugnance for food on the other, with dyspepsia, should lead us to suspect diabetes. The unusual thirst of diabetics prompts them to drink large; quantities of water at night, and such a habit should suggest DISEASES OP THE URINARY SYSTEM. 215 strict inquiry for other symptoms. As a general rule it may be said that whenever there is muscular debility, emaciation and anaemia, without discoverable local cause, the urine should be examined, and will almost always be found to contain either sugar or albumen. The prognosis in a case of Diabetes Mcllitus improves with the age of the patient ; occurring in elderly persons, with ordinary care, it does not appear to shorten life (Da Costa). DIABETES INSIPIDUS AND HYDRUBIA. The habitual discharge of an excessive amount of urine of low specific gravity, and containing neither albumen nor sugar, if accompanied with progressive emaciation, excessive thirst, and loss of vital power, constitutes diabetes insipidus ; but under various conditions excessive diuresis may be temporarily present, as in hysteria and other cerebro-spinal and nervous affections, without serious general symptoms, and constitute the condition of hydruria. The distinction between the two can be made by noting the coincident disease in the latter form, the slight direct impairment of the general health, the varying amount of urine voided, and by the fact that the quantity, although large, never attains those extraordinary mea- sures — thirty to fifty pints daily — which marked cases of diabetes insipidus present. A large amount of urine is discharged by patients with amyloid degeneration of the kidney. BILE IN URINE. The significance of bile in urine is the same as that of jaundice (see page 200), as it indicates the presence of bile in the blood. The tests are those for the bile pigment and those for the biliary salts. The color test usually employed is that of Gmelin ; a few drops of urine are placed upon a white plate and nitric acid dropped at its side; if bile pig- ment be present a play of colors, from grass-green to red, is produced. The same may be obtained by adding sulphuric acid to urine in a test tube, and dropping in a crystal of potassium nitrate. The tests for the biliary salts are so complicated that they are entirely unreliable, as gener- ally applied. For cautions and directions for their use the reader is referred to Neubauer and Vogel's " Chemistry of the Urine." 21 G DIFFERENTIAL DIAGNOSIS. URINARY CALCULI. There are but three forms of calculi which are at all of common occurrence, and which are, therefore, likely to demand analysis. These are uric /s!in<' are found, though very rarely. 1. Uric aoid calculi arc the most common. They are either red or some shade of red, and usually smooth, but may be tubcrculated. They leave a mere trace of residue after iguitiou. 2. Oxalate of lime calculi are frequently met with. They are generally of a dark brown or dark gray color, and from their frequently tubcrcu- lated surface have been called mulberry calculi. They may, however, also be smooth. Considerable residue remains after ignition. The calculus is soluble in mineral acids without effervescence. 3. Calculi of the mixed phosphates or fusible calculi are composed of the phosphate of lime and of the triple phosphate of ammonia aud mag- nesia. They form the external layer of many calculi of different compo- sition, and may form entire calculi, but very seldom form the nuclei of other calculi. They are white, exceedingly brittle, fuse in the blowpipe flame, and are soluble in acids, but insoluble in alkalies. Few calculi of large size are of the same composition throughout. Oxalate of lime is the most frequent nucleus ; uric acid may also serve as a nucleus, but phosphates, as stated, almost never. Small collections of organic matter, as blood-clots, frequently form nuclei, and may often be recognized by the odor of ammonia on ignition. It is not uncommon to find calculi made up of concentric layers of different composition. TO DETERMINE THE COMPOSITION OF CALCULI.* Heat a portion of the powdered calculus to redness upon platinum foil. Note whether there is a residue. A. There is a fixed residue. To a portion of the original powder apply the murexid test. (This is as follows : Dissolve a small portion of the powder in a drop of nitric acid on a porcelain plate, then carefully evaporate over a spirit lamp. When dry add a drop or two of liquor * The processes here given are taken, with slight alterations, from Tlmdi churn's work on the Pathology of the Urine. DISEASES OF THE UEINAItY SYSTEM. 217 ammonias, when, if uric acid is present, a beautiful purple color will appear where the ammonia spreads). I. A purple color results ; uric, acid is present. Observe whether a portion of the calculus melts on being heated. a. It melts and communicates — 1. A strong yellow color to the flame of a spirit lamp : sodium urate. 2. A violet color to the flame ; potassium urate. b. It does not melt. Dissolve the residue after ignition in a little dilute HC1, add ammonia until alkaline, and then ammonium carbonate solution. 1. A white precipitate falls ; calcium urate. 2. No precipitate. Add some hydric sodic phosphate solution; a white crystalline precipitate falls; magnesium urate. II. No purple color results. Observe whether a portion of the calculus melts on being heated strongly. a. It melts (fusible calculus). Treat the residue with acetic acid ; it dissolves. Add to the solution ammonia in excess ; a white crystalline precipitate falls ; ammonio-magnesium phosphate. In case the melted residue is insoluble in acetic acid, treat with HC1 ; it dissolves. Add to the solution ammonia ; a white precipitate indicates calcium phosphate. b. It does not melt. Moisten the residue with water, and test its reaction with litmus paper ; it is not alkaline. Treat with HC1 ; it dissolves without effervescence. Add to the solution ammonia in excess ; white precipitate ; calcium phosjyhate. Treat the calculus with acetic acid ; it does not dissolve. Treat the residue after heating with acetic acid ; it dissolves with effervescence ; calcium oxalate. Treat the original calculus with acetic acid ; it dissolves with efferves- cence ; calcium carbonate. B. There is no fixed residue. Apply the niurexid test (p. 216). I. A purple color is developed. a. Mix a portion of the powdered calculus with a little lime, and moisten with a little water ; ammonia is evolved, and a _ 1 B DIFFERENTIAL DIAGNOSIS. red litmus paper suspended over the mass is turned blue; ammonium urate. b. Xo ammonia ; uric acid. II. No purple color. a. But the nitric acid solution turns yellow as it is evaporated, and leaves a residue insoluble in potassium carbonate ; xanthine. b. The nitric acid solution turns dark brown, and leaves a residue soluble in ammonia ; cystine. INDEX. Abdominal phthisis, 195. Abscess, cerebral, 85. Acidity of the stomach, 186. Acute yellow atrophy of liver, 203. Albrecht, R. , relapsing fever, 52. Albuminoid liver, 202. kidney, 211. Amyloid liver, 202. kidney, 211, 212. Amyotrophic paralysis, 101. Anaemic murmurs, 173. Anaemia, pernicious, 66 ; cerebral, 75 Angina pectoris, 174. Anstie, F. E., neuralgia, 117; test for hoi, 76. Aortic diseases, 175. Apoplexy, 75-77. meningeal, of the cord, 95 spinal, 96. pulmonary, 161. Appetite, 185. Arthritic dyscrasia, the, 54. Arthritis, rheumatica deformans, 66. Ascarides, 206. Asthma, 162. Atrophy of the liver, 203. Barlow, Thos., hysteria, 115. Bennett, J. H., 142. Bile in the urine, 215. Billroth, T., dyscrasia, 54. Blood, diseases of, 54. in malarial fever, 42. relapsing fever, 52. pernicious anaemia, 67. leukaemia, 67. Blood-cell counting, 67. Bocher, Dr. , rheumatic gout, 66. Boxichut, ophthalmoscope, 80. Boulimia, 185. Bowels, obstruction of, 196. Brain tumors, 85. Bramwell, B., anaemia, 67. Bri£>ht' s disease, 208. Broca, Dr., 86. Bronchitis, 148, 152. alco- Browne, L., diseases of the larynx, 135. Brown-S^quaiu), on paraplegia, 105. Bullard, Gr. B., 34. Calculi, biliary, 201. urinary, 216. Cancer of the lung, 165. liver, 203. Capillary bronchitis, 155. Cardiac dilatation, 180. hypertrophy, 181. degeneration, 170. Catarrhal phthisis, 143. Cerebral abscess, 85. anaemia, 75. apoplexy, 75-77. congestion, 75. cortex, lesions of, 86. disorders, chronic, 84. exhaustion, 75. hemorrhage, thrombosis and em- bolism compared, 75, 77. inflammations, 78. meningitis, 78. sclerosis, 85. sinuses, thrombosis of, 85. Cerebro- spinal affections, 98. fever, 43. sclerosis, 104. Cirrhosis of liver, 204. kidney, 211. Clubbing of fingers, 172. Charcot, Prof., cerebro-spinal affections, Cheyne-Stokes respiration, 182. Colitis, 197. Concussion of brain, 75. Congestive chills, 39. or pernicious malarial fever, 39, 44. Consumption, galloping, 150. Continued fever, 33. Copland, Dr., 32. Cord, diseases of the. 91, 93. congestion of the, 95, 96. Croup, 130. 219 lNl'KX. m;ium. D. D.. zymotic . P., scrofula, 57. Diabetes, 212. Diagnosis between [Inflammatory and essential fevers, 20. Essential and eruptive fevers, 21. Rotheln, scarlel fever, measles, and smallpox, 24. Typhoid and typhus, 28. Typhoid ami malarial, 34. Typhoid and typho-malarial, 37. Typhoid state and typhoid fever, 38. Cerebro-spinal fever and congestive per- nicious malarial fever, 41. Epidemic and sporadic cerebro-spinal meningitis, 45. Epidemic cerebro-spinal vs. typhus fever, 46. Yellow and bilious remittent, 51. Relapsing and typhoid, 53. Scrofulosis, tuberculosis, and inherited syphilis. 60. Diseases bkely to be confounded with acute rheumatism. 61. Diseases likely to be confounded with chronic rheumatism, 62. Gout and rheumatism, 65. Cerebral congestion and ansemia, 75. Cerebral apoplexy vs. drunkenness, uraemia, etc., 75. Acute cerebral inflammations, 78. Cerebral hemorrhage, thrombosis, and embolism, 77. Forms of headache, 83. Eypertrophy and hydrocephalus, 84. Intelligence, deficient, and cerebral scle- rosis, 85. Forms of paralysis, 89. Spinal paralysis. 91. Spinal diseases, 93. Acute spinal diseases, 96. Myelitis, meningitis, and spinal conges- tion. 96, Locomotor-ataxia, multilocular sclerosis. disseminated syphilosis, general pa- ralysis, 98. Cerebro-spinal sclerosis, paralysis agi- tans, and locomotor-ataxia. KM. Paraplegia from reflex irritation and from myelitis. 105. General paralysis and locomotor-ataxia. 112. True and svphilitie general paralysis, 113. Spinal irritation and spinal weakness, 114 Epilepsy and hystero-epilepsy, 116. Neuralgia and myalgia, 118. Cerebral abscess and neuralgia, 119. Insanity, forms of, 120. Spasmodic and inflammatory croup, 130. .Membranous croup and diphtheria, 181. Tonsillitis, catarrhal and parenchyma- tous, 132. Diseases of respiratory system, 142. Chronic catarrhal pneumonia (inflam- matory phthisis), interstitial pneumo- nia (fibroid phthisis), and tubercular phthisis, 144, 145. Incipient phthisis and bronchitis, 148. Bronchitis, acute and chronic, 153, 154. Capillary bronchitis and pneumonia, 155. Pneumonia and pleurisy, 155, 158. Pleurisy and hydrotliorax, 157. Pulmonary apoplexy and pneumonia, 161. Pneumothorax and hydro-pneumotlm- rax, 164. Emplvyscnia, vesicular and interlobular, 164. Pulmonary cancer and phthisis, 166. and pleurisy, 166. and syphilis, 166. Heart diseases, 170. Aortic obstruction and incompetency. 175. Pulmonary obstruction and tricuspid re- gurgitation, 178. Mitral obstruction and mitral incompe- tency. 176. Endocardial and exocardial sounds, 180. Dilated heart and pericardial effusions, 180. Hypertrophy and dilatation of heart, 181. Acidity of stomach from fermentation vs. hypersecretion, 186. Gastric and cerebral vomiting, 189, 190. Atonic dyspepsia, chronic gastritis, gas- tric ulcer and gastric cancer, 193. Indigestion and dyspepsia, 194. Enteritis and dysentery, 197. INDEX. ■l->\ Obstructive and symptomatic jaundice, 200. Diabetes mellitus and glycosuria, 213. Forms of Bright' s disease, 210. Diabetes insipidus and hydruria, 215. Diagnosis of incipient phthisis, 145. Diarrhoea, 197. Dilatation of heart, 181. Diphtheria, 130. Dobell, H., pain at the heart, 173. Donnet, J. J. L., 50. Dowell.G., yellow fever, 49. Dowse, Dr., cerebro-spinal meningitis, 45. Drachmann, Dr., on rheumatic gout, 66. Drake, D., on remitto-typhus, 36. malignant remittent, 40. Drunkenness, 75. Duchenne, Dr., pseudo-hypertropliic pa- ralysis, 108. Duggan, J., scarlatina, early diagnosis of, 22. Dyscrasise, the, 54. Dysentery, 197. Dyspepsia, 185, 191. Eichhorst, Dr., pernicious anaemia, 66. Embolism, cerebral, 75-77. Emphysema, 164. Empyema, 160. Endocardial sounds, 169, 170, 180. Enteritis, 197. Entero-miasmatic fever, 34. Epidemic meningitis, 43. Epilepsy, 75, 116. Erb, spinal disorders, 103. Eructation, 188. Eruptive fevers, 21. Essential fever, 19. paralysis, 101. Exanthemata, the, 21. Exocardial sounds, 180. Fatty degeneration of heart, 181. of liver, 203. of kidney, 210. Febrile state, the, 15. Fingers, clubbing of, 172. Flatulence, 188. Flint, A., cerebral disorders, 77. Fox, vomiting, 190. Gallstones, 201. Garrod, A. B., on gout, 65. Gastric fever, 33. ulcer, 191. cancer, 191. Gee, meningitis, 79. G-ELPKE, Dr., 71. General disease defined, 13. paralysis of fch< 109. symptoms of nervous disease, '■•■ Germ theory, 68. Glycosuria, 212. Gmelin's test, 215. Gout, 65. rheumatic, 66. Gowers, Dr., blood-cell counting. 66. diseases of spinal cord. 09, 107. Griffin, W. and D., 114. Habershon, S. O., 61. Hall, J. C, 42. Hamilton, A. M., on cerebro-spinal fever. 44. on tubercular meningitis, 48. Hardy, Dr., rheumatic diathesis. 55. Hatden, cerebro-spinal meningitis, 45. heart disease, 182. Headache, 82. Heart disease, 170. pain in, 173. Hemorrhage, cerebral, 75-77. Hemorrhagic malarial fever, 40. Hensch, paralysis, 90. Hepatic disease, 202. abscess, 203, 204. Herpes zoster, 62. Hewitt, P., symptoms of arthritic dia- thesis, 55. Hume, E. M., typhoid and malarial fevers, 34. Hutchinson, congenital syphilis, 88. gout vs. rheumatism. 54. Hydruria, 215. Hydrocephalus, 84. Hydrothorax, 157. Hydatids in the liver, 203, 206. Hyperplasia of the liver, z02. Hypertrophy of the brain, 84. heart, 181. Hysteria, 115. Hysterical paralysis, 109. Hystero-epilepsy, 116. Impotence, a symptom of diabetes. 214. Indigestion, 194. Inflammatory fever, 19. diarrhoea, 197. Inman, myalgia, 63. Intelligence, defective, 85. Insanity, 120. Intercostal neuralgia, 118. 90.9. l.NDKX. Intermittent fever, 38. Internal parasites, 205. Intussusception, 190. Jaundice, 200. Jurgexskx, Dr., typhoid fever, 20. Kki.su. A., malarial blood, 42. Kidney, diseases of, 210. Lateral sclerosis, 99. Labrabee, A., prodromata of typhoid fever; 29. Laryngitis, 135. Larynx, diseases of, 124. Lead poisoning, paralysis from, 108. Lepto-meningitis, 78. Leukaemia, 66. Liver, diseases of, 198. Local diseases defined, 13. symptoms of essential fevers, 20. Localization of brain disease, 86, and spinal cord, 87, 93. Locomotor-ataxia, 63, 100, 104. Love, Wm. A., tongue of malaria, 41. Lumbrici, 206. Lungs, diseases of the, 132. cancer of, 165. Mac Ewex, test for alcoholism, 70. Mac Swixey, Dr., syphilitic phthisis, 152. Malarial fever, 34, 38, 48. toxaemia, 41. Malignant remittent, 39. Mania. 120. Measles, 24. Melancholia, 120. Meningeal apoplexy, 95. Meningitis, cerebral, 78. cerebro-spinal or epidemic, 43. chronic, 85. sporadic or basic, 43. acute tubercular, granular, 48. Methods of physical examinations, 136. Miliary tuberculosis, 130. Milk leg, 02. Mitral diseases, 170. Monti, Alois, condition of throat in scarlatina, 23. Moss, E. L., blood of malaria, 43. Multilocular sclerosis, 104. Myalgia, 03, 118. Myelitis, acute primary, 96. chronic, 90-98. Narcotic poisoning, 96. Nephritis, acute and chronic, 210. Nervous disorders, 73. Neuralgia. 94, 117. compared with chronic rheu- matism, 62. with myalgia, 118. Neurasthenia, spinalis, 11">. Xir.MKvr.u. F. Vox, on gastric fever, 88. Obstruction of the bowels, 196. ( Ophthalmoscope, 80. Osler, Dr., initial rashes of eruptive fevers, 23. Paget, Sir. J., symptoms of arthritic dia- thesis, 56. Pain at the heart, 173. in the stomach, 187. in the liver, 199. Paralysis agitans, 104. general, 109. the forms of, 89, 93. pseudo-hypertrophic, 107. from lead poisoning, 108. Paraplegia, 105. Parasites, internal, 205. Parenchymatous renal degeneration, 211. 1'kxtimalli, syphilitic phthisis, 152. Pericarditis, 178. Pericarditis with effusion, 180. Perichondritis, 128. Pernicious anaemia, 66. Phthisis, 143, 149. syphilitic, 152. abdominal, 195. Physical diagnosis, 132* Pleurisy, 157, 160. Pleurodynia, 118. Pneumonia, 155-100. Pneumothorax, 162. Pneumo-hydro-thorax, 163. Poisoning, narcotic, 76; uraemic, 75. Progressive locomotor ataxia, see scle- rosis, posterior spinal. Pseudo-hypertrophic paralysis, 107. Pulmonary apoplexy, 161. embolism, 161. cancer, 165, obstruction, 158. thrombosis, 161. Pulse in leading fevers, 17. Pyaemia, 62. Relapsing fever, 52, Remittent fever, 39, Rem itto- typhus lever, 34. Renal disease, 64, 210. INDKX. 223 Retinitis albuminurica, 209. Reynolds, R., symptoms of rheumic dia- thesis, 55. Rheumatic gout, 66. Rheumatism, 62 ; compared with gout, 65. chronic, 62. Rheumatoid arthritis, 66. Rheumic dyscrasia, the, 54. Richardson, J. G., leukaemia, 67. Ringer, S., 16, 18. Romberg, cerebral vomiting, 189. Rosenthal, Dr., 76. Rotch, T. M., sign of pericardial effu- sion, 181. Rubeola, 25. Scarlet fever, 22. Sclerosis, 85. posterior spinal, 63, 100, 104. multilocular, 104. of antero-lateral column, 99, 104. Scrofulous dyscrasia, the, 56. Segdin, E. C., lesions of cortex, 87. Shingles, 62. Skin in fever, 187. disease of diathetic origin, 55. Smallpox, 22. Softening of brain, 85. Southey, R. , tubercular meningitis, 48. Spinal apoplexy, 96. congestion, 95, 96. diseases, acute, 91, 93 ; chronic, 97. tumors, 97. irritation, 114. meningitis, 96. Spirillium in relapsing fever, 52. Spotted fever, 43. Stille, A., epidemic cerebro-spinal fever and typhus, 46. Stokes, Wm., on fever, 20. Strumous dyscrasia, the, 56. Sunstroke, 75. Symptomatic fever, 19. Synovitis, acute, 62. Syphilis, osteocopic pains of, 63. Syphilitic dyscrasia, the, 58. laryngitis, 126. phthisis, 152. teeth, 58. general paralysis, 109. Syphilosis, disseminated, of the cord, 113. Tache c6r6brale, the, 49. Tape worm, 206. Teeth, rheumatic markings on, 64. syphilitic, 68. Temperal are in fever, 17. rules for taking, L6. of leading febrile <\\ ■ -.< • . 17. Tendon-reflex, 102. Thread worms, 206. Throat in eruptive fevers, 21. Thrombosis, cerebral, 75, 77, 85. Tongue in digestive disorders, 184. in fever, 16. in malarious disease, 41. Tonsillitis, 132. Tremors, 97. Tricuspid regurgitation, 178. Trichinosis, 206. Trousseau, A., scarlatinal sore throat, 52. Tubercular dyscrasia, the, 59. laryngitis, 127. peritonitis, 195. meningitis, 78. Tuberculosis of lung, 143. Typhlitis, 34. Typhoid fever, 28. types of, 33. state, the, 37. Typho-malarial fever, 34. Typhus fever, 29. Urtemia, 75. Urinary calculi, 216. organs, diseases of, 208. Urine in fever, 18. Variola, 21. Vertigo, 188. Vomit, black, 49. Vomiting, 189. Warter, J. S., on fever, 17. Waters, A. T. H., tuberculous dyscrasia, 59. Wegscheider, H., 16. Westphal, Dr. , tendon reflex, 102. Whittle, W., uraemia, 76. Wood, H. C. Jr., spinal disease, 91. Woodward, J. J., typho-malarial fever, 36. Worms, 206. Wunderlich, temperature in fever, 17. Yellow fever, 49. MEDICAL PERIODICALS AND BOOKS PUBLISHED BY D. 6, BRINTON, M. D, 115 SOUTH SEVENTH ST,. PHILADELPHIA, PA. y of these works will be forwarded by mail, postpaid, on receipt of the printed price. THE MEDICAL k SURGICAL REPORTER. A WEEKLY JOTJRlV^ILu Edited by D. G. BRINTON, M. D. ISSUED EVERY SATURDAY. Large Octavo, Double Columns, 26 to 28 Pages of Reading Matter in Each Number. The Reporter has now been issued as a weekly journal twenty - three years, and by its recent enlargement gives as much, if not more, reading matter, than any other medical periodical in the United States. It has always been an independent journal, edited strictly in the interests of the profession, and sustained by the most distinguished medical writ- ers in America. It has ever been the aim of the Reporter to make practical medi- cine — the actual business of the doctor — the leading feature in its pages. Hence the lectures, articles, hospital reports it gives, are mainly devoted to pathology, diagnosis, surgery and therapeutics, rather than to matters of theory, scientific curiosities, or recondite research. This will continue to be its aim. It has also been its object to be broadly national in tone and in value. Its contributions are sought in all parts of the Union ; no society, college or clique controls it. It is a perfectly independent organ of the whole regular and scientific profession of medicine. As such, it will continue. In the department of News, the Reporter is intended to be, in the full sense of the word, a medical newspaper. Its weekly visits will keep the isolated practitioner fully conversant with all that is going on in the great cities, at the societies, in the colleges and legislative halls, which has a bearing on his profession ; as well as with such personal intelligence as is proper to be published. The price is $5.00 per year, payable in advance. Specimen copies will be sent gratis on application. 1 THE HALF-YEARLY Compendium of Medical Science, ISSUED JANUARY 1 AND JULY 1, is an epitome or abstract of the most important articles which have appeared in European and American Medical Journals during the six months previous to its publication. It is the only publication of the kind which embraces both American and European journals. Each number contains 300 large 8vo pp. with Index. i^°It is especially adapted to be taken along with the Reporter, as none of the articles in the one publication appear in the other. The price of the Compendium is $2.50 per year. The Reporter and Compendium together are §7.00 per year. THE PHYSICIAN'S DAILY POCKET RECORD. All who have made use of this Visiting List prefer it to any of the others in the market. It has a "Perpetual Calendar," which allows it to be commenced any time in the year, and it continues good for one year from that time. It contains a complete posological table in the metric and ordinary systems, and a large amount of very practical memoranda, closely condensed and very perspicuously arranged. It is bound with a spring! clasp, in durable morocco, and is adapted either to thirty-five or seventy patients per week. Price for thirty-five patients, SI. 50, seventy patients, $2.00. i^ The Reporter and Compendium for one year and a copy of the Pocket Record, with the name of the purchaser neatly stamped in gilt on the cover, will be sent to one address on receipt of eight dollars (SS.00). From hundreds of unsolicited letters of the kind we choose at random the following testimonials to the worth of the Reporter. "The Reporter comes regularly to my address, for which many thanks. It is the best publication of a medical kind I receive." L. C. BUTLER, M.D., Ex-President of the Vermont State Medical Society. "I find the Reporter superior to all other medical journals which I have taken. It always embodies the most advanced, practical and important medical literature." DR. THOS. M. WOODRON, Tennessee. "For the daily needs of a busy practitioner your journal is, without doubt, superior to any other printed." DR. C. E. RICHARDS, Milwaukee. "lean find nothing BO practical as the Reporter. I think it the best of journals for the busy practitioner." DR. A. L. WILLIAMS, Ohio. "I would regret the absence of the Reporter more than any one of the ten medical journals I receive." DR. W. H. SOLIS, Michigan. 2 THE MODERN T herapeutics S eries EDITED TO 1880. I.— MODERN MEDICAL THERAPEUTICS. A Compendium of Recent Formulae and Specific Therapeutical directions from the practice of eminent contemporary physicians, American and foreign. By Geo. H. Napheys, a.m., m.d. 1 vol., 8vo., pp. 007. Price, cloth, S4.00; sheep, $5.00. II.— MODERN SURGICAL THERAPEUTICS. A Compendium of Current Formulae, Approved Dressings and Specific Methods for the treatment of Surgical Diseases and Injuries. By Geo. H. jSTapiieys, a.m., m.d. 1 vol., 8vo., pp. 008. Price, cloth, $4.00; sheep, |5.00. III.— THERAPEUTICS OF GYNECOLOGY AND OBSTETRICS. Edited by ¥i. B. Atkinson, m.d., etc. 1 vol., 8vo., pp. 306. Price, cloth, $3.00; sheep, $3.50. This Series of Therapeutics has been recognized by the Medical Press, both of England and the United States, to be the most practically valu- able to the physician of any which is now in the market. The following hints as to its plan will give some idea of its exceeding usefulness: — IN THE MEDICAL THERAPEUTICS the total number of authors quoted is 723, and the precise formulae given, 1124. Each disease is taken up and its treatment presented according to the latest and best authorities in Europe and this country. Many of the directions and formulae have never been published elsewhere. A "Resume of Remedies" follows each disease, showing all the drugs which have a well-merited reputation in the therapeutics of the complaint. Xor are the descriptions confined to drugs only, but every therapeutic resource in a disease is specified, including electricity, bathing, mineral waters, external applications, climate, diet, sanitation, etc., etc. IN THE SURGICAL THERAPEUTICS the number of authors quoted is 418 ; the number of their prescriptions given, 1008. The spe- cial object of this work is to set forth the medical aspect of Sitrgery, to collect in one volume the Therapeutics of Surgery, the formulae and medical treatment of Surgical diseases of the most eminent surgeons. THE THERAPEUTICS OF GYNECOLOGY AND OBSTETRICS presents a condensed, carefully weighed and accurately presented review and estimate of the therapeutical resources of the gynaecologist and obstetrician. The remarkable activity which has characterized this specialty of late years has vastly increased its materia medica and forms of therapeutics; and a summary of these discoveries and improvements cannot fail to be welcome. The most recent publications of the European press and all the special journals of both continents have been laid under contribution. OPINIONS OF THE PRESS AND OF READERS. "This is a useful and interesting hook, which no one can take up without finding something he did not know before." — British Medical Journal, August, 1880. "After a close scrutiny we have come to the conclusion that the thorough revision given to the seventh edition of this book (the MEDICAL Theeapeutios) has made it the most valuable work on treatment a practitioner can possibly procure. It is abreast of the latest views." — Medical Press and Circular (London), September, 1880. "This work iB well conceived aud carefully executed, and will be of very great service to the practitioner. The Lancet, London, August, 1879. "Napheyb' Therapeutics is a work with which the profession has become well acquainted through its former editions. The present edition is much changed from the last. Many additions have been made, gathered from recent sources, and, in fact, the work has been thoroughly revisod. As a means of familiarizing with the methods and remedies employed in different parts of the world by hading practitioners, no other book is equal to it." — Pacific Medical Journal, January, 1880. "Divested ns they are of all that is not S'.rictly practical, containing such information as is of every day requirement, and containing no useless verbiage, these books are such as the general practitioner particularly will find of great assistance." — Michigan Medical News, March, 1880. "Give a practitioner these three volumes, and one or two good journals, and he needs little else, practically, in the way of books." DR. Til' >S. M. MATTHEWS, Texas. "An admirable compendium * * * an eminently practical work." — Michigan Medical News. "A unique book; it shows vast labor on the part of the author." — St. Louis Clinical Record. "A very valuable aid to practice, indeed, almost indispensable." — St. Louis Medical and Surgi- cal Journal. "Cannot fail to help almost any practitioner." — Louisville American Practitioner. " It is eminently a practical work." — Louisville Medical News. "In no other work can the practiti ir Irani BO easily the favorite medicines in treating disease, and the best methods in compounding them."— Louisv ille American Medical Biweekly. "Of the utmost practical utility to every physician and surgeon. Tiny arc all, and more, than the editor claim- for tin m."— Richmond, Virginia, Medical Monthly. The following opinions refer to the Therapeutics of Gynaecology and Obstetrics : — "This book is one which the general practitioner will find of great assistance to him." — Michigan Medical News, .March, 1880. "It is concise and intensely practical, and we cordially commend it, both to the profession and tin- -tudent."— The Therapeutic Gazette, March, 1880. "We consider it superior to either one of tin- other volumes."— Cincinnati Medical News. March, 1880. "We recommend it as tilliii- :. general want."— Atlanta Medical and Surgical Journal, February, I 4 A BIOGRAPHICAL DICTIONARY OF CONTEMPORARY AMERICAN PHYSICIANS AND STJROBOITS. Edited by "WJVE. H. ATKINSON, M!. D., Permanent Secretary of the American Medical Association, and of the Pennsylvania State Medi- cal Society ; LecHirer on Diseases of Children at the Jefferson Medical College, etc. One Volume, Royal Ociavo, Double Columns, 780 pp., on Fine, Tinled Paper. JB®" REDUCED PRICE.°®a With 52 Full-page Steel Portraits, Half Leather, . $7.50 Same without the portraits, only 4.00 This really monumental work, the fruit of enormous labor and outlay, contains the biographical sketches of more than twenty- eight hundred contemporary regular physicians of the United States, prepared from materials in most instances furnished by themselves, and hence entirely trustworthy. Indexes of names and places are appended. The effort has been made to embrace all who have visibly contributed to the advancement of medical science in all parts of the Union, and the volume presents a mass of most valuable historical, biographical and scientific material. IN PRESS. READY MARCH 1st, 1881. THE PRINCIPLES AND METHODS OF THERAPEUTICS. BY ALPHONSE GUBLER, M.D., Professor of Therapeutics in the Faculty of Medicine of Paris, etc. TRANSLATED FROM THE FRENCH. ONE VOL., 8vo. Gtjbler may be said to have been the most distinguished exponent of scientific therapeutics — in the best sense of the term — of this genera- tion. Following Trousseau in the professional chair, aud a pupil of that great teacher, he toek a long step in advance of his master, and may be said to have developed the only method of therapeutics which reconciles the empirical and clinical art of medicine with the demands of exact and logical science. His labors created a new epoch in professional practice in France, and in all other countries where they have become known have made a profound impression on the professional mind. 5 DIFFERENTIAL DIAGNOSIS: A MANUAL OF THE COMPARATIVE SEMEIOLOGY OF THE MORE IMPORTANT DISEASES. By DE HAVILLAND HALL, M.D., Assistant Physician to the Westminster Hospital, London. Second American Edition, with Extensive Additions. EDITED BY FRANK WOODBURY. M.D. One Volume, Svn. pp. -2'2:\. Printed on handsome tinted paper; bonnd in Knglish pebbled cloth, with beveled boards. Price $2.00. Dr. Hall's work has received the highest encomiums from the English medical press, for its lucid arrangement, completeness and accu- racy. He himself is known in London as a practitioner of great skill, and an unusually successful medical teacher. Most of the diseases which may he confounded are presented in comparative tables, setting forth their distinctive characteristics in the clearest possible light, and thus greatly facilitating their prompt diag- nosis. THE DISEASES OF LIVE STOCK, INCLUDING HORSES, CATTLE, SHEEP AND SWINE. Containing a description of all the usual diseases to winch these animals are liable, and the most successful treatment of American, English and European Veterinarians. 13y LLOYX> V. TELLOR, M. r>. 1 vol. 8vo. pp. 474. Price. Cloth, $2.50. This work is divided into four parts, as follows : I. General Princi- ples of Veterinary Medicine. II. Diseases of the Horse. III. Diseases of Cattle, Sheep and Swine. IV. Hygiene and Medicines. The author of this work is a regular physician, whose practice in the country has led him to study the diseases of domestic animals, and we can point to it as the first and only hook, by an American physician, which describes, with scientific accuracy, and yet in plain language, these common and important maladies. From WILLIAM A. HAMMOND, M.D., of New York City, Late Surgeon General, U. S. Army. "I have gone through Dr. Tellor's book very carefully, and regard it as admirably ndapted for the use of those who are obliged to treat their own animals. It is eminently practical and full of common sense." 6 LESSONS IN GYNECOLOGY. BY ¥M. GOODELL, A.M., M.D., Professor of Clinical Gynaecology in the University of Pennsylvania. SECOND EDITION. THOROUGHLY REVISED AND CONSIDERABLY ENLARGED, WITH NUMEROUS ILLUSTRATIONS. One Volume, Svo. Price, Cloth, $4.00; Sheep, $4.50. The Second Edition of this able work was demanded within three months from the publication of the first. The author has, however, taken the time to give it a very careful revision, and has added a large amount of new and unpublished material. "This volume is one which must take a high rank among works upon the subject of which it treats. It presents striking and rare merits, showing close observation, accurate description and sound reasoning." — Medical Times and Gazette, London, November, 1880. "We commend this book to those who are, or who wish to become, gynascologists. Its great value is its practicalness. Little points of detail teem up on almost every page, showing that it is the work of a man who has often done what he wishes his readers to do. — Glasgow Medical Jour- nal, November, 1880. COMMON MIND-TROUBLES, AND THE SECRET OF A CLEAR HEAD. By J. MORTIMER-GRANVILLE, M.D., F.R.C.S., LONDON, etc. One Vol., Crown 8vo, Cloth, pp. 185. Price $1.00. Reprinted from the Eleventh, thousand, of the London Edition, with additions by the American Editor. CONTEXTS. PART I. Mental Failings — Defects of Memory — Confusions of Thought — Sleeplessness from Thought — Hesitations in Speech — Low Spirits— Good and Bad Tempers — Mental Languor and Listlessness — Morbid Fears — " Creatures of Circumstance." PART II. Temperature — Habit — Time — Pleasure— Self-Import- ance — Consistency — Simplicity — The Secret of a Clear Head. 7 Atkinson. Hints on the Obstetric Procedure. Svo. Cloth, SI. 00. "The nmnv valuable points cited, the practical manner in which they are stated, together with Die Bound \ i>'« b of practice enunciated, make this little monograph truly valuable." — The Southern Practitioner, January, 1879. •• It is the gist of the obstetric ait in convenient form, and will Berve to refresh the practitioner's mind in any case pertaining thereto." — Maryland Medical Journal, June, 1879. Bernard and Huette. Operative Surgery and Surgical Anatomy. Magnificently illustrated on steel. Colored plates. New edition in preparation. Dowell. Yellow Fever and Malarial Diseases. With a Map. Cloth, $2.00. Dobell. On Coughs, Consumption, and Diet in Disease, pp. 222. Cloth, $2.00. As an authority on the above Biibjects Dr. Dobell ranks second to none in Great Britain. His . ■\|"-rii-ii(-'' has been immense, and the peculiarly practical tone of his mind renders his writings unusually instructive to the practicing physician. Hargis. Yellow Fever, its Ship Origin and Prevention. Svo. (Just issued). Cloth, 51.00. Landolt. Manual of Examination of the Eyes. Illustrated, pp. 307. Numerous illustrations and Chart, $3.00. "This hook is a most admirable and complete exposl of our means and methods of making a thorough scientific examination of the human eye. Written in the attractive, easy style of lectures, unencumbered by unnecessary mathematical formulae, printed on heavy paper and in large and char type, translated with care and skill into fluent English, this book will contribute largely toward awakening greater interest for ophthalmology 'among the reading members of our profession." — Chicago Medical Journal and Examiner, August, 1870. Seiler. Compendium of Microscopical Technology, pp. Svo. (Just issued.) Price, $1.00. Dr. Carl Seiler, of Philadelphia, gives in this admirably lucid opitome of microscopy just that information which the student and physician requires to work the microscope advantageously. It is well illustrated and contains a comparative table of neoplasms of great value. In Preparation. Ready about A-pril 1, 1881. HYDROPHOBIA, .A. Monograph, for the Profession and the Public. By H. R. BIGEL0W, M.D. This treatise, the outcome of several years' study of this terrible complaint, will contain the latest investigations into its pathology, causes, communicability, prognosis, prophylaxis and treatment. 8 COLUMBIA UNIVERSITY This bqo.k is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE BORROWED C26'63B>MBO RC71 Hall H14 1881 " H